Concerns raised 1 Failure to use the specialist National Early Warning Score matrix for prenatal women throughout the hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Dhananji Denawawake Dona · 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 Dhananji Denawawake Dona attended hospital while pregnant, experiencing bleeding, abdominal pain, sepsis and a miscarriage. There was a delay in her assessment, and the sepsis screening tool and specialist National Early Warning Score matrix for prenatal women were not used in the A&E department. She deteriorated and died on 2 October 2024; the principal concern was that the specialist warning-score matrix was not used throughout the hospital and there were no plans to introduce it within a reasonable timescale.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use the specialist National Early Warning Score matrix for prenatal women throughout the hospital
Wider context from the report “1. That although the specialist National Early Warning Score matrix for prenatal women, should be used within the whole of the hospital , it still was not , and there were no plans to introduce this within a reasonable timescale .
” Open source report
Concerns raised 5 Failure of PSII actions to achieve effective safety improvement View source Failure of continuous training to achieve effective learning View source Lack of national guidelines on severe invasive soft tissue infections View source National lack of knowledge of severe invasive soft tissue infections View source Failure to maintain an audit trail for omitted medication doses View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Christopher Granville Bradbury · 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
Christopher Granville Bradbury fell at home, sustained a cut to his right foot, and was admitted to hospital several days later with diarrhoea, vomiting, collapse, and swelling of the right leg. He was diagnosed with a severe invasive soft tissue infection and underwent a below-the-knee amputation, but died the following day. Concerns included a lack of national knowledge and guidelines for these infections, ineffective training and learning measures, and the absence of an audit trail when medication was omitted because it was unavailable or for another reason.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of PSII actions to achieve effective safety improvement
Wider context from the report “ii) The evidence given was that, training is being delivered continuously, and the actions from the PSII have been carried out but this is not making significant inroads , it had not been effective at all , and it is thought that this will happen again.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of continuous training to achieve effective learning
Wider context from the report “ii) The evidence given was that, training is being delivered continuously , and the actions from the PSII have been carried out but this is not making significant inroads , it had not been effective at all , and it is thought that this will happen again.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines on severe invasive soft tissue infections
Wider context from the report “i) A national lack of knowledge of Severe Invasive Soft Tissue Infections, that are not (but are closely related to) necrotising fasciitis combined with a lack of national Guidelines on this . This being exacerbated by the large number of Drs expected to specialise in 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation National lack of knowledge of severe invasive soft tissue infections
Wider context from the report “i) A national lack of knowledge of Severe Invasive Soft Tissue Infections, that are not (but are closely related to) necrotising fasciitis combined with a lack of national Guidelines on this. This being exacerbated by the large number of Drs expected to specialise in 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an audit trail for omitted medication doses
Wider context from the report “iii) When signing medication out, at the hospital, if the medication is not available, no signature is required when choosing option 5 “omitted dose” . This means that there is no audit train , if a patient is not given their medication, because it is unavailable, or omitted for some other reason .
” Open source report
Concerns raised 2 Failure to promptly review and escalate deteriorating patients View source Failure to provide 1:1 registered nurse staffing in the Emergency Department resuscitation area View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Philip John UNWIN · 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
Philip John Unwin, aged 68, was admitted to hospital with fever, shortness of breath and chest pain, and was later confirmed to have sepsis secondary to pneumonia. His condition deteriorated while he remained in the Emergency Department resuscitation area, and he died in hospital on 3 April 2024 from multi-organ failure secondary to pneumonia. Concerns included delayed medical review and escalation to intensive care, staffing in the resuscitation area not complying with national guidance, and recommendations from an internal investigation not having been acted upon in this respect.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly review and escalate deteriorating patients
Wider context from the report “Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation area of the Emergency Department of Royal Stoke University Hospital . It was accepted by witnesses from the hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when concerns had been raised by staff and family, and that review and escalation to intensive care should have been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death).
As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients.
However, the inquest was told that although the Emergency Department Resuscitation area was where the illest patients were placed awaiting review, staffing levels were not in compliance with national guidance. The Royal College of Emergency Medicine (RCEM) “Nursing Workforce Standards for Type 1 Emergency Departments” (Appendix 5) states “There will be a minimum of Registered Nurse to each patient in the resuscitation area”. The recommendation continued that there should be a named nurse allocated to each patient which should be 1:1 as per National Guidance.
The concern is that the current model of staffing within the Emergency Department Resus area is not in compliance with national guidance and the recommendations following internal investigation into the care afforded to the deceased have not been acted upon in this respect.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide 1:1 registered nurse staffing in the Emergency Department resuscitation area
Wider context from the report “Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation area of the Emergency Department of Royal Stoke University Hospital. It was accepted by witnesses from the hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when concerns had been raised by staff and family, and that review and escalation to intensive care should have been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death).
As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients.
However, the inquest was told that although the Emergency Department Resuscitation area was where the illest patients were placed awaiting review, staffing levels were not in compliance with national guidance . The Royal College of Emergency Medicine (RCEM) “Nursing Workforce Standards for Type 1 Emergency Departments” (Appendix 5) states “There will be a minimum of Registered Nurse to each patient in the resuscitation area ”. The recommendation continued that there should be a named nurse allocated to each patient which should be 1:1 as per National Guidance .
The concern is that the current model of staffing within the Emergency Department Resus area is not in compliance with national guidance and the recommendations following internal investigation into the care afforded to the deceased have not been acted upon in this respect.
” Open source report
Concerns raised 2 Failure of bank staff to access patient notes before assessments View source Failure of computer systems to enable different NHS Trusts to access patient notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alix Elizabeth Knowles · 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
Alix Elizabeth Knowles, aged 30, attended hospital on 8 December 2023 after attempting to cut her throat and threatening suicide, but was discharged home after a mental health assessment. In the early hours of 9 December 2023, she jumped from a bridge onto the road below and was hit by two motor vehicles. The substantive concerns were that bank staff could not access patient notes before assessments and that different NHS Trusts could not access one another’s patient notes because of incompatible computer systems.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of bank staff to access patient notes before assessments
Wider context from the report “1. Bank Staff are not able to access patient notes before assessments ;
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of computer systems to enable different NHS Trusts to access patient notes
Wider context from the report “2. Different NHS Trusts are unable to access patient notes , because the computer systems used do not allow this .
” Open source report
Concerns raised 3 Failure to maintain sufficient staffing and funding capacity for timely surgery View source Failure to ensure adequate and experienced staffing for Friday injuries View source Limited weekend clinical cover for injuries sustained on Fridays View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Kathleen Booth · 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 Kathleen Booth was admitted to hospital after a fall in her garden on 9 June 2023, sustaining a fractured neck of femur. Surgery was delayed for four days and, after the operation, she deteriorated suddenly and died. The concerns included staffing and funding pressures, limited weekend cover, and the potential disadvantage to patients injured on a Friday.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient staffing and funding capacity for timely surgery
Wider context from the report “1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding ; and wards having to undertake elective and emergency work at the same time . Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate and experienced staffing for Friday injuries
Wider context from the report “1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time. Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Limited weekend clinical cover for injuries sustained on Fridays
Wider context from the report “3. Patients can be disadvantaged by not receiving treatment if an injury is sustained on a Friday as cover over the weekend is limited .
” Open source report
Concerns raised 2 Failure to enable gastroscopy for stable patients with gastric bleeding before hospital bed allocation View source Failure to ensure consultant awareness and timely review of allocated patients remaining in Accident and Emergency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Roy WALKLET · 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
Roy Walklet died at Royal Stoke University Hospital on 9 April 2022 from multiorgan failure caused by a massive gastroduodenal haemorrhage, contributed to by ibuprofen, after multiple large bleeds from a duodenal ulcer. Concerns included delays in performing a gastroscopy because a hospital bed had not been allocated, and a failure to ensure that the consultant gastroenterologist reviewed him during the morning ward round after he was allocated to the consultant’s patient list.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to enable gastroscopy for stable patients with gastric bleeding before hospital bed allocation
Wider context from the report “On 7th April 2022 the deceased Mr Walklet attended the Accident and Emergency Department of the Royal Stoke University Hospital suffering from a bleeding duodenal ulcer. A consultant gastroenterologist decided that a gastroscopy should be undertaken that same day to identify and treat the cause of the bleeding. The gastroenterologist felt that it was important for the gastroscopy to be undertaken without delay because there was potential for Mr Walklet to suffer another big bleed, which could be fatal.
No gastroscopy took place on 7th April 2022. During the inquest I was told that this was because Mr Walklet had not been allocated a bed in the hospital and a gastroscopy would not take place until a bed had been allocated to him because a patient cannot be returned to the Accident and Emergency Department from the gastroscopy department . A gastroscopy eventually took place on 8th April 2022.
Mr Walklet later suffered further bleeding from the duodenal ulcer which resulted in his death.
The delay in undertaking the gastroscopy was not causative of Mr Walklet’s death, but I was told that systems and procedures in the Hospital remain as they were at the time of Mr Walklet’s death – i.e. that a stable patient with a gastric bleed who was being cared for in the Accident and Emergency Department could not have a gastroscopy until a bed for them became available in the 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consultant awareness and timely review of allocated patients remaining in Accident and Emergency
Wider context from the report “I was further told during the inquest that Mr Walklet was allocated a bed in the Hospital either late on 7th April 2022 or early on 8th April 2022 and that his care was allocated to a consultant gastroenterologist ███████ who should have seen Mr Walklet during his morning ward round but did not do so . ███████ told me that he was not aware that Mr Walklet had been allocated to his list of patients . Mr Walklet’s family believe that this error occurred because, whilst Mr Walklet had been allocated a bed on the ward, he actually remained in the Accident and Emergency department . As a result, Mr Walklet’s condition and care was not reviewed by the consultant gastroenterologist until later that day. At the time Mr Walklet was still suffering from a bleeding duodenal ulcer from which he was to die later the same day.
” Open source report
Concerns raised 5 Unavailability of a fully staffed major trauma consultant function View source Failure to follow up on radiological signs of possible bowel injury View source Failure to assess polytrauma patients as a whole across specialty boundaries View source Lack of prompt and secure delivery of radiology reports during interhospital transfers View source Failure to establish clear cross-specialty responsibility for review and escalation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sara Anest JONES · 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
Sara Anest Jones died at Royal Stoke University Hospital on 2 April 2021 from complications of a bowel injury sustained in a road traffic collision on 30 March 2021. The concerns included delayed and unconfirmed delivery of a CT radiology report between hospitals, failure to follow up signs of possible bowel injury, and the absence of a protocol for prompt and secure delivery of radiology reports in such circumstances.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a fully staffed major trauma consultant function
Wider context from the report “The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole. At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient.
Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury.
Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up on radiological signs of possible bowel injury
Wider context from the report “A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th March 2021. The deceased was then transferred to the Royal Stoke University Hospital, Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was available. Because of this the patient was transferred without the radiologist's report. The radiologist's report became available shortly before 1:00am on 31st March 2021, but was not sent to the Royal Stoke University Hospital until 5:35am that day. It was not clear that safe receipt of the report in Stoke-on-Trent was ever confirmed. Doctors in Stoke-on-Trent then failed to follow up on signs of a possible bowel injury which were indicated in the radiologist's report on the CT scan.
During the inquest I was told that the circumstances of this case were unusual and that there was not a protocol in place to ensure the prompt and secure delivery of radiology reports in circumstances like 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to assess polytrauma patients as a whole across specialty boundaries
Wider context from the report “The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole . At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient.
Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury.
Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of prompt and secure delivery of radiology reports during interhospital transfers
Wider context from the report “A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th March 2021. The deceased was then transferred to the Royal Stoke University Hospital, Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was available. Because of this the patient was transferred without the radiologist's report. The radiologist's report became available shortly before 1:00am on 31st March 2021, but was not sent to the Royal Stoke University Hospital until 5:35am that day. It was not clear that safe receipt of the report in Stoke-on-Trent was ever confirmed. Doctors in Stoke-on-Trent then failed to follow up on signs of a possible bowel injury which were indicated in the radiologist's report on the CT scan.
During the inquest I was told that the circumstances of this case were unusual and that there was not a protocol in place to ensure the prompt and secure delivery of radiology reports in circumstances like 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear cross-specialty responsibility for review and escalation
Wider context from the report “The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole. At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient .
Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury.
Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time.
” Open source report
Concerns raised 1 Excessive delays in handing over patients at hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shaun Mansell · 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
Shaun Mansell, aged 50, was found deceased at home after an ambulance response to a 999 call was delayed by 8 hours and 15 minutes. The post-mortem cause of death was acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism, but the medical evidence could not determine whether the delay contributed to his death. The principal concerns were excessive ambulance handover delays at hospital and a welfare call during the delay that involved no direct contact with Shaun and was conducted by a paramedic without prior training for such calls.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Excessive delays in handing over patients at hospital
Wider context from the report “(1) There were excessive delays in handing over patients at hospital . The West Midlands Ambulance Service issued a recent report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours . This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands.
” Open source report
Concerns raised 1 Failure to correctly interpret scans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Diana Iris Joan Reay · 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
Diana Iris Joan Reay was transferred to hospital on 17 February 2021, where she was diagnosed with community acquired pneumonia, which led to sepsis and an acute kidney injury. A concern was raised that scans were repeatedly misinterpreted, causing a fluid-filled cyst to be mistaken for a full bladder and resulting in unnecessary re-catheterisations.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly interpret scans
Wider context from the report “(1) Numerous doctors failed to interpret the scans that Diana Reay had correctly. It was accepted that they were wrongly interpreted so that a fluid filled cyst was mistaken for a full bladder . This resulted in numerous re-catheterisations of Mrs Reay when this was un-necessary.
” Open source report
Concerns raised 2 Failure to consistently document the content and timing of inter-hospital clinical conversations View source Failure to communicate patients’ clinical condition and observations between clinicians when telephone advice is sought View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alex Louise Shaw · 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
Alex Louise Shaw, who had methylmalonic aciduria and chronic kidney failure, died on 22 October 2018 after developing fluid overload, pulmonary oedema and respiratory failure during hospital treatment. The principal concerns were poor communication and documentation of her clinical observations and telephone advice between clinicians at Royal Stoke University Hospital and Birmingham Children’s Hospital, including failure to communicate her rising heart rate.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently document the content and timing of inter-hospital clinical conversations
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate.
(2) The evidence also revealed it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented.
(3) Consideration should be given as to how a patient’s observations are communicated to the clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patients’ clinical condition and observations between clinicians when telephone advice is sought
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) There was poor communication of the patient’s clinical condition/observations between the Registrar at the Royal Stoke University Hospital and the Consultant at the Birmingham Children’s Hospital when advice was sought by telephone. There was also poor documentation of the contents of the information that had been provided during that conversation and the timing of when the call was made. The evidence of the Consultant at the Birmingham Children’s Hospital was that her advice would have been different if she had been made aware of the patient’s rising heart rate.
(2) The evidence also revealed it was a “judgment call” when the clinician felt that a dialogue between clinician’s at a different hospital needed to be documented.
(3) Consideration should be given as to how a patient’s observations are communicated to the clinician’s between the University Hospital and the Birmingham Children’s Hospital, the time, content, advice and documentation of the conversations.
” Open source report
Concerns raised 7 Failure to align product promotion with safety information about feeding and drainage suitability View source Insufficient product description of the tube bore restriction View source Failure to fully evaluate the size 14FR tube before replacing previous drainage tubes View source Lack of compulsory root cause analysis training for clinicians View source Failure to train sales marketing staff to recognise and communicate the tube bore restriction View source Failure to respond appropriately when NG tubes are not adequately draining View source Wider product labelling failure to communicate the connector-related bore restriction View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen James Oakes · 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
Stephen James Oakes, aged 59, died in hospital on 23 December 2017 after a carefeed 14F nasogastric tube inadequately drained stomach contents, allowing vomit to pass the tube and leading to aspiration pneumonia in the context of metastatic bronchial carcinoma and small bowel obstruction. The principal concerns included inadequate product description and staff training, insufficient hospital evaluation of the tube, failure to recognise inadequate drainage or consider alternatives, and possible wider product-labelling problems.
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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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to align product promotion with safety information about feeding and drainage suitability
Wider context from the report “(6) Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage . Please see attached link to the Nursing times. https://www.nursingtimes.net/clinical-archive/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient product description of the tube bore restriction
Wider context from the report “(1) The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to fully evaluate the size 14FR tube before replacing previous drainage tubes
Wider context from the report “(3) The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14F feeding and drainage tube . Feedback was generally difficult to obtain .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory root cause analysis training for clinicians
Wider context from the report “(5) There is no compulsory training of clinicians required to undertake root cause analysis .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to train sales marketing staff to recognise and communicate the tube bore restriction
Wider context from the report “(2) Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to respond appropriately when NG tubes are not adequately draining
Wider context from the report “(4) Nursing staff did not consider alternative action when the NG tubes were not adequately draining . There was no general recognition of the need to aspirate the tube .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Wider product labelling failure to communicate the connector-related bore restriction
Wider context from the report “(7) This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasogastric tube being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube . The inquest was aware that other Hospital Trusts had also need to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes.
” Open source report
Concerns raised 8 Lack of compulsory root cause analysis training for clinicians View source Inadequate evaluation and feedback before wholesale replacement of drainage tubes View source Continued promotion of the product as suitable for feeding and drainage despite safety information View source Wider product labelling problem regarding the tube's restricted bore View source Failure to train sales marketing staff to recognise and communicate the tube's restricted bore View source Insufficient product description of the tube's restricted bore View source Lack of recognition of the need to aspirate the tube View source Failure to consider alternative action when nasogastric tubes do not adequately drain View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter John Hussey · 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
Peter John Hussey died after post-surgical complications following reversal of an ileostomy. A carefeed 14F nasogastric tube inadequately drained his stomach, allowing vomiting and contributing to aspiration pneumonia. Concerns included insufficient product description and staff training, inadequate evaluation of the tube, and failure to recognise poor drainage and consider alternative treatment or escalation.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of compulsory root cause analysis training for clinicians
Wider context from the report “(5) There is no compulsory training of clinicians required to undertake root cause analysis .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate evaluation and feedback before wholesale replacement of drainage tubes
Wider context from the report “(3) The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube . Feedback was generally difficult to obtain .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Continued promotion of the product as suitable for feeding and drainage despite safety information
Wider context from the report “(6) Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage . Please see attached link to the Nursing Times. https://www.nursingtimes.net/clinical-archive/nutrition/selection-and-management-of-commonly-used-enteral-feeding-tubes-18-02-2019/
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Wider product labelling problem regarding the tube's restricted bore
Wider context from the report “(7) This was a joint inquest into the deaths of two patients who died in quick succession as a result of the Enteral 14F nasogastric tubes being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to train sales marketing staff to recognise and communicate the tube's restricted bore
Wider context from the report “(2) Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient product description of the tube's restricted bore
Wider context from the report “(1) The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of the need to aspirate the tube
Wider context from the report “(4) Nursing staff did not consider alternative action when the nasogastric tubes were not adequately draining. There was no general recognition of the need to aspirate the tube .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider alternative action when nasogastric tubes do not adequately drain
Wider context from the report “(4) Nursing staff did not consider alternative action when the nasogastric tubes were not adequately draining . There was no general recognition of the need to aspirate the tube.
” Open source report
Concerns raised 2 Failure to prescribe guideline-concordant antibiotics for patients previously colonised with ESBL View source Failure to identify and correct inappropriate antibiotic continuation during ward transfer and medical reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Michele Brenda Duckworth · 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
Michele Brenda Duckworth, who had paraplegia, end stage renal failure and a renal transplant requiring immunosuppression, was admitted with profuse diarrhoea and low blood pressure and later deteriorated with sepsis. She died on 23 February 2020, with the post-mortem finding death due to Escherichia coli bacteraemia of unknown source. The principal concern was that Tazocin was prescribed and continued despite previous ESBL colonisation, contrary to the trust guideline.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe guideline-concordant antibiotics for patients previously colonised with ESBL
Wider context from the report “(1) The deceased was incorrectly prescribed Tazocin when she was previously colonised with ESBL . It was initially prescribed when she was on the renal ward and was continued when she was transferred to the Intensive Care Department. The antibiotic given in that context was not the antibiotic suggested in the trust guideline , and it was missed after several medical reviews.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and correct inappropriate antibiotic continuation during ward transfer and medical reviews
Wider context from the report “(1) The deceased was incorrectly prescribed Tazocin when she was previously colonised with ESBL. It was initially prescribed when she was on the renal ward and was continued when she was transferred to the Intensive Care Department . The antibiotic given in that context was not the antibiotic suggested in the trust guideline, and it was missed after several medical reviews .
” Open source report
Concerns raised 2 Inadequate pre- and post-procedure written documentation of advice to seek further medical attention after vomiting View source Insufficient length of post-procedure observation after vomiting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Gladys Margaret Borgogno · 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
Gladys Margaret Borgogno underwent an ERCP procedure for bile duct stones on 24 April 2018 and was discharged after four hours of observation despite vomiting bile. She was found lifeless the following morning and was confirmed dead on 25 April 2018; concerns related to the length of post-procedure observation after vomiting and the clarity of written advice and documentation about seeking further medical attention.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate pre- and post-procedure written documentation of advice to seek further medical attention after vomiting
Wider context from the report “(2) The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital . In evidence at inquest, the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family’s confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged from hospital. He advised that he would recommend that the hospital review its pre and post procedure ERCP documentation provided to patients.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient length of post-procedure observation after vomiting
Wider context from the report “(1) The length of the post procedure observation period where there has been an episode of vomiting in the absence of any other symptoms and normal observations.
” Open source report
10 Jan 2019 Richard John Lockley · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Poor communication during transfers between County Hospital and Royal Stoke View source Difficulties in finding gastroenterology beds at Royal Stoke View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Richard John Lockley · 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
Richard John Lockley had throat and neck cancer and sustained falls that resulted in cervical spine fractures. He died in hospital on 11 September 2018, with suitable feeding not arranged before his death. The concerns were poor communication during a proposed transfer between County Hospital and Royal Stoke University Hospital, and difficulties finding a gastroenterology bed at Royal Stoke.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor communication during transfers between County Hospital and Royal Stoke
Wider context from the report “(1) Mr Lockley’s condition was a complex one but following discussions it was decided that he should be admitted to a gastroenterology ward at the Royal Stoke University Hospital for a radiologically inserted gastrostomy. Mr Lockley was at County Hospital. There appears to have been very poor communication between County Hospital and Royal Stoke in respect of the transfer. I wonder if this could be improved generally where patients need to be transferred between County Hospital and Royal Stoke.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Difficulties in finding gastroenterology beds at Royal Stoke
Wider context from the report “(2) I am always cautious about making reports involving resources but there also appears to have been difficulties in actually finding a gastroenterology bed at Royal Stoke for Mr Lockley. I raise this just in case anything can be realistically be done about this.
” Open source report
Concerns raised 3 Failure to take or record a full set of observations View source Failure to investigate persistent back pain and tenderness View source Failure to undertake further imaging in borderline presentations of significant head injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Robert Maltby Worthington · 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 Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to take or record a full set of observations
Wider context from the report “(2) Mr Worthington persistently complained of back pain. He saw his GP on the 13th April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or recorded . He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate persistent back pain and tenderness
Wider context from the report “(2) Mr Worthington persistently complained of back pain. He saw his GP on the 13th April 2017. He was tender on his back. No further investigation was recommended and a full set of observations were not taken or recorded. He presented to the hospital 3 days later with irreversible bronchopneumonia. A full set of observations may have given an earlier indication of the developing problem.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake further imaging in borderline presentations of significant head injury
Wider context from the report “(1) The deceased attended A&E on the 4th April 2017.He had a very significant head injury 10 cm long requiring 15 stitches and exposing the skull. He had fallen downstairs. He gave a history of a fall from 4 steps. He complained of back and neck pain. Examination of the spine did not reveal any tenderness and other observations were within normal parameters. Further investigations were considered unnecessary and the NICE guidelines were considered. . The deceased’s presenting complaint appeared to fall within a grey area/borderline decision warranting further investigation by way of x-ray/scan. A decision was made not to do this. He later died from injuries sustained in that fall. It is understood that nationally work may be underway to reduce the threshold in such borderline cases. It may be of benefit to future patients for this matter to be further considered.
” Open source report
Concerns raised 5 Delays in reporting falls through the incident reporting system View source Failure to maintain up-to-date transfer-of-care information View source Poor communication with relatives View source Failure to conduct nurse-to-nurse discharge communication between hospitals View source Failure to include falls in hospital discharge information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Kenneth William Horne · 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
Kenneth William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting falls through the incident reporting system
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date transfer-of-care information
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor communication with relatives
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct nurse-to-nurse discharge communication between hospitals
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to include falls in hospital discharge information
Wider context from the report “(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter.
(2) There was no nurse to nurse discharge call between the hospitals.
(3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital.
As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December.
” Open source report
Concerns raised 6 Failure to apply cricoid pressure when clinically indicated View source Lack of a bronchoscope on the standard anaesthetic equipment trolley View source Unavailability of a functional bronchoscope suction button View source Unavailability of previous medical records for clinical decision-making View source Failure to provide a rapid-tilt trolley for anaesthesia View source Failure to use NG tubes when clinically indicated View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Donald John TILL · 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
Donald John TILL, a 68-year-old man with a history of small bowel adenocarcinoma, presented with abdominal pain and vomiting caused by a large bowel obstruction. After emergency surgery on 4 January 2017, he aspirated faeculent material during anaesthesia, developed aspiration pneumonia, deteriorated in intensive care, and died on 5 January 2017. Concerns included unavailable previous medical records, anaesthesia on a ward bed without rapid tilt, problems sourcing suitable bronchoscopy equipment, and the non-use of cricoid pressure and a nasogastric tube before anaesthesia.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to apply cricoid pressure when clinically indicated
Wider context from the report “4. Cricoid pressure and NG tubes were not used in this case .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a bronchoscope on the standard anaesthetic equipment trolley
Wider context from the report “3. A bronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a functional bronchoscope suction button
Wider context from the report “3. A bronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of previous medical records for clinical decision-making
Wider context from the report “1. The deceased’s previous medical records were not available . Different clinical decisions might have been made had they been available.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a rapid-tilt trolley for anaesthesia
Wider context from the report “2. The deceased was anaesthetised on a ward bed and it would have helped if he had been on a trolley with rapid tilt .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use NG tubes when clinically indicated
Wider context from the report “4. Cricoid pressure and NG tubes were not used in this case .
” Open source report
Concerns raised 2 Lack of a consultant-led out-of-hours on-call rota for postoperative patients View source Failure to escalate matters for comprehensive serious incident or root cause review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nadim Muzzfar BUTT · 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
Nadim Muzzfar BUTT died on 5 September 2014 after complications following laparoscopic gastric bypass surgery, including small bowel obstruction, systemic inflammatory response syndrome and multi-organ failure. The report raised concerns that the hospital review was not escalated to a serious untoward incident or root cause analysis, and that no consultant-led out-of-hours on-call rota was in place for postoperative 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a consultant-led out-of-hours on-call rota for postoperative patients
Wider context from the report “2. Despite the recognition that a consultant-led out of hours on-call rota is required for patients having undergone surgery , no such rota is yet in place .
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate matters for comprehensive serious incident or root cause review
Wider context from the report “1, Whilst the hospital sought a review of procedures and protocols the matter was not elevated to a serious untoward incident or root cause analysis where all matters including clinical and nursing decisions were reviewed and subjected to critical examination .
” Open source report
Concerns raised 2 Failure to provide food in the required softened form View source Failure to provide drinks using an appropriate cup or glass View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen Richardson · 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
Stephen Richardson, who had Down syndrome and lived in a care home, suffered a fractured pelvis after an unrecognised injury and later developed a chest infection before dying in hospital on 16 January 2015. Concerns were raised about hospital nursing care, including the provision of solid food and inappropriate drinking equipment despite recorded instructions, which might have caused aspiration.
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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide food in the required softened form
Wider context from the report “At the inquest I heard evidence from two professional carers for the deceased. They drew to my attention concerns which arose from nursing on ward 225 at the Royal Stoke University Hospital. Care was needed with what the deceased took orally. His food needed to be softened and drinks had to be given via a normal cup or glass. He had Downs Syndrome and he did not know better himself. He was, despite notices above his bed, fed chocolate biscuits, pastry, baked beans and other solid foods all of which he might have aspirated . Drinks were often given with Tippee cups or in glasses with straws, both of which were inappropriate and again could have caused aspiration. Four copies of ‘traffic light notes’ were handed in to avoid this type of problem and the carers when visiting consistently had to reinforce these messages to nursing staff. It is unlikely that he did aspirate but he might have done. It is depressing to note the frequent lack of care and attention to detail and I would like a report from the Ward Manager as to the issues raised.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide drinks using an appropriate cup or glass
Wider context from the report “At the inquest I heard evidence from two professional carers for the deceased. They drew to my attention concerns which arose from nursing on ward 225 at the Royal Stoke University Hospital. Care was needed with what the deceased took orally. His food needed to be softened and drinks had to be given via a normal cup or glass . He had Downs Syndrome and he did not know better himself. He was, despite notices above his bed, fed chocolate biscuits, pastry, baked beans and other solid foods all of which he might have aspirated. Drinks were often given with Tippee cups or in glasses with straws, both of which were inappropriate and again could have caused aspiration . Four copies of ‘traffic light notes’ were handed in to avoid this type of problem and the carers when visiting consistently had to reinforce these messages to nursing staff. It is unlikely that he did aspirate but he might have done. It is depressing to note the frequent lack of care and attention to detail and I would like a report from the Ward Manager as to the issues raised.
” Open source report
Concerns raised 2 Failure to communicate additional safety and consent requirements for procedures View source Insufficient controls over requisitioning MRI and CT procedures View source
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Arthur Lindsay Fry · 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
Arthur Lindsay Fry was diagnosed with a glioblastoma and underwent tumour debulking surgery on 14 April 2014. He developed severe neurological complications, including a subdural haematoma and extensive brain infarction, and died on 17 April 2014. The principal concern was a breakdown in communication that led to a planned MRI scan not being carried out, which may have impacted his 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate additional safety and consent requirements for procedures
Wider context from the report “During the course of the inquest I heard evidence that an MRI scan had been scheduled for 15th April 2014 because of a down turn in the deceased's condition. He was taken to the MRI scanning department but he was declined for scanning by the radiographer because an issue over safety and a further consent form was required by two doctors. This requirement was not made known to the consultant or his team and there was a breakdown in communication . The failure to carry out the MRI scan may have impacted upon the deceased's care. Tighter controls concerning the requisitioning of procedures (in this case MRI and CT scans) need to be designed to avoid confusion and potential failures to carry out the procedures. I am aware that some recommendations have been put forward but I would like to be sure that they are being implemented.
” 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 Stoke University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient controls over requisitioning MRI and CT procedures
Wider context from the report “During the course of the inquest I heard evidence that an MRI scan had been scheduled for 15th April 2014 because of a down turn in the deceased's condition. He was taken to the MRI scanning department but he was declined for scanning by the radiographer because an issue over safety and a further consent form was required by two doctors. This requirement was not made known to the consultant or his team and there was a breakdown in communication. The failure to carry out the MRI scan may have impacted upon the deceased's care. Tighter controls concerning the requisitioning of procedures (in this case MRI and CT scans) need to be designed to avoid confusion and potential failures to carry out the procedures . I am aware that some recommendations have been put forward but I would like to be sure that they are being implemented.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations