8 Dec 2017 Roger Albert Saxby · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 7 Insufficient discussion with patients about their care View source Unstructured discussions about patients’ subsequent care View source Failure to consider patients’ best interests before repeat hub-to-hub transfers View source Delays in decisions to transfer patients between vascular hubs View source Delays in starting thrombolysis after arrival at a receiving vascular hub View source Failure to provide urgent clinical decision-making and care View source Failure of a vascular hub to maintain required staffing and resources 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.
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AI-generated summary
Roger Albert Saxby · 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
Roger Albert Saxby died from natural causes, to which delay in treatment and lack of urgency contributed. Concerns included inadequate staffing and resources at Royal Sussex County Hospital, delays in transfer and thrombolysis, and an unstructured discussion about his subsequent care, including two hub-to-hub transfers within 36 hours.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient discussion with patients about their care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Unstructured discussions about patients’ subsequent care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured .
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider patients’ best interests before repeat hub-to-hub transfers
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest .
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in decisions to transfer patients between vascular hubs
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in starting thrombolysis after arrival at a receiving vascular hub
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed .
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide urgent clinical decision-making and care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of a vascular hub to maintain required staffing and resources
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” Open source report
8 Dec 2017 Paul Eric GANDER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Failure to provide authorised personnel with access to electronic records across hospital departments during weekends and out-of-hours periods 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
Paul Eric GANDER · 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
Paul Eric GANDER’s death was investigated, with the inquest concluding on 27 November 2017 with a narrative conclusion. The principal concern was that, during weekends and out-of-hours, the Consultant Orthopaedic and Trauma Surgeon could not access other departments’ electronic hospital records, and that authorised personnel should have full access to all hospital records.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide authorised personnel with access to electronic records across hospital departments during weekends and out-of-hours periods
Wider context from the report “That at a weekend and out of hours the Consultant Orthopaedic and Trauma Surgeon involved was not able to access the electronic records of other departments within the hospital .
This is completely unacceptable.
This information is imperative.
Arrangements must be made to ensure that full access is given to properly authorised personnel to all hospital records.
” Open source report
12 Aug 2016 Jean Stockley · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Reluctance among nursing staff to escalate to senior doctors View source Unclear designation of the doctor to contact after an acute NEWS change View source Inconsistent policies governing NEWS observation escalation View source Failure to review patients after acute NEWS score deterioration View source See 1 more concern
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
Jean Stockley · 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
Jean Stockley was admitted after an unwitnessed fall down 13 stairs that caused spinal fractures. Her respiratory condition later deteriorated, leading to respiratory failure, intensive care treatment and her death on 20 April 2015. Concerns included failure to review her after a significant NEWS score increase, uncertainty about which doctor should be contacted, reluctance to escalate concerns to senior doctors, and possible benefits of automated NEWS monitoring.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Reluctance among nursing staff to escalate to senior doctors
Wider context from the report “3. The nurse who had monitored Mrs Stockley throughout the night and contacted the junior doctor when the NEWS score spiked handed over to the day nurse shortly after her conversation with the doctor. From evidence heard at inquest, there may still be reluctance for nursing staff to contact doctors at a more senior level if a junior doctor does not take appropriate action such as a patient 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Unclear designation of the doctor to contact after an acute NEWS change
Wider context from the report “2. Further, although the nurse quite rightly telephoned a doctor it was far from clear whether the right doctor had been contacted . The national NEWS forms were in use at the time of Mrs Stockley's death to record observations but the policy that governed their use was the 2012 MEWS Escalation Policy and the two policies were different. From evidence heard from both doctors and nurses, it suggests the need to revisit how the NEWS policy is applied locally especially around which doctor should be contacted when there is an acute 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Inconsistent policies governing NEWS observation escalation
Wider context from the report “2. Further, although the nurse quite rightly telephoned a doctor it was far from clear whether the right doctor had been contacted. The national NEWS forms were in use at the time of Mrs Stockley's death to record observations but the policy that governed their use was the 2012 MEWS Escalation Policy and the two policies were different. From evidence heard from both doctors and nurses, it suggests the need to revisit how the NEWS policy is applied locally especially around which doctor should be contacted when there is an acute 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients after acute NEWS score deterioration
Wider context from the report “1. On 9 April, Mrs Stockley's respiratory condition was clearly deteriorating necessitating critical care review who recommended careful and consistent observation of principally her oxygen saturation levels. The NEWS score was a vital tool to alert clinical staff to an acute change yet despite the fact the score went from 4 to 8, the junior doctor did not review the patient. I heard evidence from nursing staff that the doctor felt the patient may simply have been anxious. This suggests a potential training need for doctors and/or nurses.
” Open source report
31 Oct 2014 Maureen Annette ELLETT · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 15 Failure to provide in-person clinical review of unclear ECGs View source Excessive shifts and inadequate breaks for Clinical Decisions Unit nursing staff View source Failure to complete initial N.E.W.S. scoring View source Failure to complete emergency department nursing documentation and falls assessment View source Excessive shifts and inadequate breaks for A & E staff View source Failure to formulate a detailed and complete senior clinical plan View source Failure of Senior Nurse verification and completion of N.E.W.S. scores View source Lack of protocol and assigned responsibility for admission bloods View source Unavailability of ECG machines in the Clinical Decisions Unit View source Failure to account for junior doctor unfamiliarity during senior review View source Failure to document ECG review, instructions and reviewer identification View source Failure to complete initial A & E assessment documentation View source Failure to complete required transfer documentation and countersignature View source Failure to use a hands-on approach during observations View source Deployment of an inexperienced agency nurse in the Clinical Decisions Unit View source See 12 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
Maureen Annette ELLETT · 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
The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide in-person clinical review of unclear ECGs
Wider context from the report “(7) If, as in this case, the first ECG is unclear ; rather than simply requesting that it should be repeated, the Doctor who reviews it should take the opportunity to review the patient in person and if it was the Junior Doctor who requested the ECG (as it was in Mrs. Ellett's case) it is considered that it is that Junior Doctor who should have the opportunity of reviewing that ECG, thus giving continuity of care to the patient.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Excessive shifts and inadequate breaks for Clinical Decisions Unit nursing staff
Wider context from the report “(8) The Staff Nurse in the Clinical Decisions Unit on the night of the 16th / 17th June 2014 was an Agency Nurse who had no previous experience ever of working in the Emergency Department or a Clinical Decisions Unit. She was assisted by an experienced Health Care Assistant. However, the Staff Nurse was also working a 12½ hour shift and had had no break until over nine hours into that shift . It is considered that this compromises the care of the patients in the Clinical Decisions 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete initial N.E.W.S. scoring
Wider context from the report “(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet.
Acopia was recorded as the main diagnosis.
None of the early A & E paperwork was completed.
The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed .
No Admission bloods were taken and in this respect there is no protocol or guidance concerning:
a) that bloods should be taken when patients are admitted to A & E by Ambulance or
b) who should take these bloods.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete emergency department nursing documentation and falls assessment
Wider context from the report “(4) The second Triage Nurse in A & E did the assessment on Mrs. Ellett at the end of a 12½ hour shift which was due to end at 20:00 hours on the 16th June, 2014. She saw Mrs. Ellett at approximately 19:20 hours and out of the two pages of emergency department Nursing Documentation which require over 80-pieces of information recorded, she recorded merely 12 pieces of information . The Falls Risk Assessment was completely blank and yet Mrs. Ellett was at high risk of falls and should have been provided with a green wrist band to alert all staff to this. It is thought that this shift is too long and at the end of it, staff who have had no proper breaks will be exhausted.
It is considered that all staff should be trained on the importance of completing hospital documentation.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Excessive shifts and inadequate breaks for A & E staff
Wider context from the report “(4) The second Triage Nurse in A & E did the assessment on Mrs. Ellett at the end of a 12½ hour shift which was due to end at 20:00 hours on the 16th June, 2014. She saw Mrs. Ellett at approximately 19:20 hours and out of the two pages of emergency department Nursing Documentation which require over 80-pieces of information recorded, she recorded merely 12 pieces of information. The Falls Risk Assessment was completely blank and yet Mrs. Ellett was at high risk of falls and should have been provided with a green wrist band to alert all staff to this. It is thought that this shift is too long and at the end of it, staff who have had no proper breaks will be exhausted .
It is considered that all staff should be trained on the importance of completing hospital documentation.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to formulate a detailed and complete senior clinical plan
Wider context from the report “(2) Discussion by the Junior Doctor with the Senior Doctor as to the plan for Mrs. Ellett was brief to the point of transient.
No proper detailed plan was formulated.
Clues to the patient's condition were missed, probably because the discussion was so brief and the paperwork required for transfer to the short-stay ward, also known as the Clinical Decisions Unit, was signed by the A&E Consultant but neither dated nor timed by him.
The plan was incomplete and the counter-signatory of the Senior Nurse with date and time was completely missing. Therefore the transfer should not have taken 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of Senior Nurse verification and completion of N.E.W.S. scores
Wider context from the report “(10) The Hospital's own Observation Policy states that if N.E.W.S observations are taken by a Health Care Assistant they should be checked within 30 minutes by the Senior Nurse (in this case the Agency Staff Nurse) who should complete the N.E.W.S scores . This did not happen in Mrs. Ellett's case and thus another opportunity to spend some time with her and review her in person was 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of protocol and assigned responsibility for admission bloods
Wider context from the report “(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet.
Acopia was recorded as the main diagnosis.
None of the early A & E paperwork was completed.
The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed.
No Admission bloods were taken and in this respect there is no protocol or guidance concerning :
a) that bloods should be taken when patients are admitted to A & E by Ambulance or
b) who should take these bloods .
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ECG machines in the Clinical Decisions Unit
Wider context from the report “(5) There are no ECG machines in the Clinical Decisions Unit ; either they should be provided or staff on the Clinical Decisions Unit should not be expected to perform ECG's there.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to account for junior doctor unfamiliarity during senior review
Wider context from the report “(3) No notice appears to have been taken that the junior Doctor, discussing with the Senior was an Agency Doctor who had only worked in this busy department on two previous shifts in the last three weeks. Her last experience in an Emergency Department had been eleven months earlier when she did her rotation training. It is suggested that if the Junior Doctor is not a regular member of staff this should be noted when the Senior Review takes place to ensure that no mistakes, due to inexperience or lack of knowledge of the Hospital's own systems is impinging on the Junior Doctors work.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document ECG review, instructions and reviewer identification
Wider context from the report “(6) When the ECG is shown to one of the Doctors there should be a proper documented note of the identity of the Doctor, the time and date when he or she reviews the ECG , the Doctor's instructions on what should happen next with a time period within which this is to occur and this note should be signed and timed by the Doctor who should also print his or her name .
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete initial A & E assessment documentation
Wider context from the report “(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet .
Acopia was recorded as the main diagnosis.
None of the early A & E paperwork was completed .
The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed.
No Admission bloods were taken and in this respect there is no protocol or guidance concerning:
a) that bloods should be taken when patients are admitted to A & E by Ambulance or
b) who should take these bloods.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required transfer documentation and countersignature
Wider context from the report “(2) Discussion by the Junior Doctor with the Senior Doctor as to the plan for Mrs. Ellett was brief to the point of transient.
No proper detailed plan was formulated.
Clues to the patient's condition were missed, probably because the discussion was so brief and the paperwork required for transfer to the short-stay ward, also known as the Clinical Decisions Unit, was signed by the A&E Consultant but neither dated nor timed by him .
The plan was incomplete and the counter-signatory of the Senior Nurse with date and time was completely missing . Therefore the transfer should not have taken 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use a hands-on approach during observations
Wider context from the report “(9) The Hospital's own Protocol on Observations commends the hands-on approach to the patient which was not the approach used with Mrs. Ellett .
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Deployment of an inexperienced agency nurse in the Clinical Decisions Unit
Wider context from the report “(8) The Staff Nurse in the Clinical Decisions Unit on the night of the 16th / 17th June 2014 was an Agency Nurse who had no previous experience ever of working in the Emergency Department or a Clinical Decisions Unit. She was assisted by an experienced Health Care Assistant. However, the Staff Nurse was also working a 12½ hour shift and had had no break until over nine hours into that shift. It is considered that this compromises the care of the patients in the Clinical Decisions Unit.
” Open source report
19 Sep 2014 LINDA ANNE RIGNALL · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Failure to escalate changes in patient condition for timely medical assessment 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
LINDA ANNE RIGNALL · 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
Linda Anne Rignall's condition changed on 5 May 2014, but the change was not reported to a doctor and she was not assessed; her condition worsened approximately four hours later without a medical review. The report states that this failure to refer her for assessment resulted in the only available window of opportunity to treat her being lost, raising concern about the Acute Medical Unit's fitness for purpose.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate changes in patient condition for timely medical assessment
Wider context from the report “(1) At 17:33 on the 5th May 2014, Linda Rignall's condition changed and this was recorded on the NEWS Observation chart. This change in condition should have been reported to a Doctor on the Acute Medical Unit and she should have been assessed. The position worsened some 4 hours later (the next time observations were performed) and there was still no request for a medical review .
From the evidence it was clear to me and I found as you will see from the Conclusion that I recorded that this failure to refer Miss Rignall for assessment resulted in the only window of opportunity available to treat her, being lost.
This makes me concerned as to AMU's Fitness for Purpose at the current time. I consider this to be serious.
” Open source report
22 Aug 2014 MARTIN ARNOLD HILL · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 9 Failure to maintain accurate clinical notes View source Failure to prescribe and administer treatment for impacted faeces and constipation View source Failure to administer prescribed PABRINEX View source Failure to maintain complete and legible Medical Administration Records View source Delays in commencing antibiotics for patients requiring antimicrobial treatment View source Failure to communicate updated patient information during clinical handover View source Failure to provide adequate treatment for opioid withdrawal View source Lack of Senior Pharmacist review of Medical Administration Record charts View source Failure to refer patients to the Critical Care Outreach Team at required NEWS thresholds View source See 6 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.
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AI-generated summary
MARTIN ARNOLD HILL · 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
MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate clinical notes
Wider context from the report “(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given. In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking .
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe and administer treatment for impacted faeces and constipation
Wider context from the report “(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given . In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed PABRINEX
Wider context from the report “(3) Whilst it is noted that Mr. HILL was admitted at lunchtime on a Friday and the critical events took place over a weekend, nonetheless he was known to be an intravenous heroin user on a Methadone prescription and yet he was given no treatment for withdrawal treatment save for 2mg of Diazepam on the 28th March at 22:15 hours and another 2mg of Diazepam at 09:00 on the 30th March. Also on the 30th March PABRINEX was considered and he was written up for this, although this was not given . On the 30th March at 09:50 hours he was given 5ml of METHADONE and later at 13:00 on the 30th March he was given another 5ml of Methadone. (NB: His daily Methadone prescription was 50ml)
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and legible Medical Administration Records
Wider context from the report “(5) There are serious omissions on the Medical Administration Record . I was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend. Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the Chief Pharmacist.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing antibiotics for patients requiring antimicrobial treatment
Wider context from the report “(1) Although this man arrived in A & E on the 28th March 2014 at approximately 12:30, having been suffering confusion, abdominal pain and vomiting for some three days with raised white cell count and markedly raised C-Reactive Protein. He was not commenced on antibiotics until over 48 hours later at 14:00 hours on the 30th March, 2014 . At Inquest I was told that he should have been commenced on Pragmatic antibiotics shortly after his arrival and assessment by a Doctor in A & E.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate updated patient information during clinical handover
Wider context from the report “(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given. In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate treatment for opioid withdrawal
Wider context from the report “(3) Whilst it is noted that Mr. HILL was admitted at lunchtime on a Friday and the critical events took place over a weekend, nonetheless he was known to be an intravenous heroin user on a Methadone prescription and yet he was given no treatment for withdrawal treatment save for 2mg of Diazepam on the 28th March at 22:15 hours and another 2mg of Diazepam at 09:00 on the 30th March. Also on the 30th March PABRINEX was considered and he was written up for this, although this was not given. On the 30th March at 09:50 hours he was given 5ml of METHADONE and later at 13:00 on the 30th March he was given another 5ml of Methadone . (NB: His daily Methadone prescription was 50ml )
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of Senior Pharmacist review of Medical Administration Record charts
Wider context from the report “(5) There are serious omissions on the Medical Administration Record. I was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend . Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the Chief Pharmacist.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to the Critical Care Outreach Team at required NEWS thresholds
Wider context from the report “(2) At 20:00 hours on the 28th March 2014 after he had been admitted to The Royal Sussex County Hospital, Brighton his NEWS rose from 1 to 6. NEWS’ own Guidance and the Hospital’s Protocol require that Mr. HILL should have been referred to the Critical Care Outreach Team. He was not. His NEWS rose to 6 again on the 30th March 2014 at 00:20 hours. However, he was not referred then either. He was not referred to Critical Care Outreach until his NEWS rose to 10 at 07:00 hours on the 30th March 2014.
” Open source report
3 Apr 2014 Graham Harold WATTS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 4 Failure to communicate discharge information to receiving care providers and family View source Failure to ensure patients are medically fit for discharge View source Failure to complete discharge paperwork View source Failure to maintain an ongoing discharge process View source See 1 more concern
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
Graham Harold WATTS · 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
Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate discharge information to receiving care providers and family
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients are medically fit for discharge
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete discharge paperwork
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an ongoing discharge process
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” Open source report
26 Feb 2014 Herta Edith Maria WOODS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 7 Failure to cannulate patients appropriately View source Failure to provide appropriate care and supervision in AMU View source Failure to record the timing and reason for doctors' visits View source Failure to act on NEWS scores View source Failure to seek early senior review View source Failure to create a care plan and provide assistance View source Failure to record fluid charts correctly 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
Herta Edith Maria WOODS · 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
Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to cannulate patients appropriately
Wider context from the report “(5) Failure to cannulate her appropriately . Her cannula had initially been inserted by the ambulance crew; this isued and needed to be replaced. The requirements concerning cannulation of patients are strict. They were not adhered to in Mrs. Wood's case. This should have been dealt with in A & E.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate care and supervision in AMU
Wider context from the report “(1) The apparent abandonment of this lady in AMU .
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record the timing and reason for doctors' visits
Wider context from the report “(2) The failure to record the timing and reason for the Doctor's visit (the reason was only illicitied from evidence).
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to act on NEWS scores
Wider context from the report “(4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her. This lady was very likely near the end of her life. However, from the evidence that I heard, it was clear that she would not have died when she did had she been given appropriate care and treatment.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to seek early senior review
Wider context from the report “(3) The failure to seek an early Senior Review for the failure to record the Fluid Chart correctly - this is important because it was fluid overload that was the immediate cause of Mrs. Wood's 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to create a care plan and provide assistance
Wider context from the report “(4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her . This lady was very likely near the end of her life. However, from the evidence that I heard, it was clear that she would not have died when she did had she been given appropriate care and treatment.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record fluid charts correctly
Wider context from the report “(3) The failure to seek an early Senior Review for the failure to record the Fluid Chart correctly - this is important because it was fluid overload that was the immediate cause of Mrs. Wood's death.
” Open source report
25 Feb 2014 Stephen John PALMER · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 11 Failure of the hospital CT scanning service View source Inadequate ward round documentation View source Inappropriate transfer to an Acute Medical Unit View source Failure to appreciate the dangers of an acute abdomen View source Failure to provide ongoing surgical assessment and response to deterioration View source Delays in surgical review after referral View source Failure to arrange an emergency theatre View source Delays in initial nursing and medical assessment in A & E View source Failure to prepare a patient for urgently needed surgery View source Failure to recognise patient deterioration View source Lack of early senior review View source See 8 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 John PALMER · 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 John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.
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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the hospital CT scanning service
Wider context from the report “(10) A complete failure of the CT scanning service at this Hospital. This led Mr. Palmer to be denied a CT scan which would certainly have diagnosed his condition. This failure arose because the CT scanning system at this Hospital is unfit for purpose.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate ward round documentation
Wider context from the report “(7) There was a completely inadequate Ward Round Note made at the hurried ward round between 08:30 and 08:40 hours. This left the Nursing Staff in the Acute Medical Unit unable to look after this surgical patient efficiently.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Inappropriate transfer to an Acute Medical Unit
Wider context from the report “(3) Inappropriate transfer to an Acute Medical Unit when he should either have stayed in A & E or gone to a Surgical Unit. The concern was that he was effectively unsafe and in an inappropriate clinical environment.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate the dangers of an acute abdomen
Wider context from the report “(5) Even though his acute abdomen had been diagnosed at 07:00 hours there was a failure to appreciate the dangers of his condition.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ongoing surgical assessment and response to deterioration
Wider context from the report “(1) Delay in being seen both by Nursing Staff and Doctors in A & E.
Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013.
Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in surgical review after referral
Wider context from the report “(1) Delay in being seen both by Nursing Staff and Doctors in A & E.
Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013.
Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange an emergency theatre
Wider context from the report “(9) Failure to arrange an emergency theatre for him (CEPD).
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in initial nursing and medical assessment in A & E
Wider context from the report “(1) Delay in being seen both by Nursing Staff and Doctors in A & E.
Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013.
Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare a patient for urgently needed surgery
Wider context from the report “(8) Failure to prepare Mr. Palmer for surgery which it had been acknowledged he needed urgently.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise patient deterioration
Wider context from the report “(4) There was a failure to appreciate his deterioration largely because he was not seen by the Surgical Team in spite of requests that he should be seen.
” 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 Sussex County Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of early senior review
Wider context from the report “(2) No early senior review.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations