Recipient

Royal Hallamshire Hospital

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First report 6 Nov 2019•Latest report 18 Mar 2024

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Royal Hallamshire Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Western)

    AI-generated summary

    Darnell Errol Hugh Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Darnell Errol Hugh Smith, who had cerebral palsy, scoliosis, sickle cell disease and epilepsy, attended hospital with reduced appetite, respiratory symptoms and no bowel movements, and was later admitted to critical care, intubated and ventilated. He died on 23 November 2022 after developing ventilation-associated pneumonia and type 2 respiratory failure. The principal concerns were missed observations, pain monitoring, provision of fluids, and staff not locating or considering his health passport and individualised care plan, creating a missed opportunity to identify deterioration earlier.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Hallamshire Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure individualised care plans are readily locatable in computerised records

    Wider context from the report

    “The Court heard evidence despite a warning 'flag' being present on the computerised records identifying the existence of an individualised care plan for Darnell, the care plan was hard to locate in the records, and was not considered during admission. Individualised care plans are crucial to a patient's care and it is my view that without knowledge or sight of them by treating clinicians there is a real risk of further deaths. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Hallamshire Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of treating clinicians to consider individualised care plans during admission

    Wider context from the report

    “The Court heard evidence despite a warning 'flag' being present on the computerised records identifying the existence of an individualised care plan for Darnell, the care plan was hard to locate in the records, and was not considered during admission. Individualised care plans are crucial to a patient's care and it is my view that without knowledge or sight of them by treating clinicians there is a real risk of further deaths. ”
    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Sandra Dawne Scott · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sandra Dawne Scott was prescribed treatment for a urinary infection, but the prescription was not available for collection after changes were made to the electronic prescribing system. She was admitted to hospital with worsening symptoms on 22 April 2019, deteriorated, and died on 23 April 2019. Concerns included the failure to act on hospital urine-test results and the lack of awareness among healthcare professionals of the electronic prescribing system issue; the evidence was that receiving the prescribed or indicated medication would have meant she did not die when she did.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Hallamshire Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of electronic prescriptions to remain available for download after system details are reset

    Wider context from the report

    “1. The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unknown to the GP these changes meant the prescription was no longer available for download by the chemist. 2. This resulted in the patient not getting required medication. 3. The evidence was that the GPs colleagues were also unaware of this peculiarity of the system. 4. Other medical professionals are also likely to be unaware. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Hallamshire Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act on urine test results after patient discharge

    Wider context from the report

    “5. The Royal Hallamshire Hospital received the results of a urine test on the 20.4.19 but did not act upon them as the patient had been discharged. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Hallamshire Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness among medical professionals of the electronic prescribing system peculiarity

    Wider context from the report

    “1. The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unknown to the GP these changes meant the prescription was no longer available for download by the chemist. 2. This resulted in the patient not getting required medication. 3. The evidence was that the GPs colleagues were also unaware of this peculiarity of the system. 4. Other medical professionals are also likely to be unaware. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026