Concerns raised 2 Failure of the immunotherapy alert card pathway to trigger distinct fast-track or priority assessment View source Failure to reliably prioritise and escalate time-critical immunotherapy toxicity within urgent oncology advice triage View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Graham Ian OXLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Graham Ian Oxley developed serious toxicity after receiving pembrolizumab immunotherapy following kidney cancer surgery, including inflammation affecting his heart, muscles and nerves. He deteriorated despite hospital treatment and life-sustaining treatment was withdrawn. The investigation identified concerns about delays in urgent oncology advice and the lack of a distinct priority pathway for patients presenting immunotherapy alert cards.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the immunotherapy alert card pathway to trigger distinct fast-track or priority assessment
Wider context from the report “(2) Immunotherapy alert card pathway - Patients are issued with an immunotherapy alert card intended to signal urgent risk. The Trust's response does not show that possession or presentation of an alert card triggers a distinct fast-track or priority pathway , instead linking it to the same triage arrangements .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably prioritise and escalate time-critical immunotherapy toxicity within urgent oncology advice triage
Wider context from the report “(1) Urgent oncology advice - The Trust describes access to urgent oncology advice through a queue-based triage system and accepts that delays may occur . The response does not demonstrate how time-critical immunotherapy toxicity is reliably prioritised or escalated when delays arise .
” 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 Implement call-handling escalation when triage-line waits exceed 12 minutes and incident-report those delays.
Verbatim wording from the response “In response to your report, we have further reviewed the arrangements for the triage line and have identified that patients may still wait some time for their call to be answered. We have put in place call-handling escalation arrangements whereby if call wait times exceed 12 minutes, staff on the triage line escalate immediately to the inpatient matron, who will take action to arrange further cover. Where patients wait over 12 minutes, staff will incident report this, creating a clear record of any instances where the escalation process is enacted.” Source location Response from Sheffield Teaching Hospital NHS Foundation 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 Review the pathway for specialist oncology assessment after emergency-department medical review and consider required changes.
Verbatim wording from the response “In Mr Oxley’s case staff were aware of the alert card and recognised that his immunotherapy put him at increased risk and as such he was placed appropriately in a side room. There is a clear process following medical review in A&E for patients to receive a specialist oncology review which would, where appropriate, lead to an admission to Weston Park Cancer Centre. In response to your concerns, we will review this pathway and consider if any changes are required.” Source location Response from Sheffield Teaching Hospital NHS Foundation 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 Redesign patient contact arrangements to reduce incorrect calls and route triage-line callers to the appropriate team.
Verbatim wording from the response “In response, we have reviewed and redesigned how patients and service users contact Weston Park Cancer Centre. We have reduced the amount of contact numbers in circulation and put in place arrangements to ensure the numbers that are publicised are answered by the right team who can assist with the query. As part of this change, patients contacting the triage line are presented with three options:” Source location Response from Sheffield Teaching Hospital NHS Foundation 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 Audit the impact of the triage-line call-handling escalation changes after three months.
Verbatim wording from the response “This escalation process was introduced in early May, and we plan to audit the impact of these changes in three months’ time.” Source location Response from Sheffield Teaching Hospital NHS Foundation Trust
Open published response
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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.
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 Sheffield Teaching Hospitals 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 Teaching Hospitals 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 Teaching Hospitals 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
Concerns raised 2 Lack of regard for the mother's knowledge of her pregnancy and estimated due date View source Lack of discussion with parents about possible measures in the event of premature labour before 22 weeks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mojeri Adeleye · 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
Mojeri Adeleye was born extremely prematurely after pre-labour premature rupture of membranes and died following premature labour. The report identified concerns that staff did not sufficiently regard his mother’s knowledge of her pregnancy and estimated due date, and that his parents were not involved in discussions about possible measures before the 22-week mark.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regard for the mother's knowledge of her pregnancy and estimated due date
Wider context from the report “The lack of regard towards Mojeri's mothers knowledge of her own pregnancy and the estimated due date for Mojeri.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of discussion with parents about possible measures in the event of premature labour before 22 weeks
Wider context from the report “The lack of discussion with Mojeri's parents about the possible measures that could be taken in the event of premature labour before the 22 week mark.
” Open source report
Concerns raised 2 Lack of clarity about the roles and responsibilities of those involved in care View source Failure to include and inform patients' own care staff in ward risk assessments and care plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joan Rossington · 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 Rossington was an inpatient at the Royal Hallamshire Hospital and received daytime support from her own care staff. After those staff had left on 16 June 2022, she fell while attempting to move across the ward, sustained significant head injuries, and died from those injuries on 17 June 2022. The principal concern was that her own care staff were not included in or aware of the ward’s care plans and risk assessments, including those relating to falls, creating a potential risk of care contrary to clinical guidance.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the roles and responsibilities of those involved in care
Wider context from the report “Joan was in receipt of support on the ward from her own care staff. These staff were not included in, or aware of, the risk assessments or care plans which were in place on the ward to support Joan. This had the potential to place Joan at risk of those staff delivering care which was contrary to that which was indicated by medics and clinicians responsible for her. Involvement in care planning and delivery of those supporting Joan would have made this a safer environment for her and the roles and responsibilities of those involved in care should be made clear .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include and inform patients' own care staff in ward risk assessments and care plans
Wider context from the report “Joan was in receipt of support on the ward from her own care staff. These staff were not included in, or aware of, the risk assessments or care plans which were in place on the ward to support Joan. This had the potential to place Joan at risk of those staff delivering care which was contrary to that which was indicated by medics and clinicians responsible for her. Involvement in care planning and delivery of those supporting Joan would have made this a safer environment for her and the roles and responsibilities of those involved in care should be made clear.
” Open source report
Concerns raised 6 Failure to support midwives to seek help when needed during delivery View source Lack of discussion of birthing options before labour View source Use of language in birth documentation that influences women toward natural birth View source Lack of safeguards for women not receiving continuous foetal heart rate monitoring View source Inadequate monitoring of foetal heart rate during delivery View source Failure to consult before changing from consultant-led to midwife-led care 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.
×
AI-generated summary
Millie-Rae Needham · 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
Millie-Rae Needham was born on 6 August 2020 and died in the neonatal unit on 9 August 2020 after a 23-minute delay in delivery during which her condition was not adequately monitored. Concerns included the move from consultant-led to midwife-led care without consultation, inadequate foetal heart-rate monitoring, limited discussion of birthing options, and safeguards for patients not receiving continuous monitoring.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to support midwives to seek help when needed during delivery
Wider context from the report “1. A decision was made by the midwife who had been with ████████ throughout her delivery to move to an episiotomy. Instead, the midwife that came to support encouraged further position changes leading to delay in delivery and inadequate monitoring of the foetal heart rate. Whilst the decision seek support for the episiotomy is not one which I would criticise, people should was able to ask for help when needed, the fact that the midwife who was with ████████ was talked out of this so readily resulting in avoidable delay is concerning.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of discussion of birthing options before labour
Wider context from the report “3. The lack of discussion with ████████ about birthing options prior to labour and therefore the lack of engagement with the pregnant woman is concerning.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of language in birth documentation that influences women toward natural birth
Wider context from the report “4. I have had sight of the new documentation around 'Born in Sheffield' and I am concerned by reference to 'normal birth' on the checklist . Again, this appears as though it is encouraging expectant mothers to be influenced into a natural birth when they may prefer to explore options such as caesarean section . Language is hugely important in terms of the experience individuals have when vulnerable.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of safeguards for women not receiving continuous foetal heart rate monitoring
Wider context from the report “5. Evidence was given about fresh eyes on continuous heart rate monitoring but there appear to be no safeguards in place for those not on continuous heart rate monitoring .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring of foetal heart rate during delivery
Wider context from the report “1. A decision was made by the midwife who had been with ████████ throughout her delivery to move to an episiotomy. Instead, the midwife that came to support encouraged further position changes leading to delay in delivery and inadequate monitoring of the foetal heart rate . Whilst the decision seek support for the episiotomy is not one which I would criticise, people should was able to ask for help when needed, the fact that the midwife who was with ████████ was talked out of this so readily resulting in avoidable delay is concerning.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult before changing from consultant-led to midwife-led care
Wider context from the report “2. The decision to move ████████ from consultant to midwife led care without consultation , although not contributory to Millie-Rae's death is concerning.
” Open source report
Concerns raised 4 Lack of access to support from regional neonatology colleagues View source Failure to inform parents about plans to review, reassess and remove a central line View source Failure to assess whether the national form meets unit requirements View source Failure to document requirements for review 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
Cassian Curry · 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
Cassian Curry was born at 28 weeks gestation and died after an umbilical venous catheter was left in a suboptimal position and was not reviewed as planned. The inquest found that the plan to review and pull back the line was not adequately recorded or communicated, including to the care team and Cassian’s parents, and that this contributed to his death. Concerns included staffing burden, the design and suitability of documentation forms, and access to wider regional neonatal support.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of access to support from regional neonatology colleagues
Wider context from the report “4. I heard about the Jessops Unit having responsibility, not only for babies already in the unit but also for some of the sickest and most premature babies in the region. I did not hear any evidence of how the Jessops Unit accesses support from colleagues across the region . I heard evidence of trying to access colleagues to support the Jessops Unit directly and a buddy system but there are other neonatology consultants across the Region who could provide remote assistance potentially if encouraged to think as a system.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform parents about plans to review, reassess and remove a central line
Wider context from the report “1. Cassian's parents were not told about the Consultant Plan to review, reassess and pull back Cassian's central line . Whilst this was not Cassian's parents’ responsibility, had they known about it they would have acted as a prompt for staff on a busy ward.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess whether the national form meets unit requirements
Wider context from the report “3. I heard evidence that the pink sheets have been reviewed and redesigned following Cassian's death and are now more directive. I also heard evidence that these forms are more detailed than the national requirements. Again, there does not seem to have been consideration of whether the national form would actually meet the requirements of this unit and that less information may be preferable in these circumstances.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document requirements for review
Wider context from the report “2. I had evidence that the staffing levels on the Jessops Wing are over the national requirements. This therefore led to an assumption that staffing was not an issue or a factor which led to the failure to document Cassian's requirement for review . However, there is a possibility that the number of staff placed an additional burden on the consultant (more junior staff means more questions) and that fewer staff may have offered greater consistency.
” 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 Amend umbilical-line documentation to clarify target positions and require informing parents about suboptimal catheter position.
Verbatim wording from the response “In addition, the updated umbilical line insertion checklist has been amended and now includes a specific entry requirement for informing parents if the catheter is in a suboptimal position.” Source location Response from Sheffield Teaching Hospital NHS Foundation 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 Audit documentation completed from May to July 2022 and benchmark it against forms used in other neonatal units to identify further improvements or simplification.
Verbatim wording from the response “To evaluate the impact of these changes an audit of the new form will be conducted reviewing forms completed during May-July 2022 to assess the current levels of completion and identify whether there is further scope for improvement or indeed simplification. As part of this process, we will review the documentation used in other neonatal units in order to benchmark practice.” Source location Response from Sheffield Teaching Hospital NHS Foundation 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 The neonatal unit was not overstaffed; staff experience, particularly during junior doctor rotations, was the contributory factor.
Verbatim wording from the response “Has overstaffing been considered as a possible factor in the confusion leading to the failure to handover and document the requirement to review Cassian?” Source location Response from Sheffield Teaching Hospital NHS Foundation Trust
Open published response
Concerns raised 1 Failure to make timely referrals of concerns about individual professional capabilities and practice to relevant professional bodies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Brian Rochell · 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
Brian Rochell was admitted to hospital on 10 April 2019 for surgery related to tongue cancer. He died on 26 April 2019 after an unsuccessful extubation caused a hypoxic brain injury. The principal concerns were that the extubation decision was made without adequate risk assessment, concerns from clinicians were given insufficient weight, and there was no clear plan for reintubation. The report also raised concerns about timely referral of professional practice concerns to the relevant professional body.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely referrals of concerns about individual professional capabilities and practice to relevant professional bodies
Wider context from the report “(1) I heard that there were concerns about individual practice in this case and that the result of that was an informal conversation with the relevant professional body and agreed steps being taken to moderate practice until the conclusion of the inquest. Where there are concerns about the professional capabilities and practices of a particular individual these should be addressed with the relevant professional body at the earliest opportunity by the employer. There may be cases where there will not be a coroner’s investigation and the purpose of a coroner’s investigation is not to assess the competence of professionals but rather to investigate the circumstances of the death. This means that where practice should be reviewed by professional bodies, failure to make appropriate referrals in a timely fashion could place other patients at risk in the future.
” Open source report
Concerns raised 10 Failure to understand and properly use hospital passports View source Insufficient training to embed practical knowledge and understanding of the Mental Capacity Act View source Failure to seek parents' views in Mental Capacity Act-compliant decision-making View source Inadequate detail in best-interests documentation View source Failure of senior clinicians to understand and apply Mental Capacity Act requirements View source Failure of clinical teams to seek the patient's views View source Failure to treat best-interests decisions as specific individual decisions View source Lack of knowledge, respect and application of Mental Capacity Act principles among staff treating patients who may lack decision-making capacity View source Failure to distinguish clinical decisions from supported or best-interests decision-making View source Failure to accurately complete verification of death forms View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Laura Booth · 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
Laura Booth died at the Royal Hallamshire Hospital on 19 October 2016 after becoming unwell during an admission for a routine procedure. The inquest found that inadequate management of her nutritional needs led to malnutrition, which contributed to her death, and that clinical decisions about her care were made without properly involving her or her parents under the Mental Capacity Act. The report also raised concerns about staff understanding and application of the Mental Capacity Act and the use of Laura’s hospital passport.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and properly use hospital passports
Wider context from the report “(10) I also remain concerned at a lack of understanding about the importance and relevance of Laura's hospital passport . This is a document which if read and understood by those treating Laura should mean that they can understand her, her communication style and her support needs so that she can be involved in decision making. It also should, if utilised properly , ensure that Laura's parents could have a level of reassurance that even if they were not there, Laura would be treated as if they were as staff would know how to communicate with Laura and understand what it was that she needed from them.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training to embed practical knowledge and understanding of the Mental Capacity Act
Wider context from the report “(4) I have seen evidence of online training tools which have been undertaken; whilst some training is better than no training it is clear to me that this training is insufficient to embed, in practice, knowledge and understanding of the Mental Capacity Act in a way which protects the vulnerable people it is intended to serve.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek parents' views in Mental Capacity Act-compliant decision-making
Wider context from the report “(6) Laura was non verbal but she could communicate. There was no evidence of anyone seeking Laura's parents' views in a way which would be compliant with the Mental Capacity Act and were worryingly, no evidence of clinical teams seeking Laura's views at all.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate detail in best-interests documentation
Wider context from the report “(7) There was evidence in the clinical notes of one best interests form completed for Laura's admission for her eye surgery. The completion of this form, whilst a positive that it had been completed and is evidence that best interests had been considered, remains woefully inadequate in details and upon further exploration it was apparent that no attempt had been made to engage Laura in the decision making.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior clinicians to understand and apply Mental Capacity Act requirements
Wider context from the report “(3) Having heard evidence at the inquest I remain gravely concerned that Senior Clinicians have limited or no understanding of the Mental Capacity Act and apply it in a way which undermines the principles and requirements of the legislation .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical teams to seek the patient's views
Wider context from the report “(6) Laura was non verbal but she could communicate. There was no evidence of anyone seeking Laura's parents' views in a way which would be compliant with the Mental Capacity Act and were worryingly, no evidence of clinical teams seeking Laura's views at all .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to treat best-interests decisions as specific individual decisions
Wider context from the report “(5) There appears to be a lack of understanding that decisions, when referred to in a best interests sense, are specific . This is not an overall catch all care plan . For example, the decision about whether Laura should receive an NG tube is one specific decision it is not bound up with ceilings of care decisions or any other decisions to be made with and for Laura.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge, respect and application of Mental Capacity Act principles among staff treating patients who may lack decision-making capacity
Wider context from the report “(2) I am satisfied and remain gravely concerned about the lack of knowledge, respect and application of the Mental Capacity Act principles amongst staff treating patients who may not have capacity to make decisions for themselves .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to distinguish clinical decisions from supported or best-interests decision-making
Wider context from the report “(8) There appeared to be a view that although there was no formal best interests meeting for decisions about Laura's nutrition, clinical discussions were taking place with the right clinicians and therefore the decisions would not be changed by a best interests meeting. This is a fundamental misunderstanding about the requirements of the Mental Capacity Act and best interests, clinical decisions are not a substitute for the individual being supported to decide for themselves or for a decision made in their best interests to be reflective of their own views . In the same way as an individual with capacity may decline a treatment, even where it is recommended by a clinician in the highest possible terms, a treatment or intervention can be declined on Ps behalf where that decision is made in their best interests in accordance with the requirements of the Mental Capacity Act. Where necessary this may require application to the Court of Protection where there is a dispute.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately complete verification of death forms
Wider context from the report “(9) I remain concerned that all staff treating Laura have expressed the view that they did not expect Laura to die in this admission and were very upset when she did. I am therefore at a loss as to why the verification of death form records her as being an expected death . I would therefore challenge the Trust to consider whether there is a need to reflect on the completion of these forms and their importance and likewise whether there is a need to reflect on presumptions made about an individual's underlying health conditions when completing verification of death forms .
” 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 Analyse complaints about MCA application and feed learning into the MCA steering group and staff training where appropriate.
Verbatim wording from the response “• Complaints will be analysed to identify any concerns relating to the application of MCA, which will be fed into the MCA steering group for action and into MCA staff training, where appropriate.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Disseminate MCA information across relevant staff groups to raise awareness.
Verbatim wording from the response “agreed to ensure the appropriate dissemination of information relating to MCA across relevant staff groups, in order to raise awareness.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Make MCA and DoLS questions available for senior clinician interviews to assess relevant skills and knowledge.
Verbatim wording from the response “In addition, in order to ensure that we recruit staff with the appropriate skills and knowledge, questions relating to the understanding of the MCA and DoLS are being made available for use in interviews for senior clinicians.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
Verbatim wording from the response “In order to assess the impact of this training, the following measures have been put in place and are on-going:” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Strengthen MCA training so all front-line clinical staff have the required knowledge.
Verbatim wording from the response “Over the past few years the Trust has undertaken a wide range of actions to embed the requirements of the Mental Capacity Act (MCA) and ensure that there is proactive support for learning disability patients, and other patient groups who may lack full capacity. Prior to the inquest into Laura’s death, we had started to give this area of work greater emphasis and the conclusions that you reached give further weight to the importance of this work, which includes:” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 accessible intranet resources covering MCA guidance, staff awareness and specialist support contacts.
Verbatim wording from the response “Over the past few years the Trust has undertaken a wide range of actions to embed the requirements of the Mental Capacity Act (MCA) and ensure that there is proactive support for learning disability patients, and other patient groups who may lack full capacity. Prior to the inquest into Laura’s death, we had started to give this area of work greater emphasis and the conclusions that you reached give further weight to the importance of this work, which includes:” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Re-launch the Health Passport, All About Me booklet and Hospital Communication Booklets through a communication strategy promoting accessibility and use.
Verbatim wording from the response “The Health Passport will be re-launched, along with the ‘All About Me’ and Hospital Communication Booklets as part of the MCA communication strategy. The communications will aim to raise awareness of the Passport and encourage staff to ask relevant patients if they have a Passport; if they do, staff should ensure that this is visible and accessible and if they do not, staff should advise the patient/carer to ask their provider to fill it in with them. As part of the re-launch staff will be advised to photocopy the Health Passport and give the original back to the patient (so it does not get mislaid), then ask the patient for permission to put the Passport in a visible place so that it is accessible to all staff who come into contact with the patient.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Roll out advanced MCA training to senior decision-makers, initially targeting Clinical Directors, and monitor uptake.
Verbatim wording from the response “We are committed to rolling out this more advanced training to all senior decision makers. This will initially be targeted at Clinical Directors who will then be tasked with deciding how best to deliver this within their directorates, which cover a wide variety of services. This approach will enable us to ensure training is tailored to the intended audience and that uptake is high. The progress of this advanced training will be monitored by the Mental Health Steering Group to ensure that all appropriate staff groups receive this training.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Further develop MCA training and supporting resources after Liberty Protection Safeguards are introduced.
Verbatim wording from the response “This training and the supporting resources will be further developed following the introduction of the Liberty Protection Safeguards in April 2022. The Trust has funded and is recruiting to a specialist team to support the implementation of this new process, which will further embed MCA processes and awareness across the organisation.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 Clinical Directors will decide how advanced Mental Capacity Act training is delivered within their respective directorates.
Verbatim wording from the response “We are committed to rolling out this more advanced training to all senior decision makers. This will initially be targeted at Clinical Directors who will then be tasked with deciding how best to deliver this within their directorates, which cover a wide variety of services. This approach will enable us to ensure training is tailored to the intended audience and that uptake is high. The progress of this advanced training will be monitored by the Mental Health Steering Group to ensure that all appropriate staff groups receive this training.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
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 The death was expected after the decision to provide best supportive care, so the verification-of-death documentation was accurate.
Verbatim wording from the response “In addition to these specific actions, you also highlighted concerns about the fact that the verification of death forms Laura’s death as being expected, when this was not reflected in the views expressed by the staff caring for her. As requested, Dr ████████, Clinical Lead for Infectious Diseases, has reviewed the verification of death process in this case and I attach a copy of his report for your information. Dr ████████ notes that, whilst at the start of Laura’s admission her death was not expected, this picture changed during her stay. On the last day of her life, Laura had a respiratory arrest from which she was successfully resuscitated, after which the decision was collectively made between the clinicians and Laura’s parents to move to best supportive care and not pursue further active treatment, escalation or resuscitation attempts.” Source location 2021-0137-Response-from-Northern-General-Hospital_Published
Open published response
10 Feb 2020 Joan Howard · Prevention of Future Deaths report South Yorkshire (West)
View report summary
Concerns raised 7 Delays in displaying nutritional requirements at the bedside View source Failure to escalate inappropriate dietary choices to the clinical team View source Unavailability of thickened fluids during outpatient appointments View source Failure to act on available nutritional requirements advice at admission View source Failure to provide food consistent with specialist nutritional requirements View source Failure to follow ward processes for managing specialist nutritional requirements View source Failure of staff to understand and follow specialist diet guidelines View source See 4 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
Joan Howard · 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 Howard was admitted to hospital on 4 April 2019 with specialist dietary requirements and choked to death on 10 April 2019 after being given a sandwich that should not have been provided. The report identified failures to follow dietary guidance and hospital processes, act on information from her care home, provide appropriate fluids, and escalate concerns about inappropriate food. It found that neglect had contributed 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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in displaying nutritional requirements at the bedside
Wider context from the report “g) Temporary posters for Joan’s nutritional needs were placed above Joan’s bed by staff once they became aware of the need for Joan to have a special diet. This was over 12 hours after her admission to the ward and therefore covered an evening meal, breakfast and lunch, during which inappropriate diet could have been given to Joan and definitely was at lunch time. This was despite information being available to the Ward from the care home Joan had been brought in from about her nutritional requirements. Additionally, the Royal Hallamshire Hospital where she had been discharged from earlier the same day before admission to the Northern General Hospital, had information about her nutritional requirements. It wasn’t until the family noticed that Joan had been given a sandwich at lunch time on 5 April 2019 that staff placed temporary posters above her bed.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate inappropriate dietary choices to the clinical team
Wider context from the report “e) The Senior Sister on the ward confirmed that where someone had capacity and made an unwise choice which contradicted the indication from speech and language therapy, she would expect staff to escalate this to the clinical team to have a discussion with the patient. This was confirmed by the Matron responsible for the presentation of the Serious Incident Investigation at Court however in Joan’s case, if staff were aware that the choice of two sandwiches and a piece of cake were inappropriate for Joan, they did not escalate this to the clinical team .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of thickened fluids during outpatient appointments
Wider context from the report “f) Joan was sent to an outpatient appointment with no thickener for fluids meaning that prior to her deterioration on the 9 April 2019 she had no access to fluids for the duration of her outpatient appointment and waiting .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on available nutritional requirements advice at admission
Wider context from the report “b) The care home from which Joan was admitted had provided appropriate advice about her nutritional requirements which was available to the hospital upon admission but which was not acted upon .
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide food consistent with specialist nutritional requirements
Wider context from the report “a) The SALT input into Joan’s care was exemplary. She had appropriate assessments and following a visit on the ward the day after her admission appropriate clear posters were placed above Joan’s bed confirming what nutrition she could have. Despite these posters, on two occasions Joan was provided with inappropriate food.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow ward processes for managing specialist nutritional requirements
Wider context from the report “c) The Senior Sister on the ward gave evidence which confirmed that there are processes in place for the management of specialist nutritional requirements on the ward however in this case these were not appropriately followed by staff .
d) The Senior Sister on the ward confirmed that she would expect her staff to follow the guidelines issued by the speech and language therapy team and to understand what was meant by level 2 fluids and level 6 food. This was not the case in practice.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand and follow specialist diet guidelines
Wider context from the report “c) The Senior Sister on the ward gave evidence which confirmed that there are processes in place for the management of specialist nutritional requirements on the ward however in this case these were not appropriately followed by staff.
d) The Senior Sister on the ward confirmed that she would expect her staff to follow the guidelines issued by the speech and language therapy team and to understand what was meant by level 2 fluids and level 6 food. This was not the case in practice.
” 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 Consider extending mandatory IDDSI training to non-Trust bank and agency staff.
Verbatim wording from the response “• Regarding bank and agency staff working within the Trust, these staff are recruited through NHS Professionals, and many are existing STH staff working additional hours over their contracted hours. These staff will have received their training as part of their substantive role. For non-STH employees, IDDSI does not form part of the mandatory training provided by NHS Professionals and this is therefore an issue which we will consider further as soon as practicable. In the interim, the additional measures now in place through the SOP and the Mealtime Safety Huddles, which are the responsibility of Trust Registered Nurses, will provide a further safety barrier at mealtimes.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 Record IDDSI eating, drinking, texture and fluid requirements on the Electronic Whiteboard and populate multidisciplinary handover sheets.
Verbatim wording from the response “Work has now been completed to incorporate the national IDDSI descriptors into the Electronic Whiteboard (EWB). This work had already been planned, but was expedited as a result of this incident. As a consequence, patients’ eating and drinking requirements, food texture and fluid consistency are now recorded on EWB. This is a visible prompt to all ward staff (not just nurses) about the patient’s individual requirements. This information then automatically populates the multi-disciplinary handover sheet that is printed from the EWB for ward staff to refer to. The EWB is recognised as a prime Multi-Disciplinary Team handover and effective communication tool within the Trust.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 Consider how to achieve consistency in IDDSI training for student nurses across the two universities.
Verbatim wording from the response “• Student nurses receive formal training through the universities and this includes teaching regarding dysphagia, swallowing, thickening, and SALT. They also spend 50% of their experience in practice and this will include practical training and supervision when caring for patients with dysphagia. Both Sheffield Hallam University and the University of Sheffield cover these elements within their student nurse training programmes, however the University of Sheffield training programme also incorporates IDDSI training. Consistency in student nurse training is therefore an issue which will need further discussion and we will give this matter appropriate consideration as soon as is practicable.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 Add mandatory IDDSI training to Job Specific Essential Training for staff involved in mealtime procedures.
Verbatim wording from the response “It is accepted that this approach did not make IDDSI training mandatory, nor could we be sure that every member of staff involved in mealtime procedures (including, for example, housekeepers) had received training in IDDSI through the cascade mechanism. We recognise the need for all staff engaged in mealtime duties to receive training in IDDSI and this will be achieved as outlined below:” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 Maintain Mealtime Safety Huddles as an additional safety barrier for staff involved in mealtimes.
Verbatim wording from the response “• In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners. The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In the meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 Expand the HANAT and Power of 3 audits to monitor IDDSI, SOP and hot-food-handling compliance.
Verbatim wording from the response “• Compliance with IDDSI, including the SOP, will be monitored through two existing audits which will be expanded to include IDDSI compliance. The first audit is the biannual Hydration and Nutrition Assurance Toolkit (HANAT). This has been updated to include specific questions in relation to the SOP and will be reviewed again by the Nutrition Steering Group prior to the next audit to include questions in relation to handling of hot food. The second audit is the annual ‘Power of 3’ audit of meal service, which has been updated to include audit of IDDSI, SOP compliance, and handling of hot food. This audit is undertaken by representatives from catering, dietetics, and senior nursing and involves the completion of an audit of meal service on one ward in each of the care groups annually.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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, disseminate and make available the ward meal-service SOP covering mealtime safety huddles and dietary requirements.
Verbatim wording from the response “Following the inquest, the SOP (attached) has been updated to include a description of the purpose and approach to the mealtime safety huddle. It has also been updated so that reference is made to specialist advice on patient fluid consistency and special dietary requirements in relation to snack boxes and light bites. The updated SOP is a key component of the e-learning package. It has been shared with matrons, included in the Catering Folder on each ward, and is available to order through the Trust’s ‘Xerox ‘print on demand’ process. Compliance with the SOP will be audited as described above.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 Implement the finalised Meal Service Safety e-learning package covering IDDSI, the SOP, mealtime safety huddles and hot-food handling.
Verbatim wording from the response “• IDDSI training will no longer be delivered by cascade, but through an e-learning package entitled ‘Meal Service Safety’. This approach will ensure consistency, appropriate levels of understanding, and refresher training. The training package will consist of three elements: IDDSI, the Standard Operating Procedure (SOP) which was shared at the inquest and has since been updated (copy attached), and guidance on handling hot food. The training will ensure staff are familiar with IDDSI principles and terminology, and all stages in the SOP. There will be specific focus on the ‘Safety Pause’ which has now been labelled the ‘Mealtime Safety Huddle’ as this is a concept with which nurses are already familiar. The e-learning will also include guidance on handling hot food which, although not an issue in the serious incident, is important in maintaining staff safety.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 wards with IDDSI diet signage and related patient information forms, including visible IDDSI level descriptions.
Verbatim wording from the response “For those patients who are admitted to hospital already requiring texture modified diets in the community, the ward teams can now record the information straight onto the EWB and the correct diet signage can be placed above the patient’s bed immediately. The SOP prompts staff to ensure that swallowing assessment detail is placed above the patient’s bed, and wards will now be provided with a supply of signage and related patient information forms so that temporary signage will not be required. Signage is also available to order through the Xerox ‘print on demand’ service and can be downloaded from the Trust intranet site. Signage now also includes a description of the IDDSI levels alongside the level of diet the patient is on, so that this information is clearly visible and easily accessible for staff ‘at a glance’.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 Mandate the Meal Service Safety e-learning package within the Prepare to Care programme for trainee clinical support workers.
Verbatim wording from the response “• In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners. The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In the meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 COVID-19 operational pressures prevent implementing all planned safety changes in the near future.
Verbatim wording from the response “Having outlined the actions we have agreed to take in response to this incident and to the PFD Report, I hope that I have been able to convey how seriously we have viewed this matter. Whilst we will be unable to implement all these changes in the near future, given the urgency of the situation in relation to COVID-19, we are absolutely committed to learning from Mrs Howard’s death and implementing the remaining actions at the earliest opportunity.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
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 For temporary transfers, existing host-ward responsibility, Electronic Whiteboard access and transfer policy address dietary-information communication.
Verbatim wording from the response “In relation to patients who are transferred from the ward temporarily, for example for an outpatient appointment or tests elsewhere within the Trust, it is accepted that inpatients remain the responsibility of the host ward in many aspects of their care, including nutrition and hydration. In addition, the outpatient or diagnostic area is able to access information from the EWB, to confirm or clarify the patient’s eating and drinking requirements. Our Patient Transfer Policy clarifies that the host ward must ensure up to date information about the patient is communicated to the receiving area to enable the immediate needs of the patient to be met on arrival.” Source location 2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
Open published response
Concerns raised 3 Unavailability of the on-call consultant for prompt attendance View source Failure of on-call senior doctors to ensure they awaken when telephoned View source Failure to correctly fulfil requests for two packs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Terence Millington · 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
Terence Millington, who had severe lung disease and metastatic cancer, suffered persistent nose bleeds at Weston Park Hospital on 18 November 2015 and died after a cardiac arrest. The concerns included inadequate arrangements for the on-call senior doctor to wake when called, the consultant’s distance from the hospital, and the incorrect supply of one of two requested nasal packs.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of the on-call consultant for prompt attendance
Wider context from the report “It is acknowledged that an incident investigation was undertaken by the Trust at my invitation during the inquest which sets out steps to be taken to prevent a repetition of the contact issue. Nonetheless I believe this report remains necessary so that lessons might be learnt beyond the Sheffield Teaching Hospitals Trust.
• That an on-call senior doctor (the SpR) did not make satisfactory arrangements to ensure that she would waken if telephoned.
• That the next on-call (the consultant) would have had no opportunity to attend promptly because of the distance from his home. The AA website shows that from the centre of Retford to Weston Park would take over 50 minutes although it is accepted that the consultant may live on the Sheffield side of Retford. For clarity, it is acknowledged that the consultant would not have had time to attend in this case (from when the request was actually made) even if living much closer.
• That the request for two packs was not met correctly.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of on-call senior doctors to ensure they awaken when telephoned
Wider context from the report “It is acknowledged that an incident investigation was undertaken by the Trust at my invitation during the inquest which sets out steps to be taken to prevent a repetition of the contact issue. Nonetheless I believe this report remains necessary so that lessons might be learnt beyond the Sheffield Teaching Hospitals Trust.
• That an on-call senior doctor (the SpR) did not make satisfactory arrangements to ensure that she would waken if telephoned.
• That the next on-call (the consultant) would have had no opportunity to attend promptly because of the distance from his home. The AA website shows that from the centre of Retford to Weston Park would take over 50 minutes although it is accepted that the consultant may live on the Sheffield side of Retford. For clarity, it is acknowledged that the consultant would not have had time to attend in this case (from when the request was actually made) even if living much closer.
• That the request for two packs was not met correctly.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly fulfil requests for two packs
Wider context from the report “It is acknowledged that an incident investigation was undertaken by the Trust at my invitation during the inquest which sets out steps to be taken to prevent a repetition of the contact issue. Nonetheless I believe this report remains necessary so that lessons might be learnt beyond the Sheffield Teaching Hospitals Trust.
• That an on-call senior doctor (the SpR) did not make satisfactory arrangements to ensure that she would waken if telephoned.
• That the next on-call (the consultant) would have had no opportunity to attend promptly because of the distance from his home. The AA website shows that from the centre of Retford to Weston Park would take over 50 minutes although it is accepted that the consultant may live on the Sheffield side of Retford. For clarity, it is acknowledged that the consultant would not have had time to attend in this case (from when the request was actually made) even if living much closer.
• That the request for two packs was not met correctly.
” 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 Provide an emergency epistaxis bag for on-call staff on ward 11 and monitor its availability and contents through monthly health and safety checks.
Verbatim wording from the response “3. In response to the issue of the availability of the two nasal packs, an emergency epistaxis bag for on-call medical staff who are required to attend patients elsewhere in the Trust is now available on ward 11 at the Royal Hallamshire Hospital. The availability and the contents of the bag have been incorporated within the monthly health and safety checklist so that this will be regularly monitored.” Source location 2017-0035-Response-by-Sheffield-Teaching-Hospital-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 On-call doctors must be able to attend within 30 minutes and consultants living farther away must arrange suitable local accommodation while on call.
Verbatim wording from the response “2. Regarding the issue of the next on-call doctor (the consultant) and the distance from his home to the hospital, an investigation of the case of this specific consultant is being undertaken by ████████ the Trust’s Medical Director. The requirement is for on-call medical staff to be able to attend the hospital within 30 minutes and, whilst there are a number of consultants who live more than 30 minutes away from the hospital, they are required to make arrangements to stay locally at a location which meets the ’30-minute requirement’ when on call.” Source location 2017-0035-Response-by-Sheffield-Teaching-Hospital-NHS-Trust
Open published response
19 Jan 2017 Teresa Dennett · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Lack of a clear pathway for referral for life-saving neurosurgery View source Lack of input from stroke physicians in appropriate cases View source Deficiencies in diagnostic imaging View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Teresa Dennett · 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
Teresa Dennett suffered a rare type of stroke and was admitted to hospital on 6 February 2016. Attempts were made to arrange urgent neurosurgery, but transfer did not occur before she deteriorated and died later that morning. The principal concerns were the absence of a clear referral pathway for life-saving neurosurgery, inadequate access to diagnostic imaging, and insufficient input from stroke physicians in appropriate cases.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear pathway for referral for life-saving neurosurgery
Wider context from the report “I have identified a key concern in this case (the absence of a clear pathway for referral for life-saving neurosurgery ) and two further concerns (regarding diagnostic imaging, and input from stroke physicians into appropriate cases).
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of input from stroke physicians in appropriate cases
Wider context from the report “I have identified a key concern in this case (the absence of a clear pathway for referral for life-saving neurosurgery) and two further concerns (regarding diagnostic imaging, and input from stroke physicians into appropriate cases ).
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in diagnostic imaging
Wider context from the report “I have identified a key concern in this case (the absence of a clear pathway for referral for life-saving neurosurgery) and two further concerns (regarding diagnostic imaging , and input from stroke physicians into appropriate cases).
” 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 Share the agreed emergency neurosurgical admission protocol with catchment-area trusts through the Working Together Partnership and Medical Directors.
Verbatim wording from the response “This draft protocol is in the process of being discussed with all relevant staff and, once agreed, it will be shared widely with all of the trusts within our neurosurgery catchment area as follows:” Source location 2017-0026-Response-by-Sheffield-Teaching-Hosipals-NHS
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 Draft and share a local protocol requiring acceptance and immediate transfer of time-critical neurosurgical patients with NUH.
Verbatim wording from the response “However, we agree that in this situation, to avoid any further delay we should simply have accepted the patient and adhering rigidly to the national guidelines was not in the patient’s best interests at that time. As a result of this situation, in addition to reviewing and discussing with ████████ the protocol developed by NUH, we have drafted our own local protocol for the admission of patients requiring emergency neurosurgical procedures, and I attach a copy of this for your information. This protocol has been shared with NUH. The protocol is in line with the SBNS guidelines and, importantly, also includes the following statement:” Source location 2017-0026-Response-by-Sheffield-Teaching-Hosipals-NHS
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 Discuss and finalize the local emergency neurosurgical admission protocol with relevant staff.
Verbatim wording from the response “This draft protocol is in the process of being discussed with all relevant staff and, once agreed, it will be shared widely with all of the trusts within our neurosurgery catchment area as follows:” Source location 2017-0026-Response-by-Sheffield-Teaching-Hosipals-NHS
Open published response
Concerns raised 6 Delays in initiating investigative procedures View source Unavailability of private investigative procedures View source Inconsistent timing and pathways for investigative procedures in differential diagnosis including ARVC View source Delays in multidisciplinary review of syncope investigations View source Inconsistent advice to fit young athletes about future exercise View source Inconsistent national management of syncope in young athletes 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
Peter John Hinchliffe · 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
Peter John Hinchliffe, a fit 33-year-old man, died after collapsing while cycling on 11 September 2010; the inquest concluded that the cause of death was arrhythmogenic right ventricular cardiomyopathy, which was undiagnosed and untreated. The principal concerns were delays and differing approaches in investigating syncope, including delays in transferring investigations to the NHS, and inconsistent advice about exercise for young athletes in a recognised red-flag situation.
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 Sheffield Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in initiating investigative procedures
Wider context from the report “(2) In the private sector there was delay initiating investigative procedures after the consultation on 29th June 2010.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of private investigative procedures
Wider context from the report “(1) All investigative procedures could not be undertaken privately and transfer to the National Health Service was necessary to complete investigations.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent timing and pathways for investigative procedures in differential diagnosis including ARVC
Wider context from the report “(4) Evidence revealed significant differences in the times and routes taken to undertake investigative procedures in cases where there is a differential diagnosis including ARVC.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in multidisciplinary review of syncope investigations
Wider context from the report “(3) Although Peter John Hinchliffe died approximately two weeks after transfer into the NHS system no further progress would have been made until after the MDT meeting in early October some 4 – 5 months after the incident of syncope.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent advice to fit young athletes about future exercise
Wider context from the report “(5) The evidence revealed inconsistencies of approach in advice to fit young athletes as to future exercise in what was generally acknowledged to be a ‘red flag’ situation.
” 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 Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent national management of syncope in young athletes
Wider context from the report “(6) Whilst there has been greater awareness since 2010 both locally and nationally of the need for timely and appropriate management of syncope in young athletes the approach to the problem does not appear to be consistent nationally and there is a continuing need to emphasise and act on this issue.
” 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