17 Dec 2019 Constance Josephine Robinson · Prevention of Future Deaths report Manchester West
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Concerns raised 2 Lack of overnight Doctors in the Fairfield Hospital and Stepping Hill Hospital Hyper Acute Stroke units View source Limited overnight availability of Hyper Acute Stroke unit admission at Fairfield Hospital and Stepping Hill Hospital View source
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AI-generated summary
Constance Josephine Robinson · 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
Constance Josephine Robinson died at Stepping Hill Hospital on 27 April 2019 after an intracerebral haemorrhage while receiving warfarin for atrial fibrillation, followed by aspiration pneumonia and decompensated heart failure. The report raised concerns that Fairfield Hospital and Stepping Hill Hospital were not open 24 hours a day, causing delays and additional travel for patients requiring overnight hyper acute stroke care, and highlighted the potential benefits of round-the-clock admission and medical availability.
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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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of overnight Doctors in the Fairfield Hospital and Stepping Hill Hospital Hyper Acute Stroke units
Wider context from the report “1. During the Inquest evidence was heard that: -
i. There are 3 Hyper Acute Stroke units in Greater Manchester, namely at Fairfield Hospital in Bury, Salford Royal Hospital in Salford and Stepping Hill Hospital in Stockport. The units serve the whole of the Greater Manchester area and surrounding areas.
ii. The unit at Salford Royal Hospital is open 24 hours a day 7 days a week, whereas the units at Fairfield Hospital and Stepping Hill Hospital are open from 07.00 hours to 23.00 hours each day. Accordingly, if a patient require admission to a unit between 23.00 hours and 07.00 hours, the patient must be taken to Salford Royal Hospital.
In the case of the deceased, who lived in Chelford, Cheshire, she required admission to a Hyper Acute Stroke unit at 06.28 hours on the 15th April 2019 and the nearest unit to her address was at Stepping Hill Hospital. However, in view of the time of day and the fact that Stepping Hill would not be open until 07.00 hours, she had to be taken to the Salford Royal Hospital Hyper Acute Stroke unit. The journey to Salford Royal Hospital, rather than Stepping Hill Hospital, involved an additional journey of approximately 18 miles, by ambulance, with an additional travel time of approximately 30 minutes. If she had been admitted to Stepping Hill Hospital Hyper Acute Stroke unit on the 15th April 2019, she could have remained there for continuing treatment, rather than a subsequent transfer from Salford Royal Hospital to Stepping Hill Hospital on the 19th April 2019.
iii. Furthermore, if a patient is in a unit at Fairfield Hospital or Stepping Hill Hospital and requires an urgent medical assessment or medical treatment between 23.00 hours and 07.00 hours, the patient must be referred to the unit at Salford Royal Hospital for advice before considering a transfer to Salford Royal Hospital between those hours.
iv. Evidence given by a Consultant in Stroke Medicine at the Inquest confirmed that patients would benefit from admission to the units at Fairfield Hospital and Stepping Hill Hospital 24 hours a day 7 days a week to enable quicker assessment into a unit from all parts of Greater Manchester and to have Doctors available in each unit 24 hours a day, particularly overnight between 23.00 hours and 07.00 hours. The availability of Doctors in the units between 23.00 hours and 07.00 hours would allow immediate access to medical advice and emergency treatment and care, rather than a delay, arising from the need to refer the patient to Salford Royal Hospital.
v. The Consultant also gave evidence at the Inquest that requests had been made to the Greater Manchester Stroke Operational Delivery Network for the units at Fairfield Hospital and Stepping Hill Hospital to become 24-hour units but the requests have not been granted.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Limited overnight availability of Hyper Acute Stroke unit admission at Fairfield Hospital and Stepping Hill Hospital
Wider context from the report “1. During the Inquest evidence was heard that: -
i. There are 3 Hyper Acute Stroke units in Greater Manchester, namely at Fairfield Hospital in Bury, Salford Royal Hospital in Salford and Stepping Hill Hospital in Stockport. The units serve the whole of the Greater Manchester area and surrounding areas.
ii. The unit at Salford Royal Hospital is open 24 hours a day 7 days a week, whereas the units at Fairfield Hospital and Stepping Hill Hospital are open from 07.00 hours to 23.00 hours each day. Accordingly, if a patient require admission to a unit between 23.00 hours and 07.00 hours, the patient must be taken to Salford Royal Hospital.
In the case of the deceased, who lived in Chelford, Cheshire, she required admission to a Hyper Acute Stroke unit at 06.28 hours on the 15th April 2019 and the nearest unit to her address was at Stepping Hill Hospital. However, in view of the time of day and the fact that Stepping Hill would not be open until 07.00 hours, she had to be taken to the Salford Royal Hospital Hyper Acute Stroke unit. The journey to Salford Royal Hospital, rather than Stepping Hill Hospital, involved an additional journey of approximately 18 miles, by ambulance, with an additional travel time of approximately 30 minutes. If she had been admitted to Stepping Hill Hospital Hyper Acute Stroke unit on the 15th April 2019, she could have remained there for continuing treatment, rather than a subsequent transfer from Salford Royal Hospital to Stepping Hill Hospital on the 19th April 2019.
iii. Furthermore, if a patient is in a unit at Fairfield Hospital or Stepping Hill Hospital and requires an urgent medical assessment or medical treatment between 23.00 hours and 07.00 hours, the patient must be referred to the unit at Salford Royal Hospital for advice before considering a transfer to Salford Royal Hospital between those hours.
iv. Evidence given by a Consultant in Stroke Medicine at the Inquest confirmed that patients would benefit from admission to the units at Fairfield Hospital and Stepping Hill Hospital 24 hours a day 7 days a week to enable quicker assessment into a unit from all parts of Greater Manchester and to have Doctors available in each unit 24 hours a day, particularly overnight between 23.00 hours and 07.00 hours. The availability of Doctors in the units between 23.00 hours and 07.00 hours would allow immediate access to medical advice and emergency treatment and care, rather than a delay, arising from the need to refer the patient to Salford Royal Hospital.
v. The Consultant also gave evidence at the Inquest that requests had been made to the Greater Manchester Stroke Operational Delivery Network for the units at Fairfield Hospital and Stepping Hill Hospital to become 24-hour units but the requests have not been granted.
” Open source report
19 Dec 2017 Mrs Lindsey Parker · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 6 Inadequate completion of fluid balance charts View source Failure to ensure suitably qualified staff manage out-of-hours medical prioritisation of care View source Lack of continuity in medical care View source Failure to record vital signs and observations View source Failure to recognise deteriorating patients View source Failure to act on or escalate patient deterioration 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.
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AI-generated summary
Mrs Lindsey Parker · 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 Lindsey Parker had metastatic lung cancer and subsequently developed toxic epidermal necrolysis while receiving medical treatment. Her condition deteriorated on 8 July 2017, with concerns about delayed medical review, inadequate recognition and escalation of deterioration, gaps in observations and fluid-balance recording, lack of continuity in medical care, and the qualifications of out-of-hours coordinators. She died at Salford Royal Hospital on 9 July 2017.
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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate completion of fluid balance charts
Wider context from the report “2. Matron's review identified gaps in basic nursing care – vital signs/observations not recorded, potentially affecting the NEWS and inadequate fluid balance chart completion . Both are critical to patient care and safety, particularly given Mrs Parker's serious clinical diagnosis (TEN), against a backdrop of an already life limiting/threatening diagnosis.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure suitably qualified staff manage out-of-hours medical prioritisation of care
Wider context from the report “4. During the course of the evidence, Trust staff were unsure as to what qualifications the 'Hospital at Night' site co-ordinators held. They believed that most, if not all, were likely to be Nurses. My concern here is how/why nurses are deemed suitably qualified to manage out of hours medical prioritisation of care .
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity in medical care
Wider context from the report “1. A lack of continuity in medical care. According to the family's evidence, Mrs Parker was seen by 16 different doctors during the course of her last admission. Of these, seven were junior doctors (FY grade).
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record vital signs and observations
Wider context from the report “2. Matron's review identified gaps in basic nursing care – vital signs/observations not recorded , potentially affecting the NEWS and inadequate fluid balance chart completion. Both are critical to patient care and safety, particularly given Mrs Parker's serious clinical diagnosis (TEN), against a backdrop of an already life limiting/threatening diagnosis.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deteriorating patients
Wider context from the report “3. Failure to adequately recognise the deteriorating patient and to act and/or escalate matters accordingly.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to act on or escalate patient deterioration
Wider context from the report “3. Failure to adequately recognise the deteriorating patient and to act and/or escalate matters accordingly .
” Open source report
16 Jun 2017 Katherine Anne Derbyshire · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 5 Failure to triage clinical needs to effect timely transfer View source Inadequate communication between hospitals about dialysis transfer and bed availability View source Delays in considering alternative temporary dialysis View source Failure to transfer patients requiring ongoing dialysis treatment and care View source Failure of dialysis treatment and care plans to provide for patient deterioration 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
Katherine Anne Derbyshire · 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
Katherine Anne Derbyshire, who had end stage chronic kidney disease, was admitted on 12 November 2016 after compromised dialysis function and a presumed blockage and infection of her peritoneal catheter. She deteriorated while awaiting transfer for ongoing dialysis, became unfit for transfer, and died on 21 November 2016 after palliative end-of-life medication was prescribed. The concerns included the failure to transfer her, delays in considering temporary dialysis, and inadequate communication and contingency planning between the two hospitals.
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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to triage clinical needs to effect timely transfer
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care ;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between hospitals about dialysis transfer and bed availability
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient ;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in considering alternative temporary dialysis
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier ;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer patients requiring ongoing dialysis treatment and care
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place ;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of dialysis treatment and care plans to provide for patient deterioration
Wider context from the report “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:-
a. No transfer to Salford Royal Infirmary, in fact, took place;
b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary;
c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case;
2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that:
a. This possible alternative was not considered earlier;
b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care;
c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016.
d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient;
3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care.
” Open source report
2 Feb 2017 Gordon Arthur · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Lack of policies governing the process of investigative tests View source Lack of policies governing notification of investigative test results to responsible Consultants 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
Gordon Arthur · 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
Gordon Arthur underwent a right total hip replacement on 18 August 2016 and subsequently developed an infection at the surgical site, suffered a cardiac arrest, and died on 5 October 2016. The principal concern was the lack of policies governing investigative tests and the notification of results to consultants, which could result in patients not receiving required treatment and a future death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of policies governing the process of investigative tests
Wider context from the report “i. The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient’s care could lead to patients not being given the treatment they require, which could result in a future death. I therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to the Consultant in charge of the patient’s care in order to prevent a future 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 Salford Royal Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of policies governing notification of investigative test results to responsible Consultants
Wider context from the report “i. The lack of policies dealing with the process of investigative tests and the notification of their results to Consultants in charge of a patient’s care could lead to patients not being given the treatment they require, which could result in a future death. I therefore request that you review the policies and procedures relating to investigative procedures and the reporting of their results to the Consultant in charge of the patient’s care in order to prevent a future death.
” 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