Royal London Hospital

Private and voluntary organisations · Multi-service care provider

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First report 19 Jan 2014•Latest report 27 Nov 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 28
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

27 Nov2023
Inner North London
Concerns raised3
1. Lack of assigned responsibility for ensuring that patient notes are sent to external appointments
2. Failure to ensure that patient notes accompany external appointments
3. Poor maintenance of PICC lines
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Jennifer Ruth Whinney · 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

Jennifer Ruth Whinney developed recurrent infections in her PICC lines after being admitted to the Royal London Hospital for bowel surgery, leading to septicaemia and multi-organ failure. She died following surgery to repair a bowel fistula. The report raised concern that her medical records were not sent to a specialist appointment and that there was no individual responsibility for ensuring records accompanied patients, risking important information not being passed on.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of assigned responsibility for ensuring that patient notes are sent to external appointments
Wider context from the report
“Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queens Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent. Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure that patient notes accompany external appointments
Wider context from the report
“Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queens Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent. Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Poor maintenance of PICC lines
Wider context from the report
“Whilst at the Royal London Hospital Jennifer had at least 6 episodes of sepsis from infected PICC lines. I heard evidence that these infections were contributed to by poor PICC line maintenance. and that the consultant colorectal surgeon raised concerns about the number of PICC line infections that Jennifer and other patients on the ward were getting. I heard some evidence about steps that had been taken but I was told that it was a nursing issue and I only heard evidence from a surgeon. I did not receive any written evidence about changes that have been made. ”
Open source report
14 Nov2022
East London
Concerns raised5
1. Failure of investigation and inquest reporting to identify enoxaparin use and missing clinical justification
2. Failure to prevent falls among high-risk hospital patients
3. Inadequate recording of clinical factors supporting enoxaparin prescribing
1. Failure to assess intracranial damage before prescribing and administering enoxaparin
2. Delays in urgently requested CT head imaging
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Ghulam Mohammad · 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

Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of investigation and inquest reporting to identify enoxaparin use and missing clinical justification
Wider context from the report
“5. Neither the Trust’s initial investigation nor the consultant statement to the inquest mentioned the use of enoxaparin or the lack of clinical records justifying its use. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to prevent falls among high-risk hospital patients
Wider context from the report
“1. A patient with a high risk of falls sustained a fatal injury in an avoidable fall in hospital. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate recording of clinical factors supporting enoxaparin prescribing
Wider context from the report
“4. Inadequate record keeping meant that there was no contemporary account of the factors taken into consideration by the doctor or her supervising consultant in prescribing enoxaparin. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess intracranial damage before prescribing and administering enoxaparin
Wider context from the report
“3. Before the requested CT head was undertaken, a doctor prescribed blood thinning medication – enoxaparin to Mr Mohammed. Enoxaparin can exacerbate an intra-cranial bleed. The medication was administered on 13 & 14th October 2021. Both the prescription and the administrations of enoxaparin were made without knowing the extent of any intra-cranial damage caused by the fall on 11/10/21. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in urgently requested CT head imaging
Wider context from the report
“2. Following that fall, an urgently requested CT head was delayed for four days. ”
Open source report
30 Sep2022
East London
Concerns raised3
1. Failure to verify the most recent clinical observations and PEWS score before discharge
2. Failure of nursing and paediatric medical staff to communicate factors affecting patients and plans to resolve them before discharge
3. Pressurised Paediatric Emergency Department environment caused by high patient numbers and severe symptom acuity
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Shahan Abu Aman · 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

Shahan Abu Aman, a three-year-old boy, attended hospital on 7 December 2021 with vomiting and diarrhoea and was discharged after assessment, observation and a fluid challenge. He was found unresponsive the following morning and died in hospital; the report identified miscommunication between nursing and medical staff, failure to confirm the most recent observations and PEWS score before discharge, and a pressurised emergency department environment as concerns.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to verify the most recent clinical observations and PEWS score before discharge
Wider context from the report
“2. The doctor who authorised discharge did not satisfy himself of the most recent set of clinical observations and associated Paediatric Early Warning Sign (PEWS) score prior to discharge. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing and paediatric medical staff to communicate factors affecting patients and plans to resolve them before discharge
Wider context from the report
“1. A series of miscommunications between; nursing staff, junior and consultant paediatric medical staff resulted in concerns regarding Aman not being properly considered prior to discharge. Staff relied on assumptions that others understood the factors affecting Aman and had a plan to resolve them, this was not the case. Had effective communication occurred it was unlikely that Aman would have 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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Pressurised Paediatric Emergency Department environment caused by high patient numbers and severe symptom acuity
Wider context from the report
“3. The Paediatric Emergency Department was particularly busy that evening, with a combination of high patient numbers and severe acuity of symptoms. The accounts provided by Trust witnesses was that this resulted in a pressurised environment and that this was a situation that occurred with an increasing level of frequency over the last two years. ”
Open source report
1 Jul2022
East London
Concerns raised4
1. Failure to account for learning disability when taking a clear clinical history
2. Failure to provide effective referral communication and formal handover to the surgical team
3. Failure to consider and act on dangerously elevated creatinine results before discharge
1. Failure to review clinical records before accepting a surgical referral
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Daniel Xavier · 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

Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to account for learning disability when taking a clear clinical history
Wider context from the report
“3. Due regard was not given to Mr Xavier’s learning disability during his admission on 21st October 2021. Insufficient time and care was taken to establish a clear history from the patient, most pertinently his 7-day history of constipation. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide effective referral communication and formal handover to the surgical team
Wider context from the report
“2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place. Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider and act on dangerously elevated creatinine results before discharge
Wider context from the report
“1. Prior to Mr Xavier’s discharge from hospital on the evening of 21st October 2021, the deceased’s venous blood gas results were not considered and acted upon by staff. The results, available from 13.17, indicated that Mr Xavier had a dangerously elevated creatinine level. Evidence heard at inquest indicated that had the results been considered, Mr Xavier would not have been discharged, he would have been escalated to the resuscitation department. Further, the Trust accepted that had the creatinine levels been acted upon, it is likely that the outcome for Mr Xavier could have been different. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to review clinical records before accepting a surgical referral
Wider context from the report
“2. Mr Xavier’s referral to the surgical team by his GP was chaotic. No telephone contact was made between the GP and the on call surgical team. Mr Xavier was therefore triaged by a ED nurse and subsequently, a rapid assessment team junior doctor before he was brought to the attention of the surgical team. Despite these assessments, no formal handover was provided to the surgical team, setting out the extent of the history, clinical observations and diagnostic processes that had previously taken place. Despite these shortcomings, the surgical team accepted the referral without considering Mr Xavier’s clinical records beforehand. ”
Open source report
28 Feb2022
East London
Concerns raised7
1. Failure to consider breaking up the 1:1 carer shift
2. Insufficient involvement of family in learning disability care recommendations
3. Lack of an itemised property and medication list
1. Failure to place alerts or flags on records about patient complexities and risks
2. Failure to keep hourly observations by the 1:1 carer
3. Failure to implement action and learning from self-harming incidents
4. Failure of the allocated nurse to complete a risk assessment
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Vijaykumar Girishbhai Gadhavi · 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

Vijaykumar Girishbhai Gadhavi died from a drug overdose while an in-patient at Whipps Cross Hospital under enhanced one-to-one care. The report raised concerns about breaches of the Enhanced Care Policy, the absence of an alert or risk-management plan, inadequate recording of property and medication, insufficient family involvement, and a lack of evidence that learning from earlier self-harming incidents had been implemented.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider breaking up the 1:1 carer shift
Wider context from the report
“5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient involvement of family in learning disability care recommendations
Wider context from the report
“4. The recommendation by the learning disability nurse were not fully put into practice. In particular, there was insufficient involvement of his family. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of an itemised property and medication list
Wider context from the report
“3. Despite awareness of the previous overdoses on the ward, there was no itemised property list, including a list of medications. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to place alerts or flags on records about patient complexities and risks
Wider context from the report
“2. Despite the multiple risk incidents and foreseeability of future hospital admissions, there was no alert or flag placed on Mr Gadhavi’s records to alert new staff to the complexities and risk in his presentation. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep hourly observations by the 1:1 carer
Wider context from the report
“5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement action and learning from self-harming incidents
Wider context from the report
“1. Datix reports were generated for the multiple self-harming incidents in July and August 2020. There was no evidence at the inquest, that action and learning had been put in place as a result of these incidents. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of the allocated nurse to complete a risk assessment
Wider context from the report
“5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer. ”
Open source report
7 Jan2022
East London
Concerns raised6
1. Failure to use targeted factual communication between surgical and anaesthetic teams during surgery
2. Failure to communicate a surgeon's reasons for leaving surgery to the surgical team
3. Failure to effectively monitor when a surgeon leaves theatre
1. Lack of a system to assess the appropriateness of a surgeon leaving surgery
2. Lack of a formal preoperative risk assessment tool requirement
3. Failure to record a surgeon's early departure in the surgical notes
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs Surekha Pandharinath Shivalkar · 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

Mrs Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to use targeted factual communication between surgical and anaesthetic teams during surgery
Wider context from the report
“2. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient’s welfare passed between the two teams but no targeted questions requiring clear factual responses were asked. Had such questions been put, a different outcome may have arisen. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate a surgeon's reasons for leaving surgery to the surgical team
Wider context from the report
“3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to effectively monitor when a surgeon leaves theatre
Wider context from the report
“3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of a system to assess the appropriateness of a surgeon leaving surgery
Wider context from the report
“3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of a formal preoperative risk assessment tool requirement
Wider context from the report
“1. No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Health NHS Trust since 2018, there remains no requirement to utilise such a tool. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record a surgeon's early departure in the surgical notes
Wider context from the report
“3. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. ”
Open source report
23 Dec2021
East London
Concerns raised2
1. Inaccurate recording of MUST malnutrition risk scores
2. Failure to assess all patients for malnutrition risk using the MUST score system
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Margaret Rose Toye · 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

Margaret Rose Toye, aged 81, sustained an unwitnessed fall on 10 April 2021, suffered a left neck of femur fracture, underwent surgery on 12 April, and died following a cardiac arrest on 20 April 2021. The principal concern was that she was not assessed for malnutrition using the MUST score system; her records incorrectly recorded a score of 0, and it was considered likely that she would have scored 4, which would have prompted mitigations to maximise her nutritional intake. Contemporary ward audits indicated that one in ten patients were not assessed for malnutrition risk.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate recording of MUST malnutrition risk scores
Wider context from the report
“1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake. 2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess all patients for malnutrition risk using the MUST score system
Wider context from the report
“1. Following admission, Mrs Toye was not assessed for risks of malnutrition by use of the MUST score system. Such an assessment was required for all patients. Erroneously, her notes recorded that she scored 0 on the MUST scale which meant that no other staff members began an assessment throughout her admission. It is likely that during admission Mrs Toye would have scored 4 on a MUST assessment, as such a number of mitigations would have been introduced to maximise her nutritional intake. 2. Contemporary audits of compliance of Must scoring on the ward in question demonstrate that one in ten patients are not being assessed for risks of malnutrition. ”
Open source report
21 Dec2020
East London
Concerns raised2
1. Failure to undertake required renal monitoring
2. Failure of governance systems to assess cases as Serious Incidents requiring investigation
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Evadney Dawkins · 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

Evadney Dawkins, aged 77, fell at home and was admitted to hospital on 22 July 2018. Renal monitoring planned after assessment was not undertaken for four days, when she was found to have a Grade 3 acute kidney injury; she later suffered a cardiac arrest and was pronounced deceased on 23 August 2018. Concerns also included that the Trust’s governance systems did not identify the case as a Serious Incident requiring investigation for two years.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake required renal monitoring
Wider context from the report
“1. On 22nd July 2018, Mrs Dawkins was assessed to require renal monitoring, incorporating; a) Regular blood tests b) A renal ultrasound c) Fluid intake/output monitoring The 3 actions were not undertaken for 4 days, after which, it was discovered that the patient had deteriorated and had sustained a Grade 3 acute kidney injury. 2. The Trust’s governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of governance systems to assess cases as Serious Incidents requiring investigation
Wider context from the report
“1. On 22nd July 2018, Mrs Dawkins was assessed to require renal monitoring, incorporating; a) Regular blood tests b) A renal ultrasound c) Fluid intake/output monitoring The 3 actions were not undertaken for 4 days, after which, it was discovered that the patient had deteriorated and had sustained a Grade 3 acute kidney injury. 2. The Trust’s governance systems did not assess to a case as a Serious Incident requiring investigation for 2 years. ”
Open source report
2 Dec2020
East London
Concerns raised4
1. Limited physiological reserve increasing risk of rapid loss of consciousness following bleeding
2. Restlessness during dialysis increasing risk of needle dislodgement
3. Failure of dialysis equipment alarms to promptly alert staff to bleeding
1. Failure to position dialysis patients within a clear line of sight from the nurses station
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Ivan Merryfield O’Neill · 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

Ivan Merryfield O’Neill bled to death during a dialysis appointment after a venous needle became dislodged from his arteriovenous fistula. Concerns included his restlessness and frailty, his position outside a clear line of sight from the nurses’ station, and an alarm that did not promptly alert staff to the bleed.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Limited physiological reserve increasing risk of rapid loss of consciousness following bleeding
Wider context from the report
“2. Mr O’Neill was a frail patient with little reserve and would be more likely to swiftly lose consciousness following a bleed. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Restlessness during dialysis increasing risk of needle dislodgement
Wider context from the report
“1. Mr O’Neill was known to be a restless patient during a dialysis session. This factor must have increased the risk of needle dislodgement. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of dialysis equipment alarms to promptly alert staff to bleeding
Wider context from the report
“4. The automatic alarm triggered by the dialysis equipment was insufficiently sensitive to promptly alert staff to a bleed until between 200 – 2000 mls of blood had already been lost. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to position dialysis patients within a clear line of sight from the nurses station
Wider context from the report
“3. Mr O’Neill was placed in a position which was outside of a clear line of sight from the nurses station. ”
Open source report
12 Nov2020
East London
Concerns raised4
1. Lack of clinical instruction for nursing staff on NG tube management
2. Failure to properly escalate concerns regarding NG tube function to clinical staff
3. Use of nursing staff without training or experience in NG tube management
1. Failure to clearly record instructions on NG tube management
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Amarbai Bhudia · 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

Amarbai Bhudia was admitted to hospital with abdominal pain and vomiting and was managed for a small intestine obstruction using a naso-gastric tube. The tube was not aspirated, and she collapsed and suffered a cardiac arrest caused by aspiration of gastro-intestinal contents; concerns included unclear instructions, lack of nursing guidance and training, and inadequate escalation of concerns about the tube.

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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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clinical instruction for nursing staff on NG tube management
Wider context from the report
“1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant. 2. Nursing staff had no clinical instruction as to how to manage the NG tube. 3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management. 4. Concerns regarding the NG tube function were not properly escalated to clinical staff. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to properly escalate concerns regarding NG tube function to clinical staff
Wider context from the report
“1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant. 2. Nursing staff had no clinical instruction as to how to manage the NG tube. 3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management. 4. Concerns regarding the NG tube function were not properly escalated to clinical staff. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Use of nursing staff without training or experience in NG tube management
Wider context from the report
“1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant. 2. Nursing staff had no clinical instruction as to how to manage the NG tube. 3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management. 4. Concerns regarding the NG tube function were not properly escalated to clinical staff. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to clearly record instructions on NG tube management
Wider context from the report
“1. Instructions on the management of the NG tube were provided on a ward round by a consultant, the instructions were not clearly noted by the House Officer accompanying the consultant. 2. Nursing staff had no clinical instruction as to how to manage the NG tube. 3. Nursing staff dealing with the patient were agency staff without training or experience of NG tube management. 4. Concerns regarding the NG tube function were not properly escalated to clinical staff. ”
Open source report
30 Oct2020
East London
Concerns raised3
1. Failure to make report receipt by the appropriate clinician apparent to the reporting radiologist
2. Failure of the results-routing system to send results to the referring clinician
3. Failure of the results-routing system to prevent sending results to uninvolved doctors
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Michael Robert Collins · 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

Michael Robert Collins died at Whipps Cross Hospital on 4 April 2018 as a result of a ruptured abdominal aortic aneurysm. The report describes delays and errors in identifying, communicating, and acting on the aneurysm, which required ongoing monitoring. Concerns were also raised about the CERNER system not reliably sending results to the appropriate clinician and about the limited visibility of radiology reports for unexpected significant findings.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to make report receipt by the appropriate clinician apparent to the reporting radiologist
Wider context from the report
“1. The Inquest heard evidence that the current CERNER system does not always ensure that results are sent through to the referring clinician. The Inquest heard evidence of a “quirk” in the system whereby results will be sent through to doctors who have no involvement in the patient's care. 2. The Inquest heard evidence that radiologists can now drop reports into a folder where there are unexpected and significant radiological findings. There is a specific folder relating to the finding of abdominal aortic aneurysms. The radiologist however raised a concern at the Inquest that it is not easily apparent to the reporting radiologist that the report has reached the appropriate clinician. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of the results-routing system to send results to the referring clinician
Wider context from the report
“1. The Inquest heard evidence that the current CERNER system does not always ensure that results are sent through to the referring clinician. The Inquest heard evidence of a “quirk” in the system whereby results will be sent through to doctors who have no involvement in the patient's care. 2. The Inquest heard evidence that radiologists can now drop reports into a folder where there are unexpected and significant radiological findings. There is a specific folder relating to the finding of abdominal aortic aneurysms. The radiologist however raised a concern at the Inquest that it is not easily apparent to the reporting radiologist that the report has reached the appropriate clinician. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of the results-routing system to prevent sending results to uninvolved doctors
Wider context from the report
“1. The Inquest heard evidence that the current CERNER system does not always ensure that results are sent through to the referring clinician. The Inquest heard evidence of a “quirk” in the system whereby results will be sent through to doctors who have no involvement in the patient's care. 2. The Inquest heard evidence that radiologists can now drop reports into a folder where there are unexpected and significant radiological findings. There is a specific folder relating to the finding of abdominal aortic aneurysms. The radiologist however raised a concern at the Inquest that it is not easily apparent to the reporting radiologist that the report has reached the appropriate clinician. ”
Open source report
25 Feb2019
East London
Concerns raised8
1. Failure to assess and communicate night-time falls risk at discharge
2. Failure to reconsider the care plan when night-time circumstances changed
3. Failure to provide falls-management equipment before discharge
1. Failure to take family views into account in discharge planning
2. Lack of a discharge care plan for care provision during the trial period
3. Failure to agree key care-plan aspects with community carers before discharge
4. Insufficient care support for a safe discharge home
5. Unavailability of community support arrangements
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Brenda Kathleen GOWAN · 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

Brenda Gowan suffered a moderately severe stroke and was discharged home for a trial period despite being assessed as requiring 24-hour supervision and being at risk of falls. Five days after discharge, she fell near her bed in the early hours and sustained catastrophic head injuries, from which she died. Concerns included insufficient care and equipment, inadequate advice and assessment of night-time falls risk, and failure to reconsider the care plan after the family reported that she was getting up frequently at night.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess and communicate night-time falls risk at discharge
Wider context from the report
“(2) Brenda was at risk of falling at night. There is no evidence that the risk was fully assessed on discharge from hospital and no evidence of the family being provided with advice on how to manage the risk. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to reconsider the care plan when night-time circumstances changed
Wider context from the report
“(3) The discharge plan was based upon Brenda being settled at night time. When the family reported that this had changed and that Brenda was “up a lot” – the care plan for Brenda should have been re-considered. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide falls-management equipment before discharge
Wider context from the report
“(5) The equipment required for managing the risk of falls had not been provided prior to Brenda’s fall (5 days after discharge from hospital). ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to take family views into account in discharge planning
Wider context from the report
“(1) Brenda was discharged home, less than 3 weeks after a moderately severe stroke, for a “trial period”. She required 24 hour supervision, but only 4 hours of social care was provided. Her family were expected to provide 20 hours of care. Her family did not consider that adequate steps had been taken to ensure that systems were in place to allow Brenda’s safe return home. The family were concerned about the amount of care support in place; the equipment required and the access to community services. There is no evidence that the family’s views were taken into account by the discharging team. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of a discharge care plan for care provision during the trial period
Wider context from the report
“(6) There was no such care plan in place address key aspects such as how care would be provided during the trial period. Such a plan could include the risks identified and how they were to be managed; the equipment required and ensuring that it was provided, installed and those providing the care trained in its use and ensuring that community support is available. Such a plan should be discussed with the community carers (family in this case) and key aspects agreed with them before discharge. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to agree key care-plan aspects with community carers before discharge
Wider context from the report
“(6) There was no such care plan in place address key aspects such as how care would be provided during the trial period. Such a plan could include the risks identified and how they were to be managed; the equipment required and ensuring that it was provided, installed and those providing the care trained in its use and ensuring that community support is available. Such a plan should be discussed with the community carers (family in this case) and key aspects agreed with them before discharge. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient care support for a safe discharge home
Wider context from the report
“(1) Brenda was discharged home, less than 3 weeks after a moderately severe stroke, for a “trial period”. She required 24 hour supervision, but only 4 hours of social care was provided. Her family were expected to provide 20 hours of care. Her family did not consider that adequate steps had been taken to ensure that systems were in place to allow Brenda’s safe return home. The family were concerned about the amount of care support in place; the equipment required and the access to community services. There is no evidence that the family’s views were taken into account by the discharging team. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of community support arrangements
Wider context from the report
“(4) There were no community support arrangements in place for the family to access, as the OT services had no contractual arrangement in place with Brenda’s registered GP. ”
Open source report
18 Jan2019
Inner North London
Concerns raised1
1. Use of cuff devices in non-emergency procedures contrary to manufacturer IFU limits
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Norman Joseph Pirie · 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

Norman Joseph Pirie died on 5 October 2018 following a major haemorrhage and cardiac arrest after open surgery was required when an endovascular cuff device failed to deploy during an elective procedure. The device had been used at a 68-degree angle, beyond the manufacturer’s maximum permitted angle of 60 degrees. The principal concern was that such devices were being used outside manufacturer instructions in non-emergency procedures, increasing the risk of deployment failure and urgent open surgery with a high risk of death.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Use of cuff devices in non-emergency procedures contrary to manufacturer IFU limits
Wider context from the report
“I am concerned that: (a) Cuff devices are being used in non-emergency procedures in a way that is contrary to the IFU limits set down by the manufacturers of those devices; and (b) In such circumstances, this increases the risk that the devices do not deploy as expected, as a result of which remedial open surgery has to be urgently performed which carries with it a high risk of death. ”
Open source report
16 Nov2018
Inner North London
Concerns raised7
1. Delays in alerting hospital security when an inpatient is missing
2. Failure to retain and make available drug charts
3. Lack of clarity in the missing-person policy
1. Failure to record communications about contacting security for missing patients
2. Failure to communicate suspected illicit drug use and associated ward-leaving risk to nursing staff
3. Failure to conduct effective searches for missing patients on the ward
4. Lack of nursing care planning for patients at increased risk from illicit drug use
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Dawn Patricia GILL · 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

Dawn Patricia Gill, a long-term drug user, died from a methadone overdose after taking illicit drugs while in the Royal London Hospital alongside prescribed medication. Concerns included the absence of a nursing care plan addressing her drug use, the loss of her drug chart, failures to detect her in her room during searches, and confusion about when to alert hospital security after she was thought to be missing.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in alerting hospital security when an inpatient is missing
Wider context from the report
“4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward. There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note. There seemed to be a lack of clarity. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to retain and make available drug charts
Wider context from the report
“2. Ms Gill was prescribed methadone in hospital and died of a methadone overdose, but her drug chart was not available at inquest and appears to have been lost. If the drug chart was lost during her life, then that has implications for her care. If it was lost after her death, then that would not have affected care but, how ever innocent the true explanation, it leaves the trust open to an accusation of trying to cover up evidence. When ever it was lost, its absence is very disappointing. The Barts legal representative at inquest was unaware until I asked to see it on the day that it was missing. He had taken on the file from a colleague a week earlier. He noted that my coroner’s officer had not provided the trust with the report of the post mortem examination until the day before, so he had not known that death was the result of a methadone overdose. This was because the trust had not provided the statements requested. However, Ms Gill had been found in her room on the ward surrounded by drug paraphernalia, so it would have been evident to staff at the outset that drug toxicity was a potential cause of death. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity in the missing-person policy
Wider context from the report
“4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward. There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note. There seemed to be a lack of clarity. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record communications about contacting security for missing patients
Wider context from the report
“4. Ms Gill was thought to have left the ward for a cigarette some time before 12.30am, though she was not actually seen leaving. She was wearing her night things. When her absence was discovered, hospital security personnel were not alerted. They could have viewed the CCTV. If they had done so, they would have realised that she had never left the ward. Hopefully, this would have prompted a redoubling of the search effort of the ward. There was confusion about the circumstances when the missing person policy should be followed. I was told that the policy is not clear. The responsible nurse said it was in the back of her mind to contact security and she did not know why she had not. The sister in charge said that she would not contact security for the first two hours. The director of nursing said the contact should be immediate. The clinical site manager and the responsible nurse disagreed about the nature of the conversation between them regarding contacting security. Neither of them had made a note. There seemed to be a lack of clarity. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate suspected illicit drug use and associated ward-leaving risk to nursing staff
Wider context from the report
“1. Ms Gill was a long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital. However, while she was in hospital, no nursing care plan was made to take this into account, for example by acknowledging the higher risk that it brought. One nursing sister was not even aware that staff suspected Ms Gill of going off the ward to take drugs. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct effective searches for missing patients on the ward
Wider context from the report
“3. Ms Gill’s room was described as having been searched on numerous occasions overnight, by more than one person, the first time approximately half an hour after she had last been seen, yet her presence under clothing on the floor was not detected until 10am the following day. I heard nursing evidence that Ms Gill could not possibly have been in her room at the time of searching, but with the benefit of the CCTV it is now evident that she was. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of nursing care planning for patients at increased risk from illicit drug use
Wider context from the report
“1. Ms Gill was a long term drug user and, based on her history, was likely to take illicit drugs whether she was in or out of hospital. However, while she was in hospital, no nursing care plan was made to take this into account, for example by acknowledging the higher risk that it brought. One nursing sister was not even aware that staff suspected Ms Gill of going off the ward to take drugs. ”
Open source report
14 Mar2018
Inner North London
Concerns raised2
1. Failure to communicate genetic test results accurately
2. Failure of genetic testing to detect a pathogenic gene mutation
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Freddie Oliver DOBINSON-EVANS · 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

Freddie Dobinson-Evans had undiagnosed Dravet syndrome and died from causes recorded as post-cardiac arrest syndrome and Dravet syndrome. A genetic test report was communicated to his father as “absolutely normal”, although Freddie had a pathogenic SCN1A gene mutation; the report identified the potential for significant consequences for another child.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate genetic test results accurately
Wider context from the report
“Following a testing request made for Freddie on 20 February 2017, a report was issued from the laboratory at Great Ormond Street Hospital on 7 June 2017. It was headlined: No clearly pathogenic variant detected. Diagnosis not confirmed. ████████ spoke to Freddie’s father the following day and told him that Freddie’s genetic test results were “absolutely normal”. In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene and died as a result of Dravet Syndrome. By the time the report was issued, Freddie had already sadly died and so of course the misdiagnosis had no consequences for him, but such a situation could have significant consequences for another child. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of genetic testing to detect a pathogenic gene mutation
Wider context from the report
“Following a testing request made for Freddie on 20 February 2017, a report was issued from the laboratory at Great Ormond Street Hospital on 7 June 2017. It was headlined: No clearly pathogenic variant detected. Diagnosis not confirmed. ████████ spoke to Freddie’s father the following day and told him that Freddie’s genetic test results were “absolutely normal”. In fact, Freddie did have a pathogenic gene mutation in the SCN1A gene and died as a result of Dravet Syndrome. By the time the report was issued, Freddie had already sadly died and so of course the misdiagnosis had no consequences for him, but such a situation could have significant consequences for another child. ”
Open source report
12 May2017
Inner North London
Concerns raised13
1. Insufficient first-aid training for staff supervising pupils
2. Failure to confirm replacement medication and complete its dose in the action plan
3. Provision of inappropriate emergency asthma inhalers without spacers
1. Failure to verify school medication directly during medication reviews
2. Failure to provide and follow immediate adrenaline auto-injector administration guidance
3. Failure of school staff to familiarise themselves with pupils’ care plans
4. Failure to identify poor asthma control and excessive inhaler prescribing for specialist review
5. Failure to maintain accurate allergy action plans with medication-use instructions
6. Failure to include a school representative in medication reviews
7. Failure to maintain identical current care-plan copies across care settings
8. Emergency-services contact procedures causing avoidable delay
9. Failure to provide effective refresher training and information sharing for trained staff
10. Lack of follow-up review tracking after replacement medication is requested
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Nasar AHMED · 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

Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient first-aid training for staff supervising pupils
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to confirm replacement medication and complete its dose in the action plan
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Provision of inappropriate emergency asthma inhalers without spacers
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to verify school medication directly during medication reviews
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide and follow immediate adrenaline auto-injector administration guidance
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of school staff to familiarise themselves with pupils’ care plans
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify poor asthma control and excessive inhaler prescribing for specialist review
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain accurate allergy action plans with medication-use instructions
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to include a school representative in medication reviews
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain identical current care-plan copies across care settings
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Emergency-services contact procedures causing avoidable delay
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide effective refresher training and information sharing for trained staff
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of follow-up review tracking after replacement medication is requested
Wider context from the report
“The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? 1. While staff at Nasar’s school were waiting for an ambulance, they asked for advice from the call operator about whether to administer his EpiPen. They were put through to a paramedic, who advised not to use it, I think because the classic signs of anaphylaxis were not obvious. However, the firm view expressed to me at inquest by Nasar’s respiratory paediatrician was that, if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. He explained that any harm caused by giving intra muscular adrenaline from an auto-injector in this situation is likely to be minimal, even if it proves not to have been needed, whereas the good if it is needed is potentially lifesaving. 1. The picture presented by Nasar to his respiratory paediatrician did not accord, the consultant discovered at inquest, with that given to Nasar’s general practitioner. Nasar reported to his consultant that he was experiencing few symptoms, and he did extremely well in his last lung function test. Yet his GP found Nasar’s asthma control score to be 14 out of 25, which is poor; and his GP was prescribing 30 inhalers a year, the necessity for which is well recognised as being a risk factor for death. Nasar should have seen his consultant again. There must be a way of identifying a child in his position. For instance, could there be an automatic flag raised if excess medication is prescribed? 2. The asthma pump in Nasar’s medication box at school was an Accuhaler, which I heard from his respiratory consultant is inappropriate for an emergency situation such as this, and would not have assisted him. Moreover, the appropriate inhaler should have been accompanied by a spacer for best administration. I wonder whether there is a widespread lack of understanding of the best treatment in this situation? 3. The school nurse had updated Nasar’s care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before, the allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. There must be a way of ensuring that the care plan is accurate and up to date, and that there are identical copies stored at home, school, the GP surgery and within the hospital records. 4. Even if the correct action plan had been used, it does not give the instruction that if a person has an adrenaline auto-injector and: - has any respiratory compromise, or - there is a loss of consciousness, or - if there is doubt, then the correct and potentially lifesaving course of action, regardless of the particular constellation of signs and symptoms, is to use the EpiPen and to use it immediately. This was the very firm view of Nasar’s respiratory consultant. Is there a way of disseminating this advice more widely? 1. Although Nasar’s mother was present for Nasar’s medication review conducted by the school nurse, there was no school representative such as the year learning manager there for the meeting, contrary to school policy. 2. The school nurse identified Nasar’s medication as being out of date, and asked that in-date medication be provided, but there was no robust system for ensuring that he was booked in for further review when this was provided. 3. Although all staff at the Bow School were encouraged to familiarise themselves with pupils’ care plans, they often did not unless there was a school excursion. The internal exclusion room (IER) supervisor had not done this for the pupils in the IER. Even the deputy headteacher, who had in the past taught Nasar, did not know about Nasar’s food allergies or the fact that he had a care plan and allergy action plan when he placed Nasar in the IER. 4. Not everyone involved in trying to help Nasar was first aid trained, most notably not the learning assistant who was supervising the IER. She said that she would not have thought of looking for and retrieving his care plan. 5. Even those members of staff who were first aid trained it seemed might benefit from additional and/or more frequent training. One member of staff did not share with others the fact that Nasar had asked for this asthma pump. Another looked at his individual healthcare plan, but could not remember looking at the allergy action plan. 6. One member of staff forgot Nasar’s name. It is of course not possible for members of staff to remember the names of all pupils, but perhaps typed forms accompanied by a photograph might help? 7. Although not followed in this instance, I heard that the school policy dictates that the headteacher’s personal assistant should be contacted to telephone the emergency services. Such a stipulation would surely be guaranteed to add delay. 1. When the school nurse (employed by Compass Wellbeing) conducted a review of Nasar’s medication in May 2016, he did not have the medication stored in school in front of him at the time, but relied on its description by a school receptionist. 2. Although Nasar’s mother was present for the review, there was no school representative, such as the year learning manager (head of year), there for the meeting. 3. The school nurse then updated the care plan by using the allergy action plan (mild-moderate with asthma) instead of the correct one used the year before allergy action plan (severe with asthma). This meant that Nasar’s medication box contained an EpiPen without any description of when or how to use it. 4. He identified the medication as being out of date, and asked that in-date medication be provided, but did not diary forward to the following week to ensure that current medication was now in the box. This meant that he also did not complete the action plan with the dose of the relevant medication. These points raise issues about the actions of this particular nurse and potentially of other nurses in this role in other schools. ”
Open source report
20 Apr2017
London (East)
Concerns raised2
1. Gaps in the ICU Clinical Fellow rota
2. Lack of administrative support in the ICU
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr Errol Mann · 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

Mr Errol Mann was admitted to hospital with suspected hyperosmolar hyperglycaemia, sepsis and pulmonary embolism, and later suffered a fatal pulmonary embolism on 7 August 2015. The report identified failures to investigate or exclude pulmonary embolism and to ensure consistent VTE prophylaxis, and raised concerns about inadequate ICU staffing affecting patient care.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Gaps in the ICU Clinical Fellow rota
Wider context from the report
“Evidence was given by a Consultant in ITU that the ICU department was extremely short staffed during the week of 3rd – 6th August 2015. The Consultant confirmed that there was no administrative support and there were several gaps in the rota for Clinical Fellows. She confirmed that because of staffing issues, the time of the Consultant on duty was not fully devoted to clinical care. She gave evidence that the lack of staff directly affected the care provided to Mr Mann. She confirmed that the concerns were escalated to the Medical Director at that time but that no additional manpower was provided. When asked whether staffing on ICU was still a problem and whether this still affects patient safety, the Consultant confirmed that staffing issues vary depending upon the time of year. She stated however that “we have never been fully recruited on the clinical fellow front. There are still gaps in the rota”. She stated that even as of the 31st March 2017 gaps continue and as long as there are gaps on the rota, patient care is affected. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of administrative support in the ICU
Wider context from the report
“Evidence was given by a Consultant in ITU that the ICU department was extremely short staffed during the week of 3rd – 6th August 2015. The Consultant confirmed that there was no administrative support and there were several gaps in the rota for Clinical Fellows. She confirmed that because of staffing issues, the time of the Consultant on duty was not fully devoted to clinical care. She gave evidence that the lack of staff directly affected the care provided to Mr Mann. She confirmed that the concerns were escalated to the Medical Director at that time but that no additional manpower was provided. When asked whether staffing on ICU was still a problem and whether this still affects patient safety, the Consultant confirmed that staffing issues vary depending upon the time of year. She stated however that “we have never been fully recruited on the clinical fellow front. There are still gaps in the rota”. She stated that even as of the 31st March 2017 gaps continue and as long as there are gaps on the rota, patient care is affected. ”
Open source report
16 Dec2016
Inner North London
Concerns raised8
1. Failure to ensure functioning delivery of patient-controlled analgesia
2. Unavailability of computer systems delaying access to blood results
3. Failure to record clinically relevant discussions and diagnostic information in medical notes
1. Failure to record clinical attendance and examination in medical notes
2. Failure to review blood results promptly before emergency transfer
3. Failure to recognise the limitations of imaging in assessing active bleeding
4. Delays in transferring patients requiring emergency specialist stroke care
5. Failure to investigate discrepancies in recorded and observed patient observations
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Lita SERKES · 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

Lita Serkes underwent surgery at Whipps Cross Hospital on 22 July 2016, suffered a stroke the following morning, was transferred to the Royal London Hospital later that day, and died on 24 July. The concerns included discrepancies in observations and clinical records, delay in transfer for specialist stroke care, undelivered pain relief, and delayed recognition and assessment of a significant bleed.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure functioning delivery of patient-controlled analgesia
Wider context from the report
“4. Patient controlled administration of pain relief was arranged for Mrs Serkes, but she remained in pain. It was quite some time before it was recognised that the device was not connected and so was not delivering any analgesia. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of computer systems delaying access to blood results
Wider context from the report
“6. The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre. However, later in evidence he agreed that the scans simply showed a collection of blood and could not demonstrate whether the bleeding was active. When I asked about the haemoglobin, he responded that at 3.04pm that afternoon, it was recorded as 7 (he said 7, not 70), having dropped from a normal level of 120. He explained that this result might have been available earlier, but the computers were down in the middle of the day. After further discussion, the surgeon told me that, given the 8cm haematoma he had diagnosed at the beginning of the day (Saturday, 23 July), he now believes that more efforts should have been made to review the blood results earlier, and in any event before Mrs Serkes was transferred to the Royal London Hospital. He said that if he had considered the blood results earlier in the day, he would have recognised a much bigger bleed than he actually appreciated. He said that he would probably have advised a further laparotomy – though of course there is no way of knowing if Mrs Serkes would have survived that. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record clinically relevant discussions and diagnostic information in medical notes
Wider context from the report
“2. When Mrs Serkes’ treating consultant gynaecological surgeon attended her at 10.30am on Saturday, 23 July, he formed the impression that he was the first person to diagnose the stroke. In fact, her son and another doctor had already discussed the stroke, and her son was under the impression that they were simply waiting for an ambulance to transfer to the Royal London Hospital. (He was already making arrangements to drive his father there.) None of this is recorded in the medical notes. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record clinical attendance and examination in medical notes
Wider context from the report
“5. Mrs Serkes’ surgeon went to the Royal London Hospital to see her at 10.30pm on Saturday, 23 July. He described in court palpating her abdomen and there being no rigidity, guarding, or further distension. However, he made no record in the medical notes of his attendance and examination. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to review blood results promptly before emergency transfer
Wider context from the report
“6. The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre. However, later in evidence he agreed that the scans simply showed a collection of blood and could not demonstrate whether the bleeding was active. When I asked about the haemoglobin, he responded that at 3.04pm that afternoon, it was recorded as 7 (he said 7, not 70), having dropped from a normal level of 120. He explained that this result might have been available earlier, but the computers were down in the middle of the day. After further discussion, the surgeon told me that, given the 8cm haematoma he had diagnosed at the beginning of the day (Saturday, 23 July), he now believes that more efforts should have been made to review the blood results earlier, and in any event before Mrs Serkes was transferred to the Royal London Hospital. He said that if he had considered the blood results earlier in the day, he would have recognised a much bigger bleed than he actually appreciated. He said that he would probably have advised a further laparotomy – though of course there is no way of knowing if Mrs Serkes would have survived that. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise the limitations of imaging in assessing active bleeding
Wider context from the report
“6. The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre. However, later in evidence he agreed that the scans simply showed a collection of blood and could not demonstrate whether the bleeding was active. When I asked about the haemoglobin, he responded that at 3.04pm that afternoon, it was recorded as 7 (he said 7, not 70), having dropped from a normal level of 120. He explained that this result might have been available earlier, but the computers were down in the middle of the day. After further discussion, the surgeon told me that, given the 8cm haematoma he had diagnosed at the beginning of the day (Saturday, 23 July), he now believes that more efforts should have been made to review the blood results earlier, and in any event before Mrs Serkes was transferred to the Royal London Hospital. He said that if he had considered the blood results earlier in the day, he would have recognised a much bigger bleed than he actually appreciated. He said that he would probably have advised a further laparotomy – though of course there is no way of knowing if Mrs Serkes would have survived that. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in transferring patients requiring emergency specialist stroke care
Wider context from the report
“3. The decision was made by, at the latest 10.30am, but quite possibly an hour before then, to transfer Mrs Serkes to the Royal London Hospital for specialist care, but transfer was not effected until 2.07pm. Stroke is an emergency. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to investigate discrepancies in recorded and observed patient observations
Wider context from the report
“1. The Whipps Cross medical notes record normal observations, most specifically that Mrs Serkes was “alert” at 9.50am on Saturday, 23 July 2016. However, by that time, her son had been at her bedside for nearly an hour and had himself realised that Mrs Serkes had suffered a stroke. He saw no nurse conducting any observations at this time. Some five months on, no member of staff has yet addressed this discrepancy with the nurse who recorded the observations. ”
Open source report
2 Sep2016
East London
Concerns raised4
1. Failure to consider out-of-hours medical cover in internal investigations
2. Delays in securing timely medical review
3. Inadequate out-of-hours medical staffing
1. Loss of patient observation records
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs Catherine Dinnen · 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

Mrs Catherine Dinnen was admitted to hospital after left-sided weakness and suspected stroke, later developing vomiting, diarrhoea and breathing difficulties. She suffered a cardiorespiratory arrest on 27 August 2013 and was pronounced deceased that day. The principal outstanding concern was the timeliness of obtaining a medical review, in the context of reported difficulties securing out-of-hours medical attendance and concerns about staffing levels.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider out-of-hours medical cover in internal investigations
Wider context from the report
“2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in securing timely medical review
Wider context from the report
“2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate out-of-hours medical staffing
Wider context from the report
“2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Loss of patient observation records
Wider context from the report
“2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”
Open source report
26 Jul2016
Inner North London
Concerns raised11
1. Failure to complete nursing sections of post-falls checklists
2. Failure to conduct required neurological observations after falls
3. Failure to consider intracranial bleeding when assessing new confusion after a fall
1. Failure to draft falls prevention care plans after identified increased falls risk
2. Failure to record and identify the authorship of investigation findings
3. Unavailability of Datix reporting access for agency nurses
4. Failure to ensure communication between doctors and primary nurses after falls
5. Failure to ensure hospital investigations include appropriate clinical expertise
6. Lack of clarity about primary nursing responsibility
7. Inaccurate recording of walking aids in falls risk assessments
8. Delay in escalating falls to the responsible consultant
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Margaret Emily TUCK · 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

Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete nursing sections of post-falls checklists
Wider context from the report
“3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed. The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total. In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after. The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct required neurological observations after falls
Wider context from the report
“3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed. The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total. In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after. The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider intracranial bleeding when assessing new confusion after a fall
Wider context from the report
“4. Mrs Tuck had been alert and orientated upon admission on 13 October, and remained so until the afternoon of 16 October, despite her persistently low sodium. When a haematology registrar found her to be confused however, an assumption was made that this confusion was the result of low sodium. It may be that this doctor was unaware of the falls and as a consequence did not consider the possibility that the confusion had been caused by a bleed, but this was the time when a CT scan was indicated. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to draft falls prevention care plans after identified increased falls risk
Wider context from the report
“1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted. And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame, and it was while reaching for this Zimmer frame that she fell on the acute admissions unit. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to record and identify the authorship of investigation findings
Wider context from the report
“7. The hospital investigation into the circumstances surrounding the death was conducted by a ward manager. The thinking behind having a senior nurse explore questions of nursing care is obvious. However, the report also commented on aspects of medical care that the report author freely admitted in court were outside her area of expertise. In terms of learning lessons for the future, this seems sub optimal. Clinicians giving evidence disagreed with some of the report’s conclusions, but I was not able to explore those areas with the true originator, because the views had come from a consultant who the author had consulted informally. The report was not recorded as being co-authored, and the doctor who had been asked for his view was not an oncologist. The author thought on reflection that an oncologist would have been better placed to comment on the medical management. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of Datix reporting access for agency nurses
Wider context from the report
“6. I heard at inquest that agency nurses are unable to input into the trust reporting system (Datix). Bearing in mind that at times 50% of the ward staff are agency nurses, the matron who gave evidence suggested that agency nurses could be given a card similar to that given to locum doctors, so that they would not have to trouble their colleagues to help them make such reports. She was unsure whether this idea was going to be taken forward. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure communication between doctors and primary nurses after falls
Wider context from the report
“3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed. The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total. In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after. The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure hospital investigations include appropriate clinical expertise
Wider context from the report
“7. The hospital investigation into the circumstances surrounding the death was conducted by a ward manager. The thinking behind having a senior nurse explore questions of nursing care is obvious. However, the report also commented on aspects of medical care that the report author freely admitted in court were outside her area of expertise. In terms of learning lessons for the future, this seems sub optimal. Clinicians giving evidence disagreed with some of the report’s conclusions, but I was not able to explore those areas with the true originator, because the views had come from a consultant who the author had consulted informally. The report was not recorded as being co-authored, and the doctor who had been asked for his view was not an oncologist. The author thought on reflection that an oncologist would have been better placed to comment on the medical management. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity about primary nursing responsibility
Wider context from the report
“2. There was confusion about which nurse had primary responsibility for Margaret Tuck. Recourse was had to the bed diaries, but there was further discussion in court about whether the nurses had been sharing care. Such a lack of clarity seems undesirable. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate recording of walking aids in falls risk assessments
Wider context from the report
“1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted. And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame, and it was while reaching for this Zimmer frame that she fell on the acute admissions unit. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delay in escalating falls to the responsible consultant
Wider context from the report
“5. The consultant in charge of Mrs Tuck’s care did not learn of the 15 October fall until 17 October. It seems that the junior doctors on her ward did not bring this to her attention. Mrs Tuck’s nephew, however, was gravely concerned to find his auntie unable to communicate, and brought this to the attention of the consultant. The consultant asked him “What do you want me to do, scan her brain?” and he replied “I think that would be a very good idea”. Hence a CT scan was conducted on the afternoon of 17 October. ”
Open source report
26 Feb2016
East London
Concerns raised1
1. Lack of clear, accessible guidance for ward staff on opioid risks and side effects in orthogeriatric patients
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mr Devindar Lal Seth · 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

Mr Devindar Lal Seth, aged 94, suffered a fall, fractured his hip and underwent surgery before developing opiate toxicity after postoperative pain treatment. The opiate toxicity was not identified by ward staff until family members raised concerns, and there was also a delay in ventilation after he suffered aspiration. The report identified a lack of clear guidance for ward staff about the risks and side effects of opiate medication in older orthopaedic patients.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear, accessible guidance for ward staff on opioid risks and side effects in orthogeriatric patients
Wider context from the report
“During the course of the evidence, it was confirmed that there is no clear guidance available to ward staff on the risk of opiate medications in orthogeriatric patients and side effects to look out for. I have been provided with the WHO Analgesic Ladder and the Guidelines for Acute Pain Management in Adults. The guidelines provide substantial amounts of information in relation to the contra-indications of NSAIDs. The only information relating to opioids in the Guidelines is that regular opioids can cause constipation. It is clear that none of the ward staff in this case recognised the effect that the opiate medication was having upon Mr Seth and I consider that it would be helpful for easily accessible guidance to be available for both nursing and medical staff. ”
Open source report
22 Dec2015
Inner North London
Concerns raised4
1. Delays in performing and reporting planned CT scans
2. Failure to seek surgical consultation following concerning CT findings
3. Failure to use the modified obstetric early warning score tool appropriately to identify sepsis
1. Failure to escalate concerning postoperative symptoms for CT imaging
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Shalini GANESH-RAM · 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

Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in performing and reporting planned CT scans
Wider context from the report
“2. When a plan was made at 1.30pm on Sunday the 9ᵗʰ for a CT scan, this was not performed and reported on until approximately 7.30pm that evening. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek surgical consultation following concerning CT findings
Wider context from the report
“3. Several obstetric registrars were aware that the CT scan revealed a large volume in the peritoneum, but did not then seek a surgical consult, perhaps because the radiology registrar described no bowel wall defect having been demonstrated. I heard that the report of the radiology consultant the following day was felt to provide a clearer warning of perforation. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to use the modified obstetric early warning score tool appropriately to identify sepsis
Wider context from the report
“4. Your own serious incident report has already identified other issues around service delivery, most particularly that the modified obstetric early warning score tool was not used appropriately to identify Ms Ganesh-Ram’s sepsis. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate concerning postoperative symptoms for CT imaging
Wider context from the report
“1. Whilst Ms Ganesh-Ram underwent many consultant reviews, a raised pulse, abdominal pain and lack of urine output on Saturday the 8ᵗʰ and the morning of Sunday the 9ᵗʰ did not prompt a CT scan. Reassurance was drawn from the fact that her pain was controlled, but I wonder whether this was false reassurance, given that it was controlled by Oramorph, dihydrocodeine and paracetamol. (Abdominal distension was not noted until the middle of the day on Sunday the 9ᵗʰ, probably because it was masked by a high body mass index.) ”
Open source report
19 Feb2015
London Inner (North)
Concerns raised2
1. Failure to maintain accurate patient addresses in medical notes
2. Inappropriate early discharge home following MDT meetings
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

John DACK · 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

John Dack sustained fractures to both ankles, underwent procedures and was discharged home unable to weight bear without the planned follow-up. He later developed an infected left ankle with osteomyelitis and died on 24 September 2014 after hospital treatment. The report’s principal concern was that an incorrect address in his medical notes prevented follow-up despite notifications from his daughter; it also raised concern about early discharge home after the MDT meeting.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain accurate patient addresses in medical notes
Wider context from the report
“Mr Dack was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff of this on two separate occasions. What seems at first blush to be a relatively unimportant administrative matter can therefore have serious consequences. I heard from the surgeon treating Mr Dack that this has happened before with other patients. It seems that this part of the system of administration would benefit from review. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inappropriate early discharge home following MDT meetings
Wider context from the report
“(No witness was able to offer any suggestions for changes to the hospital system that might prevent inappropriate early discharge home following MDT meeting on another occasion.) ”
Open source report
11 Feb2015
Inner North London
Concerns raised3
1. Delays in consultant review for patients with impaired consciousness
2. Patients being expected to obtain private nursing support to receive appropriate hospital care
3. Failure to provide timely continence and personal care assistance
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Rufjan BIBI · 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

Rufjan Bibi, who had Parkinson’s disease and a previous subdural haematoma, fell at Mile End Hospital on 1 July 2014 and hit her head. The report raised concerns about inadequate nursing assistance and personal care, a suggestion that the family privately engage a nurse, and a five-hour delay before consultant review after the fall.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in consultant review for patients with impaired consciousness
Wider context from the report
“3. Having been found at just before 2pm, Ms Bibi did not receive a consultant review until 7pm, and arrangements were then made for her transfer to the Royal London Hospital. During the intervening five hours, she had a Glasgow Coma Score of ten, yet no witness was able to explain the delay. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Patients being expected to obtain private nursing support to receive appropriate hospital care
Wider context from the report
“2. Family members were also unhappy that a nurse had told them that, if they wanted closer care for Ms Bibi, then they could engage a nurse privately to come to the hospital to look after her. If this is seriously being suggested as the way for a patient in an NHS hospital to receive appropriate care, then it is worrying indeed for all patients. If it is not seriously being suggested, then it seems unkind and unnecessary. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide timely continence and personal care assistance
Wider context from the report
“1. Ms Bibi’s family told me at inquest that when they came to visit Ms Bibi, which they did daily, they often found her in need of changing (she was incontinent), and then had difficulty obtaining prompt nurse assistance. They even found her with faeces in her hair. Whilst this did not impact upon the outcome, it made me question the evidence I had been given about frequent nursing contact, in a way that I would not otherwise have done. (And of course, however busy staff are, it is not a situation that any of us would want for our loved ones.) ”
Open source report
20 Jan2015
London (East)
Concerns raised7
1. Failure to ensure communication of requests for clinically required tests
2. Delays in repeating arterial blood gas tests
3. Failure to provide medical review
1. Failure to provide close monitoring of patients at high risk of acute deterioration
2. Failure of handover of responsibilities and tasks between day and night shifts
3. Insufficient nursing observations of ward patients
4. Failure to repeat blood tests within the required timeframe
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs Awa Jeng · 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

Mrs Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed to her death.

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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure communication of requests for clinically required tests
Wider context from the report
“3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level. 4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in repeating arterial blood gas tests
Wider context from the report
“2. The ITU consultant gave a clear direction to the FY2 on Tayberry Ward during the afternoon of the 19th December 2013 that the arterial blood gases should be repeated that evening and she should be checked for signs of pulmonary oedema and fluid overload. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide medical review
Wider context from the report
“5. Mrs Jeng was also not monitored appropriately on the ward on the evening of 19 December. There was no medical review and insufficient nursing observations. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide close monitoring of patients at high risk of acute deterioration
Wider context from the report
“1. Mrs Jeng was at high risk of suffering life threatening acute renal failure. Her regular dialysis was due on the 19th December 2013. Bearing in mind the recent trauma and necessary surgery, an acute deterioration in her condition should have been foreseeable. In the circumstances, she required close monitoring. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure of handover of responsibilities and tasks between day and night shifts
Wider context from the report
“6. I note that the Trust’s internal investigation raised concerns in relation to the handover of responsibilities and tasks between day and night shifts. There is however currently no clear action to address this concern. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Insufficient nursing observations of ward patients
Wider context from the report
“5. Mrs Jeng was also not monitored appropriately on the ward on the evening of 19 December. There was no medical review and insufficient nursing observations. ”
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 London Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to repeat blood tests within the required timeframe
Wider context from the report
“3. The blood tests were not repeated until the following morning when they had deteriorated to a life threatening level. 4. It was not clear from the evidence why the blood tests were not repeated. The FY2 did write a retrospective note confirming that she had asked the on-call doctor to perform the test. Evidence from the on-call doctor denied that this information was passed on to her. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised3

Lack of assigned responsibility for ensuring that patient notes are sent to external appointments

Failure to ensure that patient notes accompany external appointments

Poor maintenance of PICC lines

Concerns raised5

Failure of investigation and inquest reporting to identify enoxaparin use and missing clinical justification

Failure to prevent falls among high-risk hospital patients

Inadequate recording of clinical factors supporting enoxaparin prescribing

Failure to assess intracranial damage before prescribing and administering enoxaparin

Delays in urgently requested CT head imaging

Concerns raised3

Failure to verify the most recent clinical observations and PEWS score before discharge

Failure of nursing and paediatric medical staff to communicate factors affecting patients and plans to resolve them before discharge

Pressurised Paediatric Emergency Department environment caused by high patient numbers and severe symptom acuity

Concerns raised4

Failure to account for learning disability when taking a clear clinical history

Failure to provide effective referral communication and formal handover to the surgical team

Failure to consider and act on dangerously elevated creatinine results before discharge

Failure to review clinical records before accepting a surgical referral

Concerns raised7

Failure to consider breaking up the 1:1 carer shift

Insufficient involvement of family in learning disability care recommendations

Lack of an itemised property and medication list

Failure to place alerts or flags on records about patient complexities and risks

Failure to keep hourly observations by the 1:1 carer

Failure to implement action and learning from self-harming incidents

Failure of the allocated nurse to complete a risk assessment

Concerns raised6

Failure to use targeted factual communication between surgical and anaesthetic teams during surgery

Failure to communicate a surgeon's reasons for leaving surgery to the surgical team

Failure to effectively monitor when a surgeon leaves theatre

Lack of a system to assess the appropriateness of a surgeon leaving surgery

Lack of a formal preoperative risk assessment tool requirement

Failure to record a surgeon's early departure in the surgical notes

Concerns raised2

Inaccurate recording of MUST malnutrition risk scores

Failure to assess all patients for malnutrition risk using the MUST score system