Recipient

Russells Hall Hospital

First report 15 Oct 2013•Latest report 15 Apr 2025

Recipient record

Reports, concerns and published responses

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

Reports: 3
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

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

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

15 Apr2025
Shropshire, Telford and Wrekin
Concerns raised4
1. Lack of documentation or process demonstrating rearrangement of care
2. Failure to rearrange required care before arranging transportation home
3. Failure to ensure access to an alarm pendant or mobile phone for summoning help
1. Failure to require notification of safe return to the hospital or care company
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

Samuel Joseph BROOKES · 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

Samuel Joseph Brookes was discharged home after a hospital admission following a fall and long lie, but his required care was not rearranged. He was immobile, lived alone, and was left unattended for two weeks without access to his pendant alarm or mobile phone; he was then found unresponsive and deceased. The principal concerns were the failure to arrange and document his care, the lack of a process requiring confirmation of his safe return, and his inability to raise an alarm or call for help.

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 Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of documentation or process demonstrating rearrangement of care
Wider context from the report
“(2) There was no record or documentation or process to show or demonstrate that the care had been rearranged. ”
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 Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to rearrange required care before arranging transportation home
Wider context from the report
“(1) The hospital arranged for Mr Brookes transportation home without rearranging the required care as set out in paragraph 4 above. ”
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 Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure access to an alarm pendant or mobile phone for summoning help
Wider context from the report
“(4) Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room). Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help. ”
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 Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to require notification of safe return to the hospital or care company
Wider context from the report
“(3) The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return. It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner. ”
Open source report
27 Jul2018
Black Country
Concerns raised4
1. Delays in assessing available blood results
2. Failure to administer antibiotics at an earlier stage
3. Failure to recognise the development of sepsis
1. Inadequate communication
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 Natalie Billingham · 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 Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.

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 Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in assessing available blood results
Wider context from the report
“1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to administer antibiotics at an earlier stage
Wider context from the report
“1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise the development of sepsis
Wider context from the report
“1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication
Wider context from the report
“1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis. ”
Open source report
15 Oct2013
Black Country
Concerns raised2
1. NICE Guidelines insufficiently emphasising blood-thinning medication in elderly people who have a fall when determining the need for a head CT
2. Delays in performing a CT scan of the head after hospital presentation
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

Lucy KILVERT · 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

Lucy KILVERT was taken to hospital on 14 June 2013 after falling at home on 10 June and subsequently deteriorating; she had hit her head and was taking blood-thinning medication. The principal concern was that she did not initially receive a head CT scan, which was performed about eight hours after hospital presentation and revealed an intracranial bleed; the report also noted possible shortcomings in how the significance of blood-thinning medication was emphasised in the relevant guidelines.

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 Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
NICE Guidelines insufficiently emphasising blood-thinning medication in elderly people who have a fall when determining the need for a head CT
Wider context from the report
“namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :- 1a) Intracranial bleed, II Chronic Kidney Failure Hypertension Heart Valve Replacement. As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment. ”
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 Russells Hall Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays in performing a CT scan of the head after hospital presentation
Wider context from the report
“namely that Mrs Kilvert was not initially at the hospital given a CT scan of the head. It was not performed until about 8 hours after presentation at hospital and revealed an intracranial bleed. The medical cause of death was :- 1a) Intracranial bleed, II Chronic Kidney Failure Hypertension Heart Valve Replacement. As it turned out neurological intervention would not have been appropriate even if a brain bleed had been discovered immediately. I was told by the consultant in emergency medicine who gave evidence, that although the NICE Guidelines were considered, the clinical judgment of the senior house officer who saw her initially was that there was no reason to suspect a bleed, although the consultant said that his judgment may have been different. The consultant felt that the Guidelines possibly insufficiently emphasised the significance of blood thinning medication in elderly people who had a fall when considering whether a CT scan of the head was necessary, albeit that eventually the matter was a question of clinical judgment. ”
Open source report

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised4

Lack of documentation or process demonstrating rearrangement of care

Failure to rearrange required care before arranging transportation home

Failure to ensure access to an alarm pendant or mobile phone for summoning help

Failure to require notification of safe return to the hospital or care company

Concerns raised4

Delays in assessing available blood results

Failure to administer antibiotics at an earlier stage

Failure to recognise the development of sepsis

Inadequate communication

Concerns raised2

NICE Guidelines insufficiently emphasising blood-thinning medication in elderly people who have a fall when determining the need for a head CT

Delays in performing a CT scan of the head after hospital presentation