Concerns raised 3 Lack of a transfer protocol or pathway for transition from childhood to adulthood View source Lack of an effective review process for adults View source Failure to provide continuing adult care for patients with hydrocephalus shunts 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
Craig John BURFIELD · 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
Craig Burfield was admitted for surgery for bladder stones on 20 February 2023 and underwent surgery on 23 February 2023. He did not regain consciousness from the anaesthetic and died on 24 February 2023 at Northern General Hospital, Sheffield, following clots in his hydrocephalus shunt and cerebral sinus that caused brain swelling. The report raised concerns that shunt care did not continue into adulthood and that there were no effective transition, transfer, or review pathways for adults with such needs.
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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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a transfer protocol or pathway for transition from childhood to adulthood
Wider context from the report “During evidence from the family and ████████, author of the internal investigation, it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult. Also, there was no process for review of patients such as Craig.
████████ gave evidence that there remained no transfer protocol or pathway in place as children move into adulthood as at the current date nor an effective review process for adults at the present time. In evidence she stated that it was important that a clear pathway, including for transitions between childhood and adulthood , was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective review process for adults
Wider context from the report “During evidence from the family and ████████, author of the internal investigation, it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult. Also, there was no process for review of patients such as Craig .
████████ gave evidence that there remained no transfer protocol or pathway in place as children move into adulthood as at the current date nor an effective review process for adults at the present time . In evidence she stated that it was important that a clear pathway, including for transitions between childhood and adulthood, was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuing adult care for patients with hydrocephalus shunts
Wider context from the report “During evidence from the family and ████████, author of the internal investigation, it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult . Also, there was no process for review of patients such as Craig.
████████ gave evidence that there remained no transfer protocol or pathway in place as children move into adulthood as at the current date nor an effective review process for adults at the present time. In evidence she stated that it was important that a clear pathway, including for transitions between childhood and adulthood, was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal.
” 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 Formalise the transition process in a written pathway clarifying how young people with shunts move from children’s to adult services.
Verbatim wording from the response “Following the concern raised by Craig’s inquest, we will formalise the process with a written pathway so that it is clear to both SCFT and STHFT what process these young people will follow when transitioning to adult services. This will be complete by September 2024.” Source location Response from Sheffield Teaching Hospitals
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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 Participate in the regional innovator project to standardise developmentally appropriate transition care, including defined roles, staff training, personalised plans and patient tracking.
Verbatim wording from the response “Early in 2023 the South Yorkshire & Bassetlaw Acute Federation Trust Paediatric Innovator Programme was established, which includes a project on standardising developmentally appropriate healthcare for young people with chronic or complex conditions transitioning from paediatric to adult secondary care. This is a provider collaboration between STHFT, SCFT, Barnsley Hospital NHS Foundation Trust, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and The Rotherham NHS Foundation Trust. It is one of nine national provider collaborative innovators.” Source location Response from Sheffield Teaching Hospitals
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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 Operate an agreed cross-trust transition pathway covering records, individual plans, transfer information and attendance at the first adult appointment.
Verbatim wording from the response “We acknowledge that the arrangements for transition have not been as robust as they could have been, and we have been working hard to address this. The current transition process is reflected in the SCFT and STHFT Transition Policy and the Cross Trust Transition pathway which have been agreed between the two organisations (enclosed). The Cross Trust Transition pathway details the process followed by both organisations and includes:” Source location Response from Sheffield Teaching Hospitals
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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 Provide specialist transition-team support, including multidisciplinary discussions and assistance with initial adult appointments or inpatient ward visits for young people with complex needs.
Verbatim wording from the response “To support the transition process there are specialist transition teams at SCFT and STHFT; these teams work closely together to support young people with complex healthcare needs who are transitioning from child to adult healthcare. For patients with complex needs the Transition Teams facilitate a multi-disciplinary team discussion with the receiving specialities to ensure appropriate arrangements are in place. Where appropriate the STH Transition Team would also support with the initial appointment(s) in adult services and where there are likely to be inpatient admissions, arrange visits to the relevant wards.” Source location Response from Sheffield Teaching Hospitals
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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 Run a monthly transition clinic for hydrocephalus patients aged 14 and over, with extended appointments covering clinical review and transition preparation.
Verbatim wording from the response “For young people with shunts SCFT runs a monthly transition clinic where all hydrocephalus patients 14 years old and over are seen by clinical nurse specialists. The more complex hydrocephalus patients or those with other neurological conditions are followed up in a Consultant Neurosurgeon’s clinic and they will start to discuss transition with them from around 14 years old as per the SCFT and STHFT Transition Policy. These visits require longer appointment times as they cover a hydrocephalus check and discuss preparation for transition. At the last appointment before transition the patient is provided with contact details for the Neurosurgical secretaries so that they know who to contact if they have any concerns about their symptoms between appointments in the adult service.” Source location Response from Sheffield Teaching Hospitals
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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 Routine shunt reviews are not clinically required after transition; patients remain able to seek advice about symptoms or concerns.
Verbatim wording from the response “There is no clinical requirement for the routine review of shunts, however during appointments both before and after transfer, patients and/or their families are made aware of the signs and symptoms of a blocked shunt and what action they should take. If, following transition, a decision is made that further routine follow-up is not required, the patient will stay active on the neurosurgery pathway. Patients will be provided with contact details, so that the patient and family are aware of who to contact, including the Consultant’s secretary, for non-urgent enquiries or the on-call Neurosurgeon for urgent enquiries.” Source location Response from Sheffield Teaching Hospitals
Open published response
Concerns raised 2 Culture preventing medics from taking account of parents' or nursing staff's views in assessing patients' overall presentation View source Failure to adequately explain learning to junior doctors after consultant overruling 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
Kyra Ali Aslam · 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
Kyra Ali Aslam was admitted to Sheffield Children's Hospital for a planned procedure to reverse a stoma, deteriorated over two days after surgery, and died on 13 August 2022. The substantive concerns relate to whether medics adequately considered the views of parents and nursing staff, and whether junior doctors receive sufficient explanation when overruled by a consultant.
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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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Culture preventing medics from taking account of parents' or nursing staff's views in assessing patients' overall presentation
Wider context from the report “1. Whether there is a culture which prevents medics from taking account of the views of parents or nursing staff when considering the overall presentation of the patients
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately explain learning to junior doctors after consultant overruling
Wider context from the report “2. Where a junior doctor is over ruled by a Consultant, is that learning adequately explained to that junior doctor to learn for next time?
” 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 Implement the Parent and Carer Escalation process across all inpatient areas, with prominent posters and continuing promotion and monitoring.
Verbatim wording from the response “The Trust has implemented a new process to enable parents and carers to escalate concerns about their child’s clinical condition if they feel they are not being listened to. This new process is called PaCE (Parent and Carer Escalation). It is acknowledged by Sheffield Children’s NHS FT that failure to recognise and treat patients whose condition is deteriorating is a cause of significant harm in healthcare environments. One resource in the early detection of deterioration is the contribution that patients and carers can make.” Source location Response from Sheffield Children's NHS Foundation 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 Launch the Quality Promise quality strategy across the Trust to embed safe, kind and outstanding care.
Verbatim wording from the response “The continued work we are doing with our Quality Strategy, known as the Quality Promise, which has just been launched across the Trust, will assist in embedding our culture to provide safe, kind and outstanding care to everyone. In implementing human factors, engagement with leaders and everyone across the Trust highlighting the importance of listening to parents/ carers and other colleagues across the Trust, along with the learning culture that is being implemented through PSIRF (Patient Safety Incident Response Framework).” Source location Response from Sheffield Children's 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 Update nurse escalation policies and support them with training.
Verbatim wording from the response “The Trust has processes and policies in place for escalation by nurses should they feel that their concerns are not being heard, these policies are being updated and will be supported by training. The new Quality Matron post will play a significant part in enabling this culture change at ward level. All clinical colleagues also have access to the Freedom to Speak Up Guardian who will take concerns and raise these directly with the Executive Team.” Source location Response from Sheffield Children's 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 Embed the In It Together culture framework within the People Plan through leadership events and line-management training.
Verbatim wording from the response “• Embedding the Trusts ‘In it Together’ culture framework within our People Plan and supporting this with leadership events and line management training.” Source location Response from Sheffield Children's NHS Foundation 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 improved supervision training for all supervisors to make clinical contacts learning opportunities.
Verbatim wording from the response “As a Trust we have introduced a new way for consultants to evidence their upskilling as a Clinical and Educational Supervisor. This is now linked to their appraisal process within their Scope of Work and gives very clear suggestions on how to meet the seven domains required by the GMC. We believe that this will maintain high standards amongst our trainers, increase their accountability and ensure they receive regular training to improve their approach to teaching and give them confidence to challenge colleagues who are not meeting the same standards. Acute medicine can at times require fast decision making by the most senior colleague present which can be appropriate in emergency situations, however embedding improved supervision training for all supervisors will work towards ensuring that all clinical contacts are viewed as learning opportunities.” Source location Response from Sheffield Children's NHS Foundation 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 Provide additional time for specialty clinical tutor posts supporting educational faculty and trainee development.
Verbatim wording from the response “We have invested in additional time for speciality clinical tutor posts which support the development of educational faculty for doctors in training and as a local support for trainees to discuss their training and training needs. Any trainee placed at Sheffield Children’s has a personal clinical supervisor assigned to them, their role is to provide learning through case-based discussions and review of their experiences (and address unmet learning needs or concerns).” Source location Response from Sheffield Children's 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 Implement processes for clinical Care Groups to review complaints and Freedom to Speak Up themes involving unheard families or colleagues.
Verbatim wording from the response “The Trust has recognised that the views of parents and nursing staff have not always been listened to, through feedback we triangulate from inquests, serious incidents and complaints. As a result of this, we have undertaken a significant amount of work to consider and improve areas within our culture and the processes that underpin our ways of working. This includes:” Source location Response from Sheffield Children's NHS Foundation 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 appraisal-linked requirements for consultants to evidence Clinical and Educational Supervisor upskilling.
Verbatim wording from the response “As a Trust we have introduced a new way for consultants to evidence their upskilling as a Clinical and Educational Supervisor. This is now linked to their appraisal process within their Scope of Work and gives very clear suggestions on how to meet the seven domains required by the GMC. We believe that this will maintain high standards amongst our trainers, increase their accountability and ensure they receive regular training to improve their approach to teaching and give them confidence to challenge colleagues who are not meeting the same standards. Acute medicine can at times require fast decision making by the most senior colleague present which can be appropriate in emergency situations, however embedding improved supervision training for all supervisors will work towards ensuring that all clinical contacts are viewed as learning opportunities.” Source location Response from Sheffield Children's NHS Foundation Trust
Open published response
Concerns raised 6 Unclear handbook guidance on chickenpox reinfection and antibiotic treatment View source Confirmation bias affecting clinical reviews View source Lack of emergency department knowledge of secondary complication risks after recent chickenpox infection View source Insufficient weight given to GP referrals arriving outside the identified referral route View source Failure of junior staff to recognise when to escalate concerns View source Lack of proper assessment of existing skin lesions in chickenpox View source See 3 more concerns
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
James Philliskirk · 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
James Philliskirk was assessed twice in A&E after becoming unwell following a recent chickenpox infection and was sent home on both occasions. He developed sepsis and died at home on 13 May 2022. Concerns included failures to escalate to senior staff, unclear guidance on chickenpox reinfection and secondary complications, confirmation bias, inadequate assessment of skin lesions, and insufficient weight given to GP referral outside the usual route.
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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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear handbook guidance on chickenpox reinfection and antibiotic treatment
Wider context from the report “2. Unclear guidance in the handbook relating to chicken pox and reinfection and the need for aggressive antibiotic treatment if reinfection occurs soon after the initial infection
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confirmation bias affecting clinical reviews
Wider context from the report “3. Confirmation bias affecting clinical reviews
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of emergency department knowledge of secondary complication risks after recent chickenpox infection
Wider context from the report “5. Lack of knowledge of the risk of secondary complications from recent chicken pox infection in the emergency department
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient weight given to GP referrals arriving outside the identified referral route
Wider context from the report “6. Insufficient weight on GP referral when not through the identified route of referral (ie presentation straight to A&E which amounts to 25% of referrals ). I heard evidence that an IT system is in development to resolve this however engagement of NHS Digital and the Commissioners is required to progress. For the avoidance of doubt, had the GP referral been processed in the usual way James would have gone through to the medical unit and the result would have been senior oversight and a strong likelihood that James would have received IV antibiotics and survived.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of junior staff to recognise when to escalate concerns
Wider context from the report “1. Junior staff not knowing when to escalate concerns
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of proper assessment of existing skin lesions in chickenpox
Wider context from the report “4. Lack of proper assessment of existing skin lesions in chicken pox even where identified by parents
” 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 Further develop the chickenpox guideline with Emergency Department, infectious disease and paediatric clinicians.
Verbatim wording from the response “As provided in evidence during this request, the guideline relating to chicken pox was amended in response to immediate learning and a copy of this was sent to you on 2 May 2023. Subsequently more work is being undertaken to develop the guidelines further with the Emergency Department clinicians, Infectious disease specialists and the Paediatricians. This work will be completed by the end of September 2023.” Source location Response from Sheffield Children's NHS Foundation Trust 2
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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 Raise staff awareness of human factors by developing educational videos for current and future Trust staff.
Verbatim wording from the response “In addition, throughout the Trust, work is being done to raise awareness of human factors, their role in decision making and how errors can occur. Funding has been acquired to make educational videos highlighting this vitally important area. They will be used to support the education of all staff groups now and future cohorts across the Trust as well as in the ED.” Source location Response from Sheffield Children's NHS Foundation Trust 2
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 the ‘Keeping Safe in ED’ induction module covering human factors, confirmation bias, chickenpox learning and listening to parents.
Verbatim wording from the response “The induction training for junior doctors now includes a module called ‘Keeping Safe in ED’. In August 2022 this was added to the induction to discuss human factor principles (including confirmation bias) and the importance of listening to parents.” Source location Response from Sheffield Children's NHS Foundation Trust 2
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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 Improve junior-doctor induction training on escalation criteria, including reattendance, fever, chickenpox and sepsis.
Verbatim wording from the response “In order to address this concern, improvements to the induction training for junior doctors have been made. These improvements have included providing information on when junior staff should escalate concerns to senior staff. The guidelines relating to reattenders, fever, chicken pox and sepsis are brought to the attention of the junior doctors so that they are clear on when it would be appropriate to escalate. In addition, junior doctors receive regular WhatsApp messages and emails alerting them to any prevalent illness and the relevant training and information they need to access at that time.” Source location Response from Sheffield Children's NHS Foundation Trust 2
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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 primary-care colleagues towards a more permanent solution for the referral pathway.
Verbatim wording from the response “Our clinical management team will be working with our primary care colleagues towards a more permanent solution for the referral aspect of the patient pathway. At this time, we are unable to confirm whether this will require a digital solution such as an electronic referral system but have oversight from our digital colleagues to ensure that if such a solution is required it can be practically implemented.” Source location Response from Sheffield Children's NHS Foundation Trust 2
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send primary-care communications reminding providers to use the correct referral pathway and provide parents with the explanatory leaflet.
Verbatim wording from the response “As confirmed in evidence at the inquest, a reminder has been sent via the Integrated Care Board communications team to primary care, reminding them of the current referral system, so that the correct referral pathway is used, including a reminder to provide a copy of a new leaflet to parents explaining the system in place and the need to attend AAU (The Acute Assessment Unit).” Source location Response from Sheffield Children's NHS Foundation Trust 2
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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 Amend the chickenpox guideline to clarify secondary bacterial infection presentations and associated complications.
Verbatim wording from the response “The amended Chicken Pox Guideline is now clearer on how secondary bacterial infections can present.” Source location Response from Sheffield Children's NHS Foundation Trust 2
Open published response
Concerns raised 1 Failure of the CAMHS GP referral form process to capture sufficient information for timely assessment 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
Noah Lomax · 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
Noah Lomax, aged 15, died on 1 August 2018 after jumping from Conisbrough Viaduct, having previously expressed suicidal intentions and made plans to take his own life. His GP referral to CAMHS was closed because it contained insufficient information for a risk assessment, and his family were not notified. The principal concern was that the referral form and process could result in inadequate information being provided and delays in care.
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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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the CAMHS GP referral form process to capture sufficient information for timely assessment
Wider context from the report “1. As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP referral form . ████████, Noah’s GP, was inexperienced she had not completed a CAMHS referral form before. She accepted she had not provided sufficient detail in the form. This resulted in CAMHS being unable to assess Noah’s risk and declining Noah’s referral. This in turn meant that Noah did not receive an appointment with CAMHS before his death.
The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay. ”
████████, CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not sure how ████████ is able to be so confident about this.
I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form.
Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care.
” 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 Maintain updated referral guidance for use with CAMHS referrals.
Verbatim wording from the response “During the inquest it was confirmed that the referral guidelines were being updated with input from a General Practitioner. This has now been completed and the guidance is now in place and being used. The current form will continue to be used alongside the new guidance in mitigation until the actions outlined below have been completed.” Source location 2019-0186-Response-by-Sheffields-Childrens-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 Update referral guidance to support the revised CAMHS referral form.
Verbatim wording from the response “consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form. Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners.” Source location 2019-0186-Response-by-Sheffields-Childrens-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 Distribute the revised CAMHS referral form and supporting guidance to all General Practitioners by 12 July 2019.
Verbatim wording from the response “consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form. Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners.” Source location 2019-0186-Response-by-Sheffields-Childrens-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 Review and amend the CAMHS referral form using General Practitioner and service-user feedback.
Verbatim wording from the response “The CAMHS team have commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning the Sheffield Clinical Commissioning Group (SCCG), for comments. This draft was reviewed by SCCG’s Clinical Reference Group, which” Source location 2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
Open published response
20 Feb 2015 Lexie Louise Harrison · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 9 Lack of local policy and/or guidelines for paediatric endoscopic banding of oesophageal varices View source Failure to standardise Consultant practice for paediatric endoscopic banding of oesophageal varices View source Lack of defined Consultant competency and supervision criteria for the procedure View source Lack of standardised post-endoscopy care requirements View source Lack of a defined pre-procedure assessment process for banding programme patients View source Lack of defined patient suitability criteria for banding programmes View source Lack of defined criteria for which varices should undergo banding View source Lack of defined assessment and management steps for variceal bleeding View source Lack of precise definitions of oesophageal varix grades View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lexie Louise Harrison · 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
Lexie Louise Harrison, who had Infantile Refsum Disease, underwent an unsuccessful attempt to band an oesophageal varix on 30 May 2013, which caused trauma and extensive bleeding. Her condition deteriorated and she died at home on 18 June 2013; the medical cause of death was recorded as liver failure and Infantile Refsum Disease. The concerns included the absence of relevant policies or guidelines at two trusts and a lack of standardisation in practice, including decisions about banding, assessment, post-endoscopy care, management of bleeding, and consultant competence.
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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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of local policy and/or guidelines for paediatric endoscopic banding of oesophageal varices
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to standardise Consultant practice for paediatric endoscopic banding of oesophageal varices
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure , by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined Consultant competency and supervision criteria for the procedure
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised post-endoscopy care requirements
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined pre-procedure assessment process for banding programme patients
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined patient suitability criteria for banding programmes
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined criteria for which varices should undergo banding
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of defined assessment and management steps for variceal bleeding
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 Sheffield Children'S NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of precise definitions of oesophageal varix grades
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations