23 Oct 2025 Mrs Rashida Sultana · Prevention of Future Deaths report Black Country
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Concerns raised 2 Lack of nursing staff understanding of when to call the EMRT during emergencies involving a DNAR View source Lack of risk assessment determining when SALT assessments should take place for patients at risk of dysphagia View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Rashida Sultana · 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 Rashida Sultana died on 20 November 2024 after choking on chips and water while admitted to hospital. Concerns included confusion among nursing staff about when to call the Emergency Medical Response Team when a DNAR was in place, and insufficient risk assessment regarding Speech and Language Therapy assessments for patients at risk of dysphagia.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing staff understanding of when to call the EMRT during emergencies involving a DNAR
Wider context from the report “2. My concern is that there was confusion and lack of understanding by nursing staff in relation to when the EMRT should be called in an emergency particularly when a DNAR was 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment determining when SALT assessments should take place for patients at risk of dysphagia
Wider context from the report “3. In addition, there was a lack of risk assessment of when SALT assessments for those patients at risk of dysphagia should take place .
” Open source report
18 Jan 2024 Dorota Marta KUKLINSKA · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure to refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, particularly after refusal of lumbar puncture View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Dorota Marta KUKLINSKA · 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
Dorota Marta Kuklinska attended hospital with a severe headache and other symptoms suggestive of a brain bleed, but her CT scan was misreported as normal. She later collapsed, was found to have an unsurvivable brain bleed caused by a right middle cerebral aneurysm, and died in hospital. The principal concern was that, despite strong clinical signs and her refusal of a lumbar puncture, she was not referred for specialist neurosurgical advice through NORSE.
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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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, particularly after refusal of lumbar puncture
Wider context from the report “1. The inquest heard evidence from a specialist neurosurgeons at University Hospital Birmingham that there are guidelines to confirm a patient with strong clinical signs of a brain bleed, should be referred through NORSE particularly when they have refused a lumber puncture which is the usual test undertaken in accordance with the NICE guidelines. Clinicians at Sandwell and West Birmingham Hospital City hospital site said they were unaware of those guidelines and didn't consider a referral for Mrs Kuklinska. Consideration needs to be given to establishing clear guidance with acute trusts to ensure patients with strong clinical signs of a brain bleed are referred for specialist neurosurgical advice .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update clinical guidance to require neurology opinions when patients refuse or have inconclusive lumbar punctures.
Verbatim wording from the response “Working with UHB, we have been able to establish their internal policies state that a ‘urgent neurology opinion should be sought if a lumbar puncture is unable to confirm or refute the diagnosis of a subarachnoid haemorrhage’. SWB have committed to aligning our internal guidance with UHB by updating our clinical guidance for the management of subarachnoid haemorrhage to include a requirement to seek a neurology opinion for those patients who either refuse or have an inconclusive lumbar puncture result. In circumstances where a patient with full mental capacity has refused a lumbar puncture, they would of course have to consent to the referral being made to UHB for the neurology opinion. This amendment is currently going through our internal governance processes and will be recirculated to staff when ratified.” Source location Response from Sandwell and West Birmingham NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recirculate the ratified guidance and provide supportive communications to staff.
Verbatim wording from the response “Working with UHB, we have been able to establish their internal policies state that a ‘urgent neurology opinion should be sought if a lumbar puncture is unable to confirm or refute the diagnosis of a subarachnoid haemorrhage’. SWB have committed to aligning our internal guidance with UHB by updating our clinical guidance for the management of subarachnoid haemorrhage to include a requirement to seek a neurology opinion for those patients who either refuse or have an inconclusive lumbar puncture result. In circumstances where a patient with full mental capacity has refused a lumbar puncture, they would of course have to consent to the referral being made to UHB for the neurology opinion. This amendment is currently going through our internal governance processes and will be recirculated to staff when ratified.” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an anonymised case in a learning session for medical staff on the need for neurology referral.
Verbatim wording from the response “As an interim measure, the sad case of Mrs Kuklinska has been anonymised and used as a learning session with medical staff to ensure they are aware of the need for neurology referral.” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A neurology referral cannot be made for a patient with full mental capacity who refuses lumbar puncture without the patient's consent.
Verbatim wording from the response “Working with UHB, we have been able to establish their internal policies state that a ‘urgent neurology opinion should be sought if a lumbar puncture is unable to confirm or refute the diagnosis of a subarachnoid haemorrhage’. SWB have committed to aligning our internal guidance with UHB by updating our clinical guidance for the management of subarachnoid haemorrhage to include a requirement to seek a neurology opinion for those patients who either refuse or have an inconclusive lumbar puncture result. In circumstances where a patient with full mental capacity has refused a lumbar puncture, they would of course have to consent to the referral being made to UHB for the neurology opinion. This amendment is currently going through our internal governance processes and will be recirculated to staff when ratified.” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
29 Dec 2023 Karmchand Gulzar · Prevention of Future Deaths report Black Country
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Concerns raised 5 Failure to utilise the surgical registrar referral pathway View source Failure to give adequate weight to concerns from carers and family familiar with a patient's presentation View source Failure to undertake an urgent CT scan for acute abdominal presentations View source Failure to recognise deterioration in patients with communication difficulties View source Lack of clinician awareness of the necessity for CT scanning in acute abdominal presentations View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Update and reissue the acute abdomen guideline with a pathway flowchart, early CT emphasis, and mandatory consultant discussion before surgical referral.
Stated completedThe respondent said that this action was complete when they made their response on 3 January 2024. View source
Action
Deliver patient experience and communication education emphasizing carers’ involvement, expertise, and contribution to care and outcomes.
Stated completedThe respondent said that this action was complete when they made their response on 3 January 2024. View source
Action
Audit the acute abdomen pathway to assess the effectiveness of the updated guidance and related safety activities.
Stated plannedThe respondent said that this action was planned when they made their response on 3 January 2024. View source
Action
Embed the updated acute abdomen guidance through staff dissemination, intranet publication, team discussions, induction and teaching, handover reminders, and anonymised case-learning discussions.
Stated completedThe respondent said that this action was complete when they made their response on 3 January 2024. View source
Action
Trial a Carers Passport and supporting documentation prompting carers to describe patients’ individual needs and pain expressions.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 January 2024. View source See 2 more actions
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AI-generated summary
Karmchand Gulzar · 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
Karmchand Gulzar was taken to Sandwell Hospital on 23 September 2022 with abdominal distension and pain and was diagnosed with acute intestinal obstruction. A CT scan and immediate surgical review were delayed; his condition deteriorated, urgent surgery took place during the evening and early morning, and he died during the operation in the early hours of 24 September 2022. Concerns included failure to follow the surgical registrar referral pathway, failure to undertake an urgent CT scan, and insufficient recognition of deterioration and concerns raised by carers and family about his condition.
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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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to utilise the surgical registrar referral pathway
Wider context from the report “(1) Karmchand was referred to the surgical nursing team instead of the surgical registrar or surgical on-call team, as required by the Emergency Department to surgical registrar referral pathway from a previous SI where it had been identified as an issue. This was not followed in this case, leading to a delay in surgery and increased risk of death. I am concerned that the surgical registrar referral pathway is not being utilised despite previous incidents in which its use was highlighted as necessary.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give adequate weight to concerns from carers and family familiar with a patient's presentation
Wider context from the report “(3) The deterioration in Karmchand’s condition was not recognised due to difficulties in communication of pain due to his mental health condition. Concerns raised by his carers and family who knew him best and his presentation were not given adequate weight. A previous SI was reported to have raised this issue, but no action point or plan was provided in the current report to set out how staff could improve the assessment of patients with communication difficulties, by using observations and relying on people who better knew their demeanour and presentation .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake an urgent CT scan for acute abdominal presentations
Wider context from the report “(2) No CT scan was undertaken as required by the acute abdominal pathway and guidance as part of the initial assessment. I was concerned by evidence that a CT scan would not be undertaken urgently as part of an acute abdominal presentation and that the necessity for a scan may not be known by junior (or some consultant) doctors.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in patients with communication difficulties
Wider context from the report “(3) The deterioration in Karmchand’s condition was not recognised due to difficulties in communication of pain due to his mental health condition. Concerns raised by his carers and family who knew him best and his presentation were not given adequate weight. A previous SI was reported to have raised this issue, but no action point or plan was provided in the current report to set out how staff could improve the assessment of patients with communication difficulties, by using observations and relying on people who better knew their demeanour and presentation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician awareness of the necessity for CT scanning in acute abdominal presentations
Wider context from the report “(2) No CT scan was undertaken as required by the acute abdominal pathway and guidance as part of the initial assessment. I was concerned by evidence that a CT scan would not be undertaken urgently as part of an acute abdominal presentation and that the necessity for a scan may not be known by junior (or some consultant) doctors .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and reissue the acute abdomen guideline with a pathway flowchart, early CT emphasis, and mandatory consultant discussion before surgical referral.
Verbatim wording from the response “The Management of Acute Abdomen guideline that was in use at the time of this incident has been updated and re-issued in June 2023. This guideline was created in consultation with the Doctors working within the Emergency Department and the Patient Safety team, to ensure the appropriate learning is incorporated into the process. The guideline aligns with the BMJ Best Practice recommendations.” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver patient experience and communication education emphasizing carers’ involvement, expertise, and contribution to care and outcomes.
Verbatim wording from the response “Additionally, we have identified training and education in patient experience and communication as Trust priorities. Every session delivered in the last year stresses the value of carer involvement, their specific expertise and knowledge and the benefits in experience and outcomes that these bring.” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the acute abdomen pathway to assess the effectiveness of the updated guidance and related safety activities.
Verbatim wording from the response “Surgical departments to ensure our teams are aware of the learning from this case. To assess the efficacy of the activities described above, an audit of the Acute Abdomen pathway is planned in March 2024.” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the updated acute abdomen guidance through staff dissemination, intranet publication, team discussions, induction and teaching, handover reminders, and anonymised case-learning discussions.
Verbatim wording from the response “In order to embed the new guideline, it has been sent to all applicable staff, published on our intranet site and discussed within team meetings and appropriate forums. The guidance is highlighted at induction sessions for new doctors and in appropriate teaching sessions. Staff have also been reminded to include outstanding referrals at the handover discussion. Mr Gulzar’s case has also been anonymised and discussed with the clinical teams within the Emergency and” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trial a Carers Passport and supporting documentation prompting carers to describe patients’ individual needs and pain expressions.
Verbatim wording from the response “In relation to the concerns regarding the recognition of deterioration not being recognised due to Mr Gulzar’s mental health condition and the concerns of his family/carers being ignored; there is considerable work being done by our Patient Experience team to support improvement in this area. Listening to and valuing the expertise that exists within carers and families is crucial to providing personalised care and treatment, and personalisation is a key-cornerstone of the Trust's Fundamentals of Care programme. Through this work a 'Carers Passport' with supporting patient documentation concentrating on the person, is being trialled in selected wards to understand the benefits this will reap for carers across the organisation. This trial will take place in April 2024, and we will then look to roll this out across the Trust.” Source location Response from Sandwell and West Birmingham NHS Trust
Open published response
31 Oct 2023 Andrew BOWLES · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Lack of access to essential patient records before mental health liaison assessment and treatment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew BOWLES · 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
Andrew BOWLES was found face down in a canal on 16 May 2023 after leaving Birmingham City Hospital, where he had been assessed following concerns about his mental health. The medical cause of death was drowning. The principal concern was that the mental health liaison nurse did not have direct access to City Hospital records containing information about command hallucinations and thoughts of self-harm, which may have affected the assessment and potential referral for psychiatric admission.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to essential patient records before mental health liaison assessment and treatment
Wider context from the report “3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records , but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system , as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission.
4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment . I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment . The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advise agency staff during local induction how to access, review and update hospital records through permanent team members.
Verbatim wording from the response “There are a small number of staff who may be called in from agencies when there are no other staff available. As these staff may be new to the team and/or to both trusts and only working one shift, it is unlikely that an account is set up immediately for them with the Hospital. In these exceptional circumstance, when the local induction takes place, they will be advised of the processes in place for them to speak with other permanent team members to access the City Hospital notes. They will review them prior to speaking with the patient and also update the records with their assessment after. Now that BSMHFT bank staff also have access to the” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate hospital-record access to bank staff regularly working within the Psychiatric Liaison Team.
Verbatim wording from the response “In the past any “bank staff” (temporary staff) who were on shift would ask a member of the permanent team to access the records, so that they could review them prior to seeing a patient and would also ask permanent staff to update the records, following their review. Following the PFD, a joint meeting has taken place between the two trusts, and we have been able to identify that a number of the bank staff are regularly working bank shifts within the PLT. Therefore these staff will now be allocated access to hospital records. This will improve matters considerably in this area.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Generic logins for agency staff cannot be provided because they would lack traceability, accountability and lawful information processing.
Verbatim wording from the response “Please be assured, we did explore all possible options including providing a generic log on for agency only staff who may be carrying out one shift. However from an information governance perspective it would not be possible to ascertain who had inputted the information and therefore there would be no traceability or accountability in place, if any problem arose. This is contra to the lawful processing of confidential information. Therefore the only option available was to strengthen the number of PLT staff who have access to the City Hospital records to address any concerns going forward and ensure smooth working.” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Open published response
5 May 2021 Sarah Brady · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to verify fulfilment of hospital-issued medication prescriptions View source Failure to limit prescription quantities and avoid duplicate prescribing for patients at high risk of medication overdose View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sarah Brady · 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
Sarah Brady, a 75-year-old woman, was admitted to hospital on 4 August 2020 after being found unresponsive at home following a presumed medication overdose. She deteriorated into multi-organ failure and died in hospital on 8 August 2020. The concerns included prescriptions exceeding the GP’s seven-day limit despite her history of overdose and erratic medication compliance, possible stockpiling of medication, and uncertainty about whether an additional hospital prescription had been fulfilled.
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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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify fulfilment of hospital-issued medication prescriptions
Wider context from the report “(2) Due to the above, Mrs Brady’s GP was only issuing 7 day prescriptions due to her high risk of overdose in order to limit medication availability. This included ████████ ████████ amongst others.
(3) Mrs Brady had already been issued with a prescription by her GP on 14/7/20 for her regular prescription medication;
(4) The inquest heard evidence that following a hospital admission in early July 2020, Mrs Brady was medically fit for discharge on 15/7/20 and a prescription was issued by the Sandwell & West Birmingham Hospital Trust for 14 days of ████████
████████████████████████████████████████████████████████████████████████
████████
(4) It was unclear from the evidence whether the prescription had actually been fulfilled by the hospital . I am concerned that Mrs Brady was issued with a prescription in excess of 7 days and for medication that had already been prescribed to her by her GP only the previous day and against a background of overdose and erratic compliance with her medications;
(5) The levels of ████████ found as a result of qualitative testing appeared to be well in in excess of her prescriptions and there was evidence that Mrs Brady may have been stockpiling medication. It is possible that the additional prescription, if supplied may have formed part of the medication taken by way of overdose.
(6) I heard at inquest that another similar prescription issued on 28/7/20 following a further admission had NOT been fulfilled .
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to limit prescription quantities and avoid duplicate prescribing for patients at high risk of medication overdose
Wider context from the report “(2) Due to the above, Mrs Brady’s GP was only issuing 7 day prescriptions due to her high risk of overdose in order to limit medication availability . This included ████████ ████████ amongst others.
(3) Mrs Brady had already been issued with a prescription by her GP on 14/7/20 for her regular prescription medication;
(4) The inquest heard evidence that following a hospital admission in early July 2020, Mrs Brady was medically fit for discharge on 15/7/20 and a prescription was issued by the Sandwell & West Birmingham Hospital Trust for 14 days of ████████
████████████████████████████████████████████████████████████████████████
████████
(4) It was unclear from the evidence whether the prescription had actually been fulfilled by the hospital. I am concerned that Mrs Brady was issued with a prescription in excess of 7 days and for medication that had already been prescribed to her by her GP only the previous day and against a background of overdose and erratic compliance with her medications ;
(5) The levels of ████████ found as a result of qualitative testing appeared to be well in in excess of her prescriptions and there was evidence that Mrs Brady may have been stockpiling medication. It is possible that the additional prescription, if supplied may have formed part of the medication taken by way of overdose.
(6) I heard at inquest that another similar prescription issued on 28/7/20 following a further admission had NOT been fulfilled.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that Mrs Brady was oversupplied with medication, stating supplies were limited or not dispensed.
Verbatim wording from the response “You will see from the attached list that, apart from the Aspirin, dispensed on 29 July 2020, medications were supplied for 7 days, 5 days or were not dispensed at all, instead giving back her own medications. The Aspirin was a new medication so was supplied to the level agreed with the CCG and in total only provided 2.1g, where the maximum daily dose for pain control is 4g.” Source location 2021-0224-Response-from-Sandwell-General-Hospital-Redacted
Open published response
31 Mar 2021 Joan Mavis COLEY · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of doctors' understanding of taking bloods from central lines and associated risks View source Failure to formally assess junior doctors' competence to take bloods from central lines View source Failure to formally assess and monitor doctors' procedural competence View source Limited medical school training on taking bloods from central lines and associated risks View source Failure to hand over junior doctors' procedural competencies between wards View source Lack of a standard written procedure for taking bloods from central lines 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
Joan Mavis COLEY · 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
Joan Mavis COLEY, who had end stage renal failure requiring dialysis, diabetes and an infected right foot, suffered a cardiac arrest after air entered her central dialysis line while blood was being taken. She was resuscitated but subsequently developed sepsis and died on 27 November 2020. The principal concerns were inadequate training, supervision, competency assessment and handover for junior doctors taking blood from central lines, together with the absence of a clear standard operating procedure.
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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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of doctors' understanding of taking bloods from central lines and associated risks
Wider context from the report “5. General understanding of the process to follow when taking blood from a central line and the associated risks: The inquest heard how there was a general lack of understanding of how to take bloods from a central line and the associated risks . The basic physiology was not understood and the consultant also did not know how to take blood from this central line . Consideration should be given to ensuring all doctors are fully aware of the basic principles when taking bloods from a central line and the associated risks.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess junior doctors' competence to take bloods from central lines
Wider context from the report “2. Induction programme for FY1 Doctors and assessment of base line competencies: The inquest heard how taking bloods from a central line is not part of the "check list" of tasks that junior doctors have to undertake . As a result there was no process in place to check whether an individual doctor was competent take bloods from a central line . This is inherently unsafe. Consideration should be given to adding "taking bloods from a central line" to the checklist of tasks.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally assess and monitor doctors' procedural competence
Wider context from the report “3. How to effectively assess and monitor competencies to undertake procedures: The inquest heard how there was no formal system for assessing a doctor's competence to undertake a particular task for example, taking bloods from a central line. The doctor would learn on the job with no formal training or assessment . When moving wards if a doctor agreed to undertake a procedure it was assumed they were competent and competent . This is inherently unsafe. The inquest heard how nurses have stringent criteria and training before they can handle any procedures. Consideration should be given to a similar process for junior doctors.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Limited medical school training on taking bloods from central lines and associated risks
Wider context from the report “1. Medical school training: The inquest heard evidence that there is very limited training on how to take bloods from a central line, the physiology involved and potential risks . The junior doctor in question did not feel she had adequate knowledge of the potential risk associated with the task she was undertaking. Urgent action is required to review what training is provided to medical students regarding taking bloods from central lines.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over junior doctors' procedural competencies between wards
Wider context from the report “4. Handover of competencies from ward to ward: The inquest heard how there was no system of hand over when junior doctors change from ward to ward . The junior doctor in this case was shadowing on a new ward and the Consultant in charge had no understanding of the doctors level of ability or competency . Consideration should be given to having a system to hand over ability and competencies.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard written procedure for taking bloods from central lines
Wider context from the report “6. Standard operating procedures for taking bloods from central lines: The inquest heard how there was no standard written procedure for taking bloods from a central line . Consideration should be given to having a national standard procedure, which should be linked with training and assessment of competency for doctors to take bloods from a central line.
” Open source report
5 Dec 2018 Mrs Sylvia Mitchell · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Inadequate communication of the risks of delayed pessary removal View source Failure to provide routine pessary cleansing View source Failure to ensure proper pessary fitting View source Failure to monitor vaginal integrity during pessary use 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
Mrs Sylvia Mitchell · 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 Sylvia Mitchell, a 90-year-old woman, died at Good Hope Hospital on 23 May 2018 after developing urosepsis associated with a fistula caused by an impacted Gellhorn pessary. The report identified inadequate communication and failures to adequately monitor and review the pessary, with delays in its removal contributing to her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of the risks of delayed pessary removal
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently .
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide routine pessary cleansing
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures .
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure proper pessary fitting
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting , routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor vaginal integrity during pessary use
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina . Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
” Open source report
29 Mar 2018 Mr Frank Hayward · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Delays in obtaining urgent CT scans View source Failure to obtain timely Trauma and Orthopaedics review View source Poor communication between the Orthotics Department and ward-based staff View source Poor systems for providing patient collars View source Failure to correctly assess and diagnose injuries in the Emergency Department View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Frank Hayward · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Frank Hayward fell at home on 12 November 2017, sustaining an odontoid peg fracture and subdural haemorrhage, and died on 10 December 2017 after his condition declined. The concerns included failures to correctly assess and diagnose his injuries, delays in Trauma and Orthopaedics review and urgent CT scanning, and poor systems and communication in obtaining a cervical collar.
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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining urgent CT scans
Wider context from the report “2. There was also evidence of poor systems in place in providing a collar for the patient and poor communication between the Orthotics Department and ward based staff. In addition there was a significant delay in obtaining an urgent CT scan .
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely Trauma and Orthopaedics review
Wider context from the report “1. Evidence emerged during the inquest that there were failures to correctly assess and diagnose his injuries in the Emergency Department and there were missed opportunities to have him reviewed by Trauma and Orthopaedics team sooner .
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication between the Orthotics Department and ward-based staff
Wider context from the report “2. There was also evidence of poor systems in place in providing a collar for the patient and poor communication between the Orthotics Department and ward based staff . In addition there was a significant delay in obtaining an urgent CT scan.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor systems for providing patient collars
Wider context from the report “2. There was also evidence of poor systems in place in providing a collar for the patient and poor communication between the Orthotics Department and ward based staff. In addition there was a significant delay in obtaining an urgent CT scan.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly assess and diagnose injuries in the Emergency Department
Wider context from the report “1. Evidence emerged during the inquest that there were failures to correctly assess and diagnose his injuries in the Emergency Department and there were missed opportunities to have him reviewed by Trauma and Orthopaedics team sooner.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor implementation of the approved head-injury guideline, including imaging, observation duration, specialist referrals and follow-through of requested actions.
Verbatim wording from the response “We will monitor the use of the approved Head Injury guideline following a period of implementation, but in particular we will be ensuring that:” Source location Frank-Hayward-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require all clinicians to use the head-injury proforma for hospital falls and Emergency Department presentations.
Verbatim wording from the response “The guideline used by clinicians to inform diagnostic testing and treatment of Head Injuries has been revised in line with the latest National Institute for Excellence (NICE) Clinical Guideline (CG176). Our guideline includes an algorithm of when to image the spine and the head injury proforma now includes a checklist for both head and neck imaging as a further prompt. This proforma was traditionally only used in the Emergency Department (ED), but will now be a requirement for all clinicians to use on any patient who sustains a fall in hospital as well as those who present to the ED. Equally the guideline will apply to anyone who has sustained a head injury, providing consistency with referrals and observations.” Source location Frank-Hayward-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide all Sandwell General Hospital wards with Orthotics contact details and substantive administrative support for timely referrals.
Verbatim wording from the response “At the time when Mr Hayward required a collar, the Orthotics Department was in the process of relocating onto the Sandwell General Hospital (SGH) site. This move, together with issues of transfer of telephone numbers and locum staff, delayed the referral being received and acted upon. All wards at SGH now have the contact details (number and email address) of the Orthotics Department to ensure contact is timely, with substantive administrative staff in place. Business Continuity plans are in place but are being reviewed to take account of staffing levels, given that this was a concern at the time of Mr Haywards admission.” Source location Frank-Hayward-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the approved head-injury guideline within one month and address identified implementation challenges.
Verbatim wording from the response “The revised draft guideline was recently shared at our Quality Improvement Half Days on 16th May, asking teams and specialties to take note of the requirements of the guideline and to highlight any challenges they see in implementing the changes and providing any solutions. The output of everyone’s sessions are being collated and shared with the Medical Director, Dr David Carruthers. We clearly need a guideline that provides for patients such as Mr Hayward, but need to balance this with any changes required to services to ensure this provision is possible. Dr Carruthers will ensure that the approved guideline is adopted within the next month, with plans to meet any specific challenges.” Source location Frank-Hayward-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold and daily replenish a stock of Miami J collars on the Newton 3 ward.
Verbatim wording from the response “Clinicians from Trauma & Orthopaedics have, since this incident, been trained in the application of Miami J collars, enabling patients to be fitted out of hours in future. A stock of Miami J collars is held on our T&O ward (Newton 3) and this is checked and replenished daily by the Orthotics team.” Source location Frank-Hayward-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the head-injury guideline to align with NICE guidance and add head-and-neck imaging prompts to the proforma.
Verbatim wording from the response “The guideline used by clinicians to inform diagnostic testing and treatment of Head Injuries has been revised in line with the latest National Institute for Excellence (NICE) Clinical Guideline (CG176). Our guideline includes an algorithm of when to image the spine and the head injury proforma now includes a checklist for both head and neck imaging as a further prompt. This proforma was traditionally only used in the Emergency Department (ED), but will now be a requirement for all clinicians to use on any patient who sustains a fall in hospital as well as those who present to the ED. Equally the guideline will apply to anyone who has sustained a head injury, providing consistency with referrals and observations.” Source location Frank-Hayward-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train Trauma and Orthopaedics clinicians to apply Miami J collars out of hours.
Verbatim wording from the response “Clinicians from Trauma & Orthopaedics have, since this incident, been trained in the application of Miami J collars, enabling patients to be fitted out of hours in future. A stock of Miami J collars is held on our T&O ward (Newton 3) and this is checked and replenished daily by the Orthotics team.” Source location Frank-Hayward-Response
Open published response
15 Jun 2017 Mrs Lily Townsend · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Failure to highlight patients as high risk before major surgery View source Inadequate consent discussions about major-surgery risks View source Inadequate preoperative medical history-taking and recording View source Failure to access relevant information across different systems View source Failure to use the existing preoperative care bundle 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
Mrs Lily Townsend · 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 Lily Townsend fell at home, was admitted to hospital with a fractured neck of femur, and died during cemented hemiarthroplasty after her oxygen saturation and blood pressure fell rapidly. Concerns included inadequate recording of her medical history, failure to identify her as being at extremely high risk for major surgery, inadequate consent, and whether an un-cemented operation might have reduced the risks.
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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight patients as high risk before major surgery
Wider context from the report “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension.
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were:
a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk .
b) Consent process inadequate.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate consent discussions about major-surgery risks
Wider context from the report “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension.
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were:
a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.
b) Consent process inadequate.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate preoperative medical history-taking and recording
Wider context from the report “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension .
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were:
a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.
b) Consent process inadequate.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to access relevant information across different systems
Wider context from the report “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension.
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were:
a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.
b) Consent process inadequate.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the existing preoperative care bundle
Wider context from the report “1. Evidence emerged during the inquest that during the preoperative assessment inadequate medical history was taken and there was a failure to record her previous myocardial infarction, ischaemic heart disease and pulmonary hypertension.
2. She had severe cardiopulmonary disease and should have been considered as at extremely high risk for major surgery. This should have been discussed with the patient and her family before consent being given.
3. The risks of the procedure may have been reduced by performing an un-cemented operation given the known potential cardiopulmonary complications of cement.
4. The Trust initiated an internal investigation and identified that the root causes were:
a) Failure to use existing care bundle and failure to access information across different systems contributed to inadequate pre-operative assessment and failure to highlight patient as high risk.
b) Consent process inadequate.
” Open source report
24 Nov 2016 Mrs Beryl Farmer · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Lack of completed falls risk assessments View source Failure to perform CT head scans after significant facial and head bruising View source Failure to justify moving patients at risk of falls from monitored to unmonitored bays View source Insufficient post-fall neurological observations before discharge View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Beryl Farmer · 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 Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the fall.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of completed falls risk assessments
Wider context from the report “1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform CT head scans after significant facial and head bruising
Wider context from the report “4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head .
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to justify moving patients at risk of falls from monitored to unmonitored bays
Wider context from the report “2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay .
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient post-fall neurological observations before discharge
Wider context from the report “3. After the fall, only one set of neurological observations were performed before her discharge .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recheck head-injury and inpatient-falls policies against NICE and NPSA standards.
Verbatim wording from the response “We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff” Source location 2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.
Verbatim wording from the response “We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March 2017.” Source location 2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the inpatient falls policy to require post-incident monitoring and link emergency-department and ward standards.
Verbatim wording from the response “We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March 2017.” Source location 2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue an internal Patient Safety Notice on neurological observations and linking inpatient falls with head-injury management.
Verbatim wording from the response “through our Intranet web site. Face to face training time will reinforce this pathway in the months ahead. Additionally we will issue a Patient Safety Notice (an internal safety alert) reminding staff of the importance of neurological observations and the link being made between the management of inpatient falls with a head injury and the pathway.” Source location 2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce the head-injury and falls-management pathway through face-to-face staff training.
Verbatim wording from the response “We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff” Source location 2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.
Verbatim wording from the response “We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff” Source location 2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
Open published response
3 Aug 2016 Winston Harris · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to communicate absconding risk in written hospital transfer documentation View source Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk View source Delays in processing DOLS applications View source Failure to include absconding risk and previous absconding behaviour in the care plan View source Failure to provide written confirmation of DOLS applications during hospital transfer View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Winston Harris · 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
Winston Harris, a resident with dementia, left hospital on 17 March 2016 after previously attempting to leave the ward. He was found at a bus stop the following day, severely hypothermic with an acute kidney injury, and died on 22 March 2016; the inquest concluded that he died from dilated cardiomyopathy contributed to by hypothermia and acute kidney injury. Concerns included inadequate documentation of his absconding risk and pending deprivation of liberty application, failure to consider an emergency deprivation of liberty safeguard, and delays in processing the application.
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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate absconding risk in written hospital transfer documentation
Wider context from the report “(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider emergency DOLS for a person presenting a relevant deprivation-of-liberty risk
Wider context from the report “(3) At no time did staff consider if Mr Harris should be subject to an emergency DOLS despite him having dementia and having tried to leave the ward on 16/03/2016. He had previously been assessed as requiring and DOLS.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in processing DOLS applications
Wider context from the report “(4) The application for DOLS order was not processed before Mr Harris’s death . I heard evidence that it often takes many months to process a DOLS application . Given these are extremely vulnerable people applications should be processed more quickly.
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include absconding risk and previous absconding behaviour in the care plan
Wider context from the report “(1) The care plan for Mr Harris did not deal with his risk of absconding . As a result when he was transferred to City Hospital with his care plan there were no details of his previous absconding behaviour .
” 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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide written confirmation of DOLS applications during hospital transfer
Wider context from the report “(2)When Mr Harris was transferred to hospital, without an escort, there was no written documentation provided to confirm that a DOLS had been applied for and that he was an absconding risk.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling audits of DoLS compliance among focused-care patients.
Verbatim wording from the response “The Trust is a national pilot site for work on Focused Care. Very commonly such patients are in receipt of capacity assessment, which then drives their additional nursing and care needs. These patients are registered centrally via our Safeguarding system. We have audited the compliance with DOLS for such patients. That audit continues on a rolling basis and we would expect to see the volume of cases rise among that cohort.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include DoLS policy and procedure requirements in induction for new staff.
Verbatim wording from the response “• An e-learning DoLS module is in development for nursing staff (ready by the end of November), and induction processes have been updated to include DoLS policy and procedure requirements for new staff.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Birmingham and Sandwell local authorities to streamline DoLS applications and address late responses.
Verbatim wording from the response “Partnership working
We are aware that both Birmingham and Sandwell Local Authorities are struggling to process the volume of DoLS requests they receive. However, we are working with them to see if there is a more streamlined approach to address the late responses to applications made by the Trust. The response periods will be centrally monitored and reported to me. Clearly as our volume of applications rises the resourcing issue will need to be faced.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Centrally monitor and report local-authority response periods for DoLS applications.
Verbatim wording from the response “Partnership working
We are aware that both Birmingham and Sandwell Local Authorities are struggling to process the volume of DoLS requests they receive. However, we are working with them to see if there is a more streamlined approach to address the late responses to applications made by the Trust. The response periods will be centrally monitored and reported to me. Clearly as our volume of applications rises the resourcing issue will need to be faced.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen Safeguarding Level 2 training with local scenarios and prioritised delivery for staff serving patients likely to need DoLS.
Verbatim wording from the response “• Strengthening the existing Safeguarding Level 2 staff training, which already includes the Mental Capacity Act and DoLS, by using local scenarios and improving the content and prioritising current training for those who may have more patients needing a DoLS.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and introduce a DoLS e-learning module for nursing staff.
Verbatim wording from the response “• An e-learning DoLS module is in development for nursing staff (ready by the end of November), and induction processes have been updated to include DoLS policy and procedure requirements for new staff.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Target relevant medical staff and require consultants to discuss DoLS implications and treatment impact with their teams.
Verbatim wording from the response “• Targeting medical staff who carry out consent procedures with patients to promote earlier consideration of the potential need for critical care in the event of a complication. Also all Consultants will be required to share this with their team to understand why DoLS may need to be applied and how treatments may impact on the need for a DoLS.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit wards and units to confirm DoLS awareness and support systems for new and temporary staff.
Verbatim wording from the response “• Structured audit with ward sisters and Unit matrons across the Trust, as the majority of the patients who may need a DoLS will be in these inpatient areas, to obtain confirmation that they have raised awareness of DoLS with all their staff and have systems in place to support new starters and temporary staff.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make a recorded DoLS workshop available as an internal training resource and publicise it across the organisation.
Verbatim wording from the response “• Videoing one of the workshops so that it can be shared both with those staff who could not attend, and as a training resource available on our Intranet. By the end of October this video will have been widely publicised inside the organisation.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspect wards and units to check whether DoLS are in place or required, and feed findings back to managers.
Verbatim wording from the response “We will use our continuing programme of in-house inspections to check that DoLS are in place or required, feeding our findings back to the ward and unit managers. The next round of visits take place on November 1st and 2nd and are focussing on the wards. Awareness of DOLS will be a key indicator in that process.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver ongoing DoLS education and awareness workshops for multidisciplinary staff.
Verbatim wording from the response “We have a well-developed training approach with staff. In recognising that the framework around DoLS is in place, the focus of attention is on the need to raise awareness, rather than revise the process. A programme of ongoing education and awareness is well advanced. To date it has included:” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a staff aide-memoire prompt for identifying and applying for DoLS.
Verbatim wording from the response “As you would expect we have the necessary policies and procedures in place. These provide both advice and instruction to staff. Having re-checked that material it remains suitable and is available to staff through our Intranet web site. What we have decided we need in order to augment that approach is an aide memoire or prompt for staff. This will be in place by the end of October.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policies, procedures and the DoLS framework remain suitable; further work should raise awareness rather than revise the process.
Verbatim wording from the response “As you would expect we have the necessary policies and procedures in place. These provide both advice and instruction to staff. Having re-checked that material it remains suitable and is available to staff through our Intranet web site. What we have decided we need in order to augment that approach is an aide memoire or prompt for staff. This will be in place by the end of October.” Source location 2016-0280-Response-by-Sandwell-and-West-Birmingham-NHS-Trust
Open published response
19 Apr 2016 Leslie William Carswell · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to reliably transmit CT scans between trusts for timely review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Leslie William Carswell · 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
Leslie William Carswell was admitted to hospital following a transcatheter aortic valve implantation, was assessed as being at high risk of falls, and suffered a serious brain bleed after falling while going to the toilet. The report raised concern that technical difficulties transmitting CT scans delayed review and treatment planning, with potential to delay lifesaving treatment for patients with urgent conditions.
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 Sandwell and West Birmingham Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably transmit CT scans between trusts for timely review
Wider context from the report “(1) There were technical difficulties transmitting the CT scans taken at 00.50 to the Queen Elizabeth Hospital in Birmingham for review which is the protocol for these west midlands. This caused a delay in deciding a treatment plan. I heard evidence at the inquest that these concerns are ongoing and no resolution has been found . There is a concern that patients with urgent conditions could have lifesaving treatment delayed due to technical difficulties between the two trusts .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all radiographers in the Image Exchange Portal and Image Link, with documented competency sign-off.
Verbatim wording from the response “3. Training – all radiographers (seventy members of staff who work various shift patterns) are being trained in IEP and Image Link, with a documented process for competency sign-off. Training commenced in June 2016 with a planned completion by the end of September 2016.” Source location 2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Image Exchange Portal procedure to clarify transmission routes, contingencies and audit-trail documentation.
Verbatim wording from the response “1. Procedure – the Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify how images are transmitted, including contingencies for out of hours and / or if there is a technical fault. The updated procedure includes changes to documentation requirements for audit trail purposes. This updated documentation procedure went live on 3 June 2016. System based audit trails are being looked into.” Source location 2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Configure all SWBH CT scanners to send images to Birmingham Children’s Hospital.
Verbatim wording from the response “2. System configuration – all three SWBH CT scanners can send images directly to UHB. One of the CT scanners at Sandwell Hospital can send to Birmingham Children’s Hospital. Work to ensure all SWBH CT scanners are configured to send images to Heartlands and Birmingham Children’s Hospital is in progress. Configuration to the Children’s Hospital is scheduled for completion by mid-June. A request for configuration work was submitted to IT colleagues at Heartlands in May 2016 and once approved it will take approximately two weeks to allow for firewall configuration and testing. These configurations will be a fixed point in our Managed Equipment Service specification.” Source location 2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Secure approval and complete configuration for all SWBH CT scanners to send images to Heartlands Hospital.
Verbatim wording from the response “2. System configuration – all three SWBH CT scanners can send images directly to UHB. One of the CT scanners at Sandwell Hospital can send to Birmingham Children’s Hospital. Work to ensure all SWBH CT scanners are configured to send images to Heartlands and Birmingham Children’s Hospital is in progress. Configuration to the Children’s Hospital is scheduled for completion by mid-June. A request for configuration work was submitted to IT colleagues at Heartlands in May 2016 and once approved it will take approximately two weeks to allow for firewall configuration and testing. These configurations will be a fixed point in our Managed Equipment Service specification.” Source location 2016-0147-Response-by-Sandwell-and-West-Birmingham-Hospitals
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations