27 Apr 2026 Michael Chadwick · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1 Failure to provide patients with advice to stop driving and notify the DVLA about cough syncope View source
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AI-generated summary
Michael Chadwick · 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
Michael Chadwick died from injuries sustained when the motorcycle he was driving left the road. The principal concern was that, despite repeated reports of cough syncope, he was not advised to stop driving or notify the DVLA, raising concern that similar guidance may not be provided to other patients.
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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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with advice to stop driving and notify the DVLA about cough syncope
Wider context from the report “1. On the multiple occasions that Mr Chadwick was assessed, and his cough syncope brought to the attention of the medical professionals, there was no advice given him to stop driving and to notify the DVLA of his cough syncope, either orally or in writing .
I am concerned that clinicians may fail to provide similar guidance to other patients , which may lead to episodes of syncope whilst driving, with potentially fatal consequences.
” 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 Disseminate DVLA fitness-to-drive guidance to clinical governance leaders and clinicians through governance meetings, reports and email, requiring clinicians to familiarise themselves with it.
Verbatim wording from the response “Communication to all Heads of Service and Clinical Governance Leads” Source location Response from Sherwood Forest Hospitals NHS Trust
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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 Add a DVLA medical-conditions link, including syncope guidance, to the Cardiology specialist intranet page.
Verbatim wording from the response “The DVLA link regarding medical conditions to be added to Cardiology intranet page.” Source location Response from Sherwood Forest Hospitals NHS Trust
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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 Implement the Trust-wide “Fitness to Drive: Ask, Advise, Document” patient safety alert.
Verbatim wording from the response “Patient Safety Alert – Fitness to Drive: Ask, Advise, Document” Source location Response from Sherwood Forest Hospitals NHS Trust
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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 Add DVLA fitness-to-drive guidance to the EOLAS learning area and resources.
Verbatim wording from the response “Add the DVLA guidance to be added to the learning area on EOLAS, as part of the extended learning and resources.” Source location Response from Sherwood Forest Hospitals 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 Add DVLA fitness-to-drive guidance to the Trust intranet.
Verbatim wording from the response “Add DVLA guidance to the Trust intranet.” Source location Response from Sherwood Forest Hospitals NHS Trust
Open published response
25 Nov 2025 Connor Nelson · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 3 Lack of evidence of improvement in Emergency Assessment Unit staff ability to respond effectively to cardiac arrest View source Lack of a robust process for necessary referral and investigation of prolonged QTc syndrome View source Lack of medical staff understanding of the importance of identifying prolonged QTc syndrome View source
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AI-generated summary
Connor Nelson · 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
Connor Nelson died at Kings Mill Hospital on 30 November 2024 from hypoxic ischaemic encephalopathy following a prolonged cardiac arrest on 10 November 2024. The report describes an undiagnosed congenital prolonged QT syndrome, a nine-minute delay in administering a necessary shock, and concerns about cardiac-arrest response and processes for identifying and investigating prolonged QTc syndrome.
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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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of evidence of improvement in Emergency Assessment Unit staff ability to respond effectively to cardiac arrest
Wider context from the report “1. The lack of evidence of any improvement in the ability of Emergency Assessment Unit staff to respond effectively to a cardiac arrest
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust process for necessary referral and investigation of prolonged QTc syndrome
Wider context from the report “2. The lack of understanding by medical staff, of the importance of identifying prolonged QTc syndrome in patients attending KMH, with a lack of a robust process for ensuring necessary referral and investigation of the condition by the KMH Cardiology 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medical staff understanding of the importance of identifying prolonged QTc syndrome
Wider context from the report “2. The lack of understanding by medical staff, of the importance of identifying prolonged QTc syndrome in patients attending KMH, with a lack of a robust process for ensuring necessary referral and investigation of the condition by the KMH Cardiology team.
” 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 Include QT-measurement learning and pathway signposting in specialty and divisional governance reports.
Verbatim wording from the response “In addition, across all specialty and divisional governance reports in February 2026 information on the importance of measuring QT when undertaking an ECG will be included as a hot topic for further trust wide learning and signposting to the Prolonged QT Interval Identified on ECG in Adults Pathway.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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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 Review reported cardiac arrests trust-wide through the resuscitation team and provide feedback to relevant area leads.
Verbatim wording from the response “Review of cardiac arrests on EAU in December 2025:
To provide further assurance regarding improvements in the management of a cardiac arrest, all cardiac arrests on EAU during the period from 1st December to 30th December 2025 were reviewed by the trust resus team. It was confirmed that EAU initiated three 2222 calls (emergency calls), of these, one was categorised as a medical emergency for which cardiopulmonary resuscitation (CPR) was not required. The remaining two incidents were audited in accordance with the cardiac arrest governance process. One case raised no concerns, while the other identified issues related to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation—specifically, that although the DNACPR decision appeared to have” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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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 Deliver teaching for medical staff on measuring QT intervals and relevant prolonged-QT cut-offs.
Verbatim wording from the response “With regard to the recognition of Long QT syndrome, it was noted that there were several missed opportunities to identify a prolonged QT interval on Connor’s ECGs as the QT did not appear to have been measured. On 22nd January 2025, a dedicated teaching session was conducted for medical staff at Grand Round, led by the cardiology team, which specifically addressed the methodology for measuring the QT interval and the relevant cut-off values. To support the ongoing sustainability of this training, the accompanying PowerPoint presentation has been disseminated to all current medical consultants, to enable regular educational sessions to be maintained for the broader medical team.” Source location Response from Sherwood Forest Hospitals 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 Book new Emergency Assessment Unit staff onto the next available Immediate Life Support course.
Verbatim wording from the response “Immediate Life Support Training:
As of 23rd January 2026 91% of registered nurses working on EAU had undergone Immediate Life Support Training and the remaining 9% of staff are booked onto courses.” Source location Response from Sherwood Forest Hospitals 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 Issue the prolonged-QT clinical pathway to Trust staff through the intranet.
Verbatim wording from the response “During the patient safety incident investigation, it was identified that there was a knowledge gap regarding the management of Long QT and the Prolonged QT Interval Identified on ECG in Adults Pathway was developed which outlines the causes,” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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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 Introduce practical AED training into mandatory resuscitation sessions for nursing, midwifery, allied health professional and medical staff.
Verbatim wording from the response “Mandatory resuscitation training:
In addition, further measures have been implemented to enhance resuscitation training across all staff at SFH. Additional AEDs have been procured to facilitate the inclusion of AEDs as a practical, hands-on component within mandatory resuscitation training sessions. The introduction of this practical element will commence in April 2026, following the conclusion of the winter pause in mandatory training. This initiative will be delivered in conjunction with the E-Learning for Healthcare (E-LfH) content, which will be utilised by nursing, midwifery, and allied health professional (N.M&AHP) staff to fulfil Resuscitation Level 1 and 2 theoretical requirements, in alignment with the broader NHS training transferability plan. Simultaneously, mandatory sessions for medical staff will also be adapted to incorporate practical AED training from April 2026 onwards.” Source location Response from Sherwood Forest Hospitals 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 the revised Advanced Life Support course format, including AED demonstrations and practical skills assessment.
Verbatim wording from the response “Advanced Life Support Training:
Since the inquest was held the Resuscitation Council UK (RCUK) has introduced a revision to training protocols, now permitting the use of an Automated External Defibrillator (AED) during cardiac arrest demonstrations, as well as the discussion of AED usage within the CPR and defibrillation skill station as part of the Advanced Life Support (ALS) course. This updated course format became effective as of 1st January 2026 nationally, and its implementation will commence with the ALS courses, consisting of 1-day online learning plus 1 day of hands-on training with a comprehensive skill station assessment, scheduled for 21st and 22nd January at Sherwood Forest Hospitals (SFH).” Source location Response from Sherwood Forest Hospitals 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 Disseminate the QT-measurement teaching presentation to current medical consultants for wider educational use.
Verbatim wording from the response “With regard to the recognition of Long QT syndrome, it was noted that there were several missed opportunities to identify a prolonged QT interval on Connor’s ECGs as the QT did not appear to have been measured. On 22nd January 2025, a dedicated teaching session was conducted for medical staff at Grand Round, led by the cardiology team, which specifically addressed the methodology for measuring the QT interval and the relevant cut-off values. To support the ongoing sustainability of this training, the accompanying PowerPoint presentation has been disseminated to all current medical consultants, to enable regular educational sessions to be maintained for the broader medical team.” Source location Response from Sherwood Forest Hospitals 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 prompt Advanced Life Support training for newly appointed Band 6 nurses.
Verbatim wording from the response “It is recognised, that the rotation of new staff within EAU has the potential to affect training compliance rates, particularly for training such as ALS. To address this, a comprehensive plan has been implemented to ensure that all new Band 6 staff promptly receive the necessary training upon appointment. Furthermore, measures are being explored to provide existing Band 5 registered nurses looking for development opportunity therefore supporting both ongoing professional development and the maintenance of a highly skilled workforce.” Source location Response from Sherwood Forest Hospitals 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 Include resuscitation-service teaching on equipment and defibrillator operation in doctor induction programmes.
Verbatim wording from the response “Changes to Doctor induction:
Effective from 3rd December 2025, the doctor induction programme now incorporates a dedicated session delivered by the trust resuscitation service. This session provides an overview of the adult resuscitation trolley and its contents, as well as instruction on the two defibrillator models used at SFHFT and their operational functions. The session is made available to Foundation Year 2 (FY2) doctors and higher at each entry point throughout the training year. Foundation Year 1 (FY1) doctors receive a separate induction covering the same material in July.” Source location Response from Sherwood Forest Hospitals 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 Complete specialty and divisional sign-off of amendments to the prolonged-QT clinical pathway.
Verbatim wording from the response “During the inquest, the introduction of this new clinical document was duly noted. However, concerns were raised regarding its level of detail, particularly in relation to its suitability for staff without specialised experience in cardiology. Consequently, amendments have been implemented to address these concerns, as reflected in the draft pathway provided in Attachment 2. The draft pathway is progressing through the specialty and divisional sign off process with an anticipated completion date at the end of February 2026.” Source location Response from Sherwood Forest Hospitals 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 Monitor Advanced Life Support compliance through monthly service-line performance meetings and escalate issues as required.
Verbatim wording from the response “ALS training compliance will now be included in the service line performance meetings monthly commencing February 2026 to enable consistent monitoring and escalation as required.” Source location Response from Sherwood Forest Hospitals 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 Deliver and continue in-situ cardiac-arrest simulation sessions for Emergency Assessment Unit nursing and medical staff.
Verbatim wording from the response “In situ skills and drills simulation sessions:
During December 2025, a total of nine simulation sessions were scheduled to be undertaken on EAU with both nursing and medical staff, with additional sessions continuing into subsequent months. These sessions were being led by the resus team and were set to include the following key topics:” Source location Response from Sherwood Forest Hospitals 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 Procure additional AEDs for practical mandatory resuscitation training.
Verbatim wording from the response “Mandatory resuscitation training:
In addition, further measures have been implemented to enhance resuscitation training across all staff at SFH. Additional AEDs have been procured to facilitate the inclusion of AEDs as a practical, hands-on component within mandatory resuscitation training sessions. The introduction of this practical element will commence in April 2026, following the conclusion of the winter pause in mandatory training. This initiative will be delivered in conjunction with the E-Learning for Healthcare (E-LfH) content, which will be utilised by nursing, midwifery, and allied health professional (N.M&AHP) staff to fulfil Resuscitation Level 1 and 2 theoretical requirements, in alignment with the broader NHS training transferability plan. Simultaneously, mandatory sessions for medical staff will also be adapted to incorporate practical AED training from April 2026 onwards.” Source location Response from Sherwood Forest Hospitals 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 Monitor incidents for prolonged-QT recognition trends and escalate concerns to the appropriate specialty.
Verbatim wording from the response “The governance support unit will continue to monitor incidents for trends and themes and ensure any concerns with incidents regarding recognition of Long QT are escalated to the appropriate specialty for review.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
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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 Three planned Emergency Assessment Unit simulation sessions were cancelled because staffing and operational constraints prevented their delivery.
Verbatim wording from the response “Of the planned sessions, six were successfully delivered, attended by 18 staff members, resulting in an average attendance of three participants per session. Three sessions were cancelled due to staffing and operational constraints. Furthermore, nine additional sessions are scheduled for January 2026. It should be noted that, owing to the small group sizes and the restricted nature of the space utilised for "in situ" training, these sessions are not directly comparable to previous simulation events. Within the limitations of the skills practised, staff performance was assessed by the trust resuscitation team to be of a satisfactory standard.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
Open published response
24 Oct 2025 Sophie Louise TOWLE · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 12 Lack of policy prompts for cross-sector consultation in foreign-body cases View source Lack of clarity about the current personality disorder service and level of provision View source Lack of staff working knowledge of the current local VTE policy View source Absence of a specialised central personality disorder service View source Failure of the foreign-object insertion policy to require mental health consultation View source Insufficient staffing capacity on mental health wards View source Insufficient experience across the mental health ward staff pool View source Ineffective communication of foreign-object insertion policy and guidance to staff View source Insufficient or ineffective training on the VTE policy View source Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases View source Failure of the local VTE policy to provide clear, robust and consistent assessment requirements View source Lack of specific, clear and robust policy guidance for managing foreign-object insertion View source See 9 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
Sophie Louise TOWLE · 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
Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy prompts for cross-sector consultation in foreign-body cases
Wider context from the report “1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies
I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body.
There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult.
If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the current personality disorder service and level of provision
Wider context from the report “3. The disbanding of the Personality Disorder Hub at NHCT
I am told that as of mid-October 2025, the Personality Disorder Hub at NHCT has been disbanded. Neither the witness who worked within the disbanded service, nor the policy witness for NHCT was able to give me any particulars as to the arrangement of the new service, beyond a general statement that it was being absorbed into the LMHTs. I was told by the witness who had worked within the PDH that his understanding for his LMHT was that there would be a personality disorder service which would consist of him, as that was his specialist interest.
Given the current inquiry into Mental Health Services in Nottinghamshire, and particularly the care of those patients with personality disorders within the service, I am concerned about the lack of clarity within the Trust as to the current position and level of service available to patients with personality disorders.
I am concerned that an absence of a specialised and central service dealing with personality disorder patients, with care provided by specialists in personality disorder, causes a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff working knowledge of the current local VTE policy
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a specialised central personality disorder service
Wider context from the report “3. The disbanding of the Personality Disorder Hub at NHCT
I am told that as of mid-October 2025, the Personality Disorder Hub at NHCT has been disbanded. Neither the witness who worked within the disbanded service, nor the policy witness for NHCT was able to give me any particulars as to the arrangement of the new service, beyond a general statement that it was being absorbed into the LMHTs. I was told by the witness who had worked within the PDH that his understanding for his LMHT was that there would be a personality disorder service which would consist of him, as that was his specialist interest.
Given the current inquiry into Mental Health Services in Nottinghamshire, and particularly the care of those patients with personality disorders within the service, I am concerned about the lack of clarity within the Trust as to the current position and level of service available to patients with personality disorders.
I am concerned that an absence of a specialised and central service dealing with personality disorder patients, with care provided by specialists in personality disorder , causes a risk of future death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the foreign-object insertion policy to require mental health consultation
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity on mental health wards
Wider context from the report “5. Staffing on mental health wards
I have been told by numerous witnesses to this inquest that the staffing levels on Fir Ward both at the time of Sophie’s admission, and now, are insufficient. The result of that, I am told, is that the wards cannot run safely and patient care and safety negatively impacted. Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require. I saw a genuine concern and regret on the faces of the hardworking healthcare professionals who gave evidence in my court of the course of this inquest, some were brought to tears. The job is relentless, and they do not feel supported by virtue of a lack of staff numbers and experience. I am told that this remains the case notwithstanding that the minimum staffing levels as governed by the Department of Health and Social Care are being met. This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board, that the wards are not functioning safely and that patients are at risk of death as a result.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient experience across the mental health ward staff pool
Wider context from the report “5. Staffing on mental health wards
I have been told by numerous witnesses to this inquest that the staffing levels on Fir Ward both at the time of Sophie’s admission, and now, are insufficient. The result of that, I am told, is that the wards cannot run safely and patient care and safety negatively impacted. Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require. I saw a genuine concern and regret on the faces of the hardworking healthcare professionals who gave evidence in my court of the course of this inquest, some were brought to tears. The job is relentless, and they do not feel supported by virtue of a lack of staff numbers and experience. I am told that this remains the case notwithstanding that the minimum staffing levels as governed by the Department of Health and Social Care are being met. This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board , that the wards are not functioning safely and that patients are at risk of death as a result.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective communication of foreign-object insertion policy and guidance to staff
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient or ineffective training on the VTE policy
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an embedded mechanism for cross-sector MDT meetings and liaison in foreign-body cases
Wider context from the report “1. Lack of joint agency policy/cross-sector working between physical and mental health trusts in relation to the insertion of foreign bodies
I heard evidence that it would have been beneficial in Sophie’s case for there to have been an MDT between Sophie’s psychiatric team (NHCT) and her physical health team (Orthopaedics and Anaesthesia at SFH). The reason that this would have been of assistance is due to the complexity of cases where there are physical and mental health considerations in play for decisions around the management of a foreign body.
There is no embedded mechanism for arranging MDT meetings, or indeed for any liaison or contact between these teams, in such cases. Similarly, there is no policy or procedure which prompts clinicians from either team to consider an MDT in these cases or, at the very least, picking up the phone for a consult.
If this had happened in Sophie’s case, it seems likely that the outcome in relation to the management of the foreign body would have been different. Sophie’s psychiatric team were keen for removal and were satisfied that they could implement a robust policy to avoid re-insertion, which was one of the main concerns of the Orthopaedic team.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the local VTE policy to provide clear, robust and consistent assessment requirements
Wider context from the report “2. VTE risk assessment and associated policy and training at NHCT
During the course of Sophie’s inquest, I heard evidence which concerns me that there is a lack of clarity in relation to the current local VTE policy. I was provided with version of the policy that I have assured was current at the outset of the inquest. All witnesses who were directly asked about this policy recognised it as the current policy in its terms. On 22 October 2025, I was sent late disclose of the correct updated policy which was ratified in April 2025 (available to view from May 2025), some 6 months before the inquest hearing began. The updated policy was materially different in its terms on the frequency and circumstances in which VTE risk assessments should be undertaken. This gives rise to a number of specific concerns:
A) The staff do not have a proper working knowledge of the current local VTE policy.
B) The knock-on concern from this is that the training around the VTE policy is not robust in its content or is otherwise not being properly engaged with by staff.
C) The current policy has been weakened in its terms, in particular at paragraph 1.6 where the requirement for an updated assessment of risk on at least a weekly basis has been removed. I understand from the evidence that, notwithstanding the wording changes to the policy, prompts are given on VTE risk assessment at the weekly MDTs. I am concerned that the policy is not reflective of the encouraged practice on the Wards. I am also concerned that, whilst this happens on Fir Ward, it is important that guidance is consistent across all wards within the Trust. The common document across the wards is the local policy and therefore I am concerned about the clarity and robustness of its terms.
In my opinion there is a risk that future deaths could occur unless action is taken in relation to this issue.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific, clear and robust policy guidance for managing foreign-object insertion
Wider context from the report “4. The policy and procedures around the management of insertion of foreign objects for SFH
I have had sight of the newly ratified local policy for management of insertion of foreign objects at SFH. I am concerned that its content is lacking in specificity, the language used is vague and open to interpretation, and it does not provide clear advice for medical professionals accessing it for guidance. It is not a robust policy in its terms.
Further, I am concerned that it does not make any reference to consultation of mental health services, whether local or acute, at all. Given that the policy recognises that in the majority of cases where management of insertion of foreign objects the patient has a mental health condition, I find this particularly concerning.
Based on the evidence that I have heard, I am also concerned that there is no effective communication of the policy and guidance to Trust staff on this issue.
” 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 and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.
Verbatim wording from the response “Upon conclusion of the Inquest, a comprehensive review of the SOP for deliberately inserted foreign bodies, as initially presented to HM Coroner, was undertaken. This review was conducted with the support and oversight of the Governance Support Unit to ensure rigorous examination and improvement of the procedure.” Source location Response from Sherwood Forest Hospitals 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 Disseminate the approved foreign-bodies guideline to staff involved in managing patients presenting with deliberately inserted foreign bodies.
Verbatim wording from the response “On 28th November 2025, the document entitled “Management of Deliberately Inserted Foreign Bodies Guideline” was formally ratified at the Surgery, Anaesthetics and Critical Care Divisional Governance meeting. The final approved guideline is now available on the Trust intranet for clinicians to access and has been disseminated to all staff directly involved in the management of patients presenting with deliberately inserted foreign bodies.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
Open published response
22 Jul 2024 Theodore Riley Bradley · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to treat bleeding in pregnancy as potentially serious until proven otherwise View source Failure to follow established antepartum haemorrhage guidance View source Failure to act promptly when women present with antepartum haemorrhage View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Continue multidisciplinary review of Antepartum Haemorrhage cases through the weekly Triggers meeting, escalating incidents and learning when required.
Stated completedThe respondent said that this action was complete when they made their response on 1 August 2024. View source
Action
Provide individualised support and training to staff who do not understand the amended guideline.
Stated plannedThe respondent said that this action was planned when they made their response on 1 August 2024. View source
Action
Update, ratify and disseminate the Antepartum Haemorrhage guideline, including immediate assessment, worst-case assumptions, telephone triage, escalation, and documentation requirements.
Stated completedThe respondent said that this action was complete when they made their response on 1 August 2024. View source
Action
Disseminate the RED React, Escalate, Diligent prompt cards and associated guidance on managing and escalating bleeding.
Stated completedThe respondent said that this action was complete when they made their response on 1 August 2024. View source
Action
Deliver and monitor mandatory training on BSOTS triage, BadgerNet documentation, cumulative blood-loss recording, and related PROMPT requirements.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024. View source
Action
Develop and provide an Antepartum Haemorrhage scenario video demonstrating telephone triage and BSOTS assessment.
Stated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024. View source See 3 more actions
×
AI-generated summary
Theodore Riley Bradley · 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
Theodore Riley Bradley was born on 14 September 2023 with no heart rate, breathing effort or movement after prolonged intrauterine hypoxia associated with a partial placental abruption. The report identifies a 37-minute delay before his mother was assessed at the maternity triage unit, and states that relevant maternity triage and antepartum haemorrhage policies were not followed. The principal concerns were a failure to respond promptly to vaginal bleeding in pregnancy and wider concerns about the management of antepartum haemorrhage.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to treat bleeding in pregnancy as potentially serious until proven otherwise
Wider context from the report “1, The lack of prompt action when a woman presents with an antepartum haemorrhage (APH). This Inquest revealed a culture within the midwifery team of not acting promptly when there is vaginal bleeding in pregnancy. There was an assumption that there was a benign cause for bleeding, rather than assuming, until proven otherwise that there is a serious cause, such as an abruption, that may require immediate intervention.
Well established APH Trust guidance was not followed
I set out that difficulty in effectively managing APH is also an accepted issue, for the neighbouring NUH NHS Trust , who are currently reviewing their guidance, and approach to managing APH.
It is clearly a regional issue and may be a national one.
I am not reassured that necessary actions to address these serious issues identified are in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow established antepartum haemorrhage guidance
Wider context from the report “1, The lack of prompt action when a woman presents with an antepartum haemorrhage (APH). This Inquest revealed a culture within the midwifery team of not acting promptly when there is vaginal bleeding in pregnancy. There was an assumption that there was a benign cause for bleeding, rather than assuming, until proven otherwise that there is a serious cause, such as an abruption, that may require immediate intervention.
Well established APH Trust guidance was not followed
I set out that difficulty in effectively managing APH is also an accepted issue, for the neighbouring NUH NHS Trust , who are currently reviewing their guidance, and approach to managing APH.
It is clearly a regional issue and may be a national one.
I am not reassured that necessary actions to address these serious issues identified are in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act promptly when women present with antepartum haemorrhage
Wider context from the report “1, The lack of prompt action when a woman presents with an antepartum haemorrhage (APH). This Inquest revealed a culture within the midwifery team of not acting promptly when there is vaginal bleeding in pregnancy . There was an assumption that there was a benign cause for bleeding, rather than assuming, until proven otherwise that there is a serious cause, such as an abruption, that may require immediate intervention.
Well established APH Trust guidance was not followed
I set out that difficulty in effectively managing APH is also an accepted issue, for the neighbouring NUH NHS Trust , who are currently reviewing their guidance, and approach to managing APH.
It is clearly a regional issue and may be a national one.
I am not reassured that necessary actions to address these serious issues identified are in place.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue multidisciplinary review of Antepartum Haemorrhage cases through the weekly Triggers meeting, escalating incidents and learning when required.
Verbatim wording from the response “Antepartum Haemorrhage cases will continue to be reviewed through our ‘triggers’ incident review meeting, to ensure that the recommendations within the updated guideline are being followed. ‘Triggers’ is a weekly multidisciplinary case review” Source location Narrative Response from Sherwood Forest Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide individualised support and training to staff who do not understand the amended guideline.
Verbatim wording from the response “The amended guideline received a multidisciplinary review including the obstetric service leads, midwifery matrons, and midwifery staff prior to ratification through the Maternity and Gynaecology Clinical Governance Meeting. Following ratification of the guideline, the updates have been shared with all staff members. The guideline updates have been shared via email and in person on shift handovers, and all staff have been asked to sign a registration sheet as evidence that they have read and understood the amendments. Additional support and training will be provided on an individualised basis to staff that do not understand the changes, this will be supported by their line manager and the practice development midwives.” Source location Narrative Response from Sherwood Forest Hospitals
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 Update, ratify and disseminate the Antepartum Haemorrhage guideline, including immediate assessment, worst-case assumptions, telephone triage, escalation, and documentation requirements.
Verbatim wording from the response “The Trust has reviewed and updated its Antepartum Haemorrhage (APH) guideline to emphasise the clinical importance of bleeding in pregnancy, and the requirement for an immediate assessment of fetal and maternal condition with any degree of bleeding. The guideline now informs staff that best practice is to treat bleeding with an expectation of a worse-case scenario and then de-escalate if appropriate, rather than treating it as benign. A telephone assessment section has been included within the Antepartum Haemorrhage guideline. This includes the need to consider transfer into hospital by ambulance and highlights the need to prepare the midwifery coordinator and obstetric staff in preparation for an incoming admission.” Source location Narrative Response from Sherwood Forest Hospitals
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 Disseminate the RED React, Escalate, Diligent prompt cards and associated guidance on managing and escalating bleeding.
Verbatim wording from the response “An acronym has been developed within Trust, RED – React, Escalate, Diligent, with guidance next to each point on the expected management of bleeding. This includes reacting to the initial reported blood loss by advising attendance to triage and consideration of calling an ambulance. Escalating to the coordinating midwife, obstetric and triage staff that an attendance with bleeding is anticipated, and being diligent around the assessment of bleeding – preparing for an abnormality until proven otherwise. Prompt cards of the acronym have been disseminated to all clinical areas and shared via email to all staff members, and additional prompt card advising the potential causes of bleeding has been shared alongside this.” Source location Narrative Response from Sherwood Forest Hospitals
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 Deliver and monitor mandatory training on BSOTS triage, BadgerNet documentation, cumulative blood-loss recording, and related PROMPT requirements.
Verbatim wording from the response “A training programme has commenced focusing on the key areas of learning. This initially included refresher training for the core triage and Band 7 coordinating midwives on the Birmingham Symptom Specific Obstetric Triage System (BSOTS) BadgerNet (the Trusts Maternity electronic patient record) requirements. Delivered by the Trust’s Digital Midwife, the training including how to correctly document triage telephone calls within BadgerNet contemporaneously and how to utilise the ‘blood loss’ form correctly which in turn ensures any cumulative bleeding throughout pregnancy is captured. In addition, a BSOTS e-learning package has been mandated” Source location Narrative Response from Sherwood Forest Hospitals
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 Develop and provide an Antepartum Haemorrhage scenario video demonstrating telephone triage and BSOTS assessment.
Verbatim wording from the response “The Maternity team are currently developing an Antepartum Haemorrhage scenario video that includes role play of a phone call in progress whilst a midwife completes the BSOTS telephone call proforma. This consists of a prompt and brief assessment (triage) of women when they present with unexpected problems or concerns, and then a standardised way of determining the clinical urgency and setting the time in which they need to be seen. This will be available for staff members to access anytime and has been included within our BSOTS Training Needs Analysis (TNA).” Source location Narrative Response from Sherwood Forest Hospitals
Open published response
2 Jul 2024 Arlo River Phoenix Lambert · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Failure to capture early reflective accounts from key staff View source Failure of the Antepartum Haemorrhage guideline to convey urgency and account for occult blood loss View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Disseminate the ratified Antepartum Haemorrhage guideline changes to maternity staff through email and shift handovers, with read-and-understood acknowledgements.
Stated completedThe respondent said that this action was complete when they made their response on 4 July 2024. View source
Action
Implement a Trust-wide system, templates, guidance, staff engagement, governance, and review prompts for capturing early factual recollections after incidents.
Stated completedThe respondent said that this action was complete when they made their response on 4 July 2024. View source
Action
Introduce Edinburgh Emergency Medicine STOP 5 hot debriefs to provide immediate team discussion, document learning, and highlight factual-recollection requirements after incidents.
Stated plannedThe respondent said that this action was planned when they made their response on 4 July 2024. View source
Action
Update and ratify the Antepartum Haemorrhage guideline to require urgent assessment, worst-case assumptions, bleeding quantification, telephone triage, and preparation for potential ambulance transfer.
Stated completedThe respondent said that this action was complete when they made their response on 4 July 2024. View source See 1 more action
×
AI-generated summary
Arlo River Phoenix Lambert · 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
Arlo River Phoenix Lambert died aged 5 days after sustaining a hypoxic-ischaemic brain injury during the intrapartum period. The report describes multiple missed opportunities to deliver him earlier, alongside systemic failings in clinical guidance, escalation, communication and handover. Concerns included a lack of urgency in the Trust’s antepartum haemorrhage guideline and the absence of a clear system for obtaining early reflective accounts from key staff.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to capture early reflective accounts from key staff
Wider context from the report “2. Failure to ensure early reflective accounts were captured from key staff in response to this significant event and others. I consider this to be a Trust wide issue. The Trust cannot begin to rectify patient safety issues, if they do not understand exactly what happened and why. This analysis can only properly occur with the input of those involved in care, and in circumstances where those individuals have had the opportunity and support of the Trust to capture early written accounts. The Trust currently has no clear system in place to facilitate this early capture of relevant accounts .
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Antepartum Haemorrhage guideline to convey urgency and account for occult blood loss
Wider context from the report “1. The Trust’s Antepartum Haemorrhage guideline gives no sense of urgency when staff are faced with a bleed – here, staff failed to appreciate the potential for a sinister cause of bleeding both at 21.18 and later at 03.40, and did not appear to appreciate the fact that a volume of the bleeding may well be occult, by the external volume representing only a small proportion of the actual blood loss . Miss Al-Samarrai accepted that further work was likely to be required in this regard.
” 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 Disseminate the ratified Antepartum Haemorrhage guideline changes to maternity staff through email and shift handovers, with read-and-understood acknowledgements.
Verbatim wording from the response “Following ratification of the guideline, the updates have been shared with all staff members. The guideline updates have been shared via email and in person on shift handovers, and all staff have been asked to sign a registration sheet as evidence that they have read and understood the amendments. Additional support and training will be provided on an individualised basis to staff that do not understand the changes, this will be supported by their line manager and the practice development midwives.” Source location Response from Sherwood Forest Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Trust-wide system, templates, guidance, staff engagement, governance, and review prompts for capturing early factual recollections after incidents.
Verbatim wording from the response “The Trust have put in place a system of capturing early Factual Recollection of Events, which are a description of involvement in an incident at the time it occurred but are not a replacement for the medical record.” Source location Response from Sherwood Forest Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Edinburgh Emergency Medicine STOP 5 hot debriefs to provide immediate team discussion, document learning, and highlight factual-recollection requirements after incidents.
Verbatim wording from the response “The Trust’s Maternity department, supported by the Professional Midwifery Advocates, are reviewing the immediate responses taken following an incident as defined within the Trusts Incident Reporting Policy and are planning to introduce the Edinburgh Emergency Medicine ‘STOP 5’ moments for ‘Hot Debriefs’. This will enable clinicians involved in an incident to have a 5-minute team debrief immediately following an incident. During this team debrief, the need to complete a Factual Recollection of Events will be highlighted to relevant staff and will provide the clinicians with a space to discuss what went well and the opportunities to improve. The debrief will be documented and saved on the Incident reporting system.” Source location Response from Sherwood Forest Hospitals NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and ratify the Antepartum Haemorrhage guideline to require urgent assessment, worst-case assumptions, bleeding quantification, telephone triage, and preparation for potential ambulance transfer.
Verbatim wording from the response “The Trust has reviewed and updated its Antepartum Haemorrhage guideline to emphasise the clinical importance of bleeding in pregnancy, and the requirement for an immediate assessment of fetal and maternal condition with any degree of bleeding. The guideline now informs staff that best practice is to treat bleeding with an expectation of a worse-case scenario and then de-escalate if appropriate, rather than treating it as benign. The causes of Antepartum Haemorrhage section within the guideline has been amended to highlight that bleeding in pregnancy is not normal and can be unpredictable, and the expectation around quantifying and documenting repeated episodes of bleeding within the patient record has been added to support the ongoing risk assessments.” Source location Response from Sherwood Forest Hospitals NHS Trust
Open published response
4 Apr 2024 Tommy Jay Gillman · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Delays in triage of ill babies in Paediatric ED View source Insufficient paediatric nursing capacity and senior nurse support in the Emergency Department View source Delays in escalation for ill babies in Paediatric ED View source Failure to provide joint assessment by senior Emergency Department and Paediatric staff View source Failure to produce clear action plans and allocated tasks from handovers and escalations View source Failure to routinely document handovers and key staff conversations View source Failure of the system for recognising an ill baby in Paediatric ED View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 19
Action
Require paediatric triage documentation to confirm SBAR verbal handover and monitor compliance through monthly audit.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Require adult nurses caring for children to complete specified paediatric experience, training, study days, e-learning and supervised shadowing.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Record paediatric nursing staffing as a significant risk and review it monthly through specialty and Trust risk committees.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Install live Nervecentre observation dashboards in clinical areas to identify elevated PEWS scores and overdue observations.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Establish a Children and Young People’s Working Group to review related policies and procedures, including joint working, pathways, recruitment and operations.
Stated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024. View source
Action
Roster registered children’s nurses during identified peak emergency-department attendance periods.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Use designated Tier 3-or-above doctors to oversee children’s care, reducing handovers and improving continuity.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Add a peak-time Band 5 registered-nurse shift and improve Healthroster displays to identify children’s-area registered children’s nurse cover gaps.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Record and electronically calculate children’s observations using Nervecentre and PEWS, with handheld devices enabling real-time access.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Train an Emergency Department adult nurse as a paediatric nurse, increasing staffing by one whole-time equivalent.
Stated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024. View source
Action
Develop a rotational pathway for registered children’s nurses through continuous Emergency Department and paediatric collaboration.
Stated plannedThe respondent said that this action was planned when they made their response on 15 April 2024. View source
Action
Review the Paediatric Sepsis 6 Care Bundle to incorporate heightened sepsis risk for children with Trisomy 21 and babies under three months.
Stated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024. View source
Action
Provide newly qualified registered children’s nurses with discipline-specific preceptors, supernumerary practice and Emergency Department induction.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Review and circulate the Children and Young People escalation tool, including triage-time triggers and required escalation actions.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Implement a supervisory Band 7 Nurse in Charge role providing visible senior nursing support across the Emergency Department, with supernumerary deployment from July 2024.
Stated plannedThe respondent said that this action was planned when they made their response on 15 April 2024. View source
Action
Review medical documentation and audit nursing records, providing feedback, education and support where required.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Produce, implement and disseminate Senior Review and out-of-hours Emergency Department Consultant Call Criteria.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Review Emergency Department escalation processes for proactively identifying and escalating nursing staffing concerns.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source
Action
Update the children’s Emergency Department operating procedure with minimum medical training requirements and restrict direct care by staff who do not meet them.
Stated completedThe respondent said that this action was complete when they made their response on 15 April 2024. View source See 16 more actions
×
AI-generated summary
Tommy Jay Gillman · 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
Tommy Jay Gillman died on 8 December 2022 at Leicester Royal Infirmary after Salmonella Brandenberg meningitis caused sepsis and multi-organ failure. The report identified missed opportunities at Kings Mill Hospital, including delays in triage, escalation, monitoring, intravenous fluids and antibiotics. Concerns included insufficient paediatric nursing cover, undocumented handovers and an inadequate system for recognising and escalating the care of seriously ill babies.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in triage of ill babies in Paediatric ED
Wider context from the report “3. The system for recognising an ill baby in Paediatric ED is not robust- from the point of attendance, through timely triage , timely escalation, and joint assessment by senior ED and Paediatric staff.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient paediatric nursing capacity and senior nurse support in the Emergency Department
Wider context from the report “1. At times of high pressure and business, the Paediatric nursing complement is insufficient in the Emergency Department . There are inexperienced Paediatric nurses trying to manage a very high workload, without senior nurse support to try and increase staffing levels on a shift. The Facing the Future (RCPCH) standards for levels of Paediatric nursing are not met
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in escalation for ill babies in Paediatric ED
Wider context from the report “3. The system for recognising an ill baby in Paediatric ED is not robust- from the point of attendance, through timely triage, timely escalation , and joint assessment by senior ED and Paediatric staff.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide joint assessment by senior Emergency Department and Paediatric staff
Wider context from the report “3. The system for recognising an ill baby in Paediatric ED is not robust- from the point of attendance, through timely triage, timely escalation, and joint assessment by senior ED and Paediatric staff .
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce clear action plans and allocated tasks from handovers and escalations
Wider context from the report “2. Handovers and key conversations between staff, both nursing and medical staff, in ED and with Paediatric staff are not routinely documented, and outcomes from handovers and escalations do not result in clear action plans and allocated tasks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document handovers and key staff conversations
Wider context from the report “2. Handovers and key conversations between staff, both nursing and medical staff, in ED and with Paediatric staff are not routinely documented , and outcomes from handovers and escalations do not result in clear action plans and allocated tasks
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for recognising an ill baby in Paediatric ED
Wider context from the report “3. The system for recognising an ill baby in Paediatric ED is not robust - from the point of attendance, through timely triage, timely escalation, and joint assessment by senior ED and Paediatric staff.
” 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 Require paediatric triage documentation to confirm SBAR verbal handover and monitor compliance through monthly audit.
Verbatim wording from the response “SBAR (Situation, Background, Assessment and Recommendation) is the recognised structure for communication and handing over patients for staff. The ED Registered Nurse local induction covers structured handovers and accountability handover and staff are provided with examples of how to use handover effectively. Whilst structured handovers must be used for any verbal handover there was no documentation requirement to confirm whether this had taken place at the time of Tommy’s attendance to the ED. The ED Paediatric triage document has been updated and nurses are now required to confirm an SBAR verbal handover has been provided:” Source location Response from Sherwood Forest Hospitals 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 Require adult nurses caring for children to complete specified paediatric experience, training, study days, e-learning and supervised shadowing.
Verbatim wording from the response “• A minimum set of core competencies that adult nurses must have completed prior to caring for a child or young person has been agreed as follows:” Source location Response from Sherwood Forest Hospitals 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 Record paediatric nursing staffing as a significant risk and review it monthly through specialty and Trust risk committees.
Verbatim wording from the response “• RNC staffing within the ED is recorded on the Trust risk register as a significant risk and is reviewed monthly by the speciality and Trust Risk Committee. This has led to the development of the rotational post (see below).” Source location Response from Sherwood Forest Hospitals 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 Install live Nervecentre observation dashboards in clinical areas to identify elevated PEWS scores and overdue observations.
Verbatim wording from the response “When considering visibility of observations, a further review was undertaken following the Inquest and it was recognised that the methodology to monitor whether patients were receiving observations at the required frequency in real time required improvement. Within both the major’s area and children’s and young people area large screens which provide a Nervecentre oversight dashboard of a specific task have been installed. The location of these was carefully considered to ensure there was no information governance risk whilst ensuring they were in a location easily visible to departmental staff. Each screen is set to live observation view which enables staff at a glance to identify any patient with an elevated PEWS and time repeat observations are required in line with PEWS escalation guidance.” Source location Response from Sherwood Forest Hospitals 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 Establish a Children and Young People’s Working Group to review related policies and procedures, including joint working, pathways, recruitment and operations.
Verbatim wording from the response “A Children and Young People’s Working Group has been established with membership from senior medical, nursing and operational staff from the Urgent Emergency Care and Women’s and Children’s Divisions. The group is reviewing current policies and Standard Operational Procedures relating to Children and Young People to include opportunities for joint working, clinical pathways, recruitment and operational working.” Source location Response from Sherwood Forest Hospitals 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 Roster registered children’s nurses during identified peak emergency-department attendance periods.
Verbatim wording from the response “• A profile of when children and young people attend the ED over a 1-year period has been obtained to ensure that RNC’s are rostered on at peak times.” Source location Response from Sherwood Forest Hospitals 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 Use designated Tier 3-or-above doctors to oversee children’s care, reducing handovers and improving continuity.
Verbatim wording from the response “SBAR is also a recognised structure for medical handover and all Sherwood Forest clinical staff are required to utilise a structured handover to ensure effective and assertive communication. In addition, use of a structured handover ensures clear recommendations are provided, preventing ambiguity through encouraging clinical staff to repeat the information back to the provider to confirm understanding and allocation of tasks. In addition, changes to the medical model and provision of a designated Tier 3 (previously referred to as a Registrar or Middle Grade) or above Doctor to oversee the care of all children reduces the number of handovers required and improves the continuity of care.” Source location Response from Sherwood Forest Hospitals 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 Add a peak-time Band 5 registered-nurse shift and improve Healthroster displays to identify children’s-area registered children’s nurse cover gaps.
Verbatim wording from the response “Healthroster, a system for producing rosters which take into account an employee’s skills is used to proactively to maximise the likelihood that each department has the appropriate number of staff whilst ensuring there is a safe skill mix. The ED children’s area rota is produced by the Band 7 lead nurse a minimum of 6 weeks in advance. An additional Band 5 RN shift has been added to the roster from 4pm-2am to support attendances at peak times. Following the Inquest improvements have been made locally to the Healthroster system to highlight specific nursing shifts for the children’s area. This change enables clearer identification of where there are gaps in RNC cover thus enabling the ED leads to ensure adult nurses with the minimum paediatric competencies are on duty.” Source location Response from Sherwood Forest Hospitals 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 Record and electronically calculate children’s observations using Nervecentre and PEWS, with handheld devices enabling real-time access.
Verbatim wording from the response “At the time of Tommy’s attendance to ED children and young people’s observations were recorded and calculated manually on paper using the Paediatric Observation Priority Score (POPS). During the Trust’s investigation concerns regarding the reliability of this were raised and following extensive consultation between Emergency Medicine and Paediatrics this was discontinued. Children and young people’s observations are now recorded on ‘Nervecentre’ a digital system that allows observations to be recorded and calculated electronically using the Paediatric Early Warning System (PEWS).” Source location Response from Sherwood Forest Hospitals 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 Train an Emergency Department adult nurse as a paediatric nurse, increasing staffing by one whole-time equivalent.
Verbatim wording from the response “• ED Adult Nurse released to complete Paediatric Nurse Training (18 months) due to complete in September 2024. This will increase staffing by 1 WTE.” Source location Response from Sherwood Forest Hospitals 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 Develop a rotational pathway for registered children’s nurses through continuous Emergency Department and paediatric collaboration.
Verbatim wording from the response “• Continuous collaborative working between ED and the division of Women and Children to develop a rotation pathway for RNC’s is planned to be in place from October 2024.” Source location Response from Sherwood Forest Hospitals 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 Paediatric Sepsis 6 Care Bundle to incorporate heightened sepsis risk for children with Trisomy 21 and babies under three months.
Verbatim wording from the response “In addition to the above training currently in place to support staff, the Paediatric Sepsis 6 Care Bundle, a document to screen and identify children at risk of sepsis and outline the appropriate treatment is under review by Emergency Medicine and Paediatrics to be completed by August 2024. The proposed changes include specifying that patients with Trisomy 21 and babies under the age of 3 months are at higher risk of developing sepsis to ensure this is taken into consideration when deciding whether to trigger commencement of sepsis treatment.” Source location Response from Sherwood Forest Hospitals 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 Provide newly qualified registered children’s nurses with discipline-specific preceptors, supernumerary practice and Emergency Department induction.
Verbatim wording from the response “Sherwood Forest Hospital provide all newly qualified RNCs with a nominated preceptor, qualified in the same discipline of nursing with at least 12 months experience. All registered nurses within the preceptorship programme undertakes a minimum period of 4 weeks supernumerary practice which includes a Trust Orientation Day and Nursing and Midwifery Induction Programme. During this supernumerary period the RNC preceptee is provided with a local induction pertinent to the ED with a particular focus on children and young people. A preceptor will integrate Trust standards, competencies, objectives and Trust CARE values into practice and contribute to an environment which facilitates learning for the Preceptee to ensure they have appropriate skills to competently undertake their role.” Source location Response from Sherwood Forest Hospitals 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 and circulate the Children and Young People escalation tool, including triage-time triggers and required escalation actions.
Verbatim wording from the response “Children and young people escalation tool.” Source location Response from Sherwood Forest Hospitals 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 Implement a supervisory Band 7 Nurse in Charge role providing visible senior nursing support across the Emergency Department, with supernumerary deployment from July 2024.
Verbatim wording from the response “It is not possible to predict sickness and short-term unplanned absence, therefore changes to staffing availability may need to be escalated and acted upon at short notice. At the time of Tommy’s attendance, the Band 7 leads were rostered on day shifts and included within the ED staffing figures. In April 2024, a new band 7 supervisory Nurse in Charge (NIC) role has been implemented within ED to ensure there is visible senior support available 24 hours a day for the entire department. At present, the NIC is included within staffing figures, however from July 2024 this role will be supernumerary.” Source location Response from Sherwood Forest Hospitals 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 medical documentation and audit nursing records, providing feedback, education and support where required.
Verbatim wording from the response “All clinical staff working in ED have been instructed that accurate and contemporaneous record keeping is mandatory, in line with Sherwood Forest Hospitals Clinical Record Keeping Standards Policy (2023). To gain assurance that medical documentation is being completed contemporaneously to a high standard, regular reviews are undertaken, and feedback, education and support provided to any” Source location Response from Sherwood Forest Hospitals 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 Produce, implement and disseminate Senior Review and out-of-hours Emergency Department Consultant Call Criteria.
Verbatim wording from the response “A Senior Review and Out of hours ED Consultant Call Criteria has been produced and implemented to provide additional guidance as to when a Consultant should be contacted out of hours. This has been shared with all Clinicians. Consultants have confirmed they are engaged and actively promote and encourage staff to contact them for support and guidance. It is however acknowledged that the criteria set out within appendix 3 is not an exhaustive list and any concerns which staff feel requires discussion with a Consultant should continue to take place.” Source location Response from Sherwood Forest Hospitals 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 Emergency Department escalation processes for proactively identifying and escalating nursing staffing concerns.
Verbatim wording from the response “The ED senior leadership team have reviewed the escalation processes in place for proactively reviewing and escalating nursing staffing concerns.” Source location Response from Sherwood Forest Hospitals 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 Update the children’s Emergency Department operating procedure with minimum medical training requirements and restrict direct care by staff who do not meet them.
Verbatim wording from the response “Implementation of core competencies to care for Children and Young People.” Source location Response from Sherwood Forest Hospitals 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 Recruitment challenges mean the Trust is unable to meet RCPCH paediatric nursing workforce standards despite active recruitment.
Verbatim wording from the response “The Royal College of Paediatrics and Child Health (RCPCH) Facing the Future: Standards for Children in Emergency Care Settings (2018) describe national standards for care applicable to children in Emergency Care settings. Recommendation 10 of these standards states that every Emergency Department (ED) must be staffed with two registered children’s nurses on each shift. However, the Care Quality Commission (CQC) and RCPCH recognise the challenges in recruiting Registered Children’s Nurses (RNC) and are working to support services through provision of guidance and an audit tool kit.” Source location Response from Sherwood Forest Hospitals NHS Foundation Trust
Open published response
3 Apr 2024 Meha Carneiro · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 PEWS escalation pathway failing to trigger senior Emergency Department doctor review for scores of 6-8 View source Failure by nursing and medical staff to recognise severity of illness in the Emergency Department View source Insufficient and ineffective handover between medical staff View source Insufficient trained paediatric nursing capacity in the Emergency Department View source Failure to escalate insufficient paediatric nursing capacity to senior nursing staff View source Failure to document key information and agreed clinical plans View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Meha Carneiro · 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
Meha Carneiro, aged five years and seven months, died at Kings Mill Hospital on 5 December 2022 after collapsing in cardiac arrest following an illness involving fever, cough, abdominal pain, diarrhoea and vomiting. The report identified concerns about insufficient trained paediatric nursing staff, inadequate recognition of the seriousness of her condition, insufficient senior review, and ineffective handover and documentation between staff.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation PEWS escalation pathway failing to trigger senior Emergency Department doctor review for scores of 6-8
Wider context from the report “3. Whilst switching from use of POPS to PEWS in ED, is likely to assist in ensuring repeat observations in a sick child, a PEWS of 6-8 only triggers review by a junior rather than a senior ED Doctor , the former less likely to recognise severity of illness and respond appropriately
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by nursing and medical staff to recognise severity of illness in the Emergency Department
Wider context from the report “2. There was overall a lack of recognition of how unwell Meha was on admission and over the subsequent hours prior to her death - this included both nursing and medical staff in ED
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient and ineffective handover between medical staff
Wider context from the report “4. There was insufficient and ineffective handover between medical staff , with lack of documentation of key information, and agreed clinical plans- between doctors in ED, and between ED and Paediatric staff
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient trained paediatric nursing capacity in the Emergency Department
Wider context from the report “1. There were insufficient trained Paediatric nurses on duty in the Emergency Department (ED) , on the day of Meha’s admission, and there was no effective escalation to senior nursing staff to highlight this
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate insufficient paediatric nursing capacity to senior nursing staff
Wider context from the report “1. There were insufficient trained Paediatric nurses on duty in the Emergency Department (ED), on the day of Meha’s admission, and there was no effective escalation to senior nursing staff to highlight this
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document key information and agreed clinical plans
Wider context from the report “4. There was insufficient and ineffective handover between medical staff, with lack of documentation of key information, and agreed clinical plans - between doctors in ED, and between ED and Paediatric staff
” 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 Review the Paediatric Sepsis 6 Care Bundle to strengthen recognition and treatment of higher-risk children.
Verbatim wording from the response “In addition to the above training currently in place to support staff the Paediatric Sepsis 6 Care Bundle, a document to screen and identify children at risk of sepsis and outline the appropriate treatment, is under review by Emergency Medicine and Paediatrics to be completed by August 2024. The proposed changes include specifying that patients with Trisomy 21 and babies under the age of 3 months are at higher risk of developing sepsis to ensure this is taken into consideration when deciding whether to trigger commencement of sepsis treatment.” Source location Response from Sherwood Forest Hsopitals 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 Record registered children’s nurse staffing as a significant risk and review it monthly through specialty and Trust risk governance.
Verbatim wording from the response “• RNC staffing within the ED is recorded on the Trust risk register as a significant risk and is reviewed monthly by the specialty and Trust Risk Committee. This has led to the development of the rotational post (see below).” Source location Response from Sherwood Forest Hsopitals 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 Develop a rotational registered children’s nurse pathway jointly between Emergency Department and Women and Children services.
Verbatim wording from the response “• Continuous collaborative working between ED and the division of Women and Children to develop a rotation pathway for RNC’s is planned to be in place by October 2024.” Source location Response from Sherwood Forest Hsopitals 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 Reintroduce paediatric sepsis e-learning as mandatory for Emergency Department medical and nursing staff and monitor compliance.
Verbatim wording from the response “The Trust paediatric e-learning training package has been made re-introduced as mandatory for all medical and nursing staff within the ED from 1st May 2024.” Source location Response from Sherwood Forest Hsopitals 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 Require adult nurses caring for children to complete defined paediatric experience, training, study-day and supervised-shadowing competencies.
Verbatim wording from the response “• A minimum set of core competencies that adult nurses must have completed prior to caring for a child or young person has been agreed as follows:” Source location Response from Sherwood Forest Hsopitals 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 Provide a 24-hour supervisory Band 7 Nurse in Charge role responsible for staffing allocation and escalation of workforce concerns.
Verbatim wording from the response “It is not possible to predict sickness and short-term unplanned absence therefore changes to staffing availability may need to be escalated and acted upon at short notice. At the time of Meha’s attendance, the band 7 leads were rostered on day shifts only and included within the ED staffing figures. A new band 7 supervisory Nurse in Charge (NIC) role has been implemented within ED to ensure there is now visible senior support available 24 hours a day for the entire department. At present, the NIC is included within staffing figures, however from July 2024 this role will be supernumerary.” Source location Response from Sherwood Forest Hsopitals 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 Update paediatric Emergency Department procedures and medical training requirements, restricting direct care by staff who lack required competencies.
Verbatim wording from the response “Recognition of an acutely unwell child is the responsibility of both medical and nursing staff within the department. As previously set out, a set of core competencies that adult nurses must have undertaken to care for children and young people is in place. The Standard Operating Procedure for Children and Young People within the Emergency Department, (see appendix 2) has been updated to reflect the new minimum training requirements for medical staff to ensure they have the appropriate skills to effectively identify an unwell child. Staff who do not meet these criteria are no longer directly responsible for the care of children and young people in the ED.” Source location Response from Sherwood Forest Hsopitals 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 Implement and disseminate senior review and out-of-hours consultant call criteria for paediatric Emergency Department care.
Verbatim wording from the response “Senior Review and Out of hours ED Consultant Call Criteria have been produced and implemented to provide additional guidance as to when a consultant should be contacted out of hours. This has been shared with all Clinicians. Consultants have confirmed they are engaged and actively promote and encourage staff to contact them for support and guidance. These criteria, set out within appendix 3, are not an exhaustive list and staff are aware that any concerns they feel require discussion with a Consultant must lead to contact being made.” Source location Response from Sherwood Forest Hsopitals 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 and circulate the Children and Young People escalation tool, specifying escalation triggers and required actions.
Verbatim wording from the response “In conjunction with changes to visibility of observations, and implementation of a supervisory NIC role the Children and Young People (CYP) escalation tool has been reviewed to ensure there is clear guidance on escalation triggers and the actions required. A copy of the Children and Young People escalation plan within appendix 1 has been circulated to all employees within the ED, however staff have been instructed this is not to be used in isolation and clinical judgement and parental/carer concerns should always be taken into consideration. Use of the updated Children and Young People escalation tool will aid timely escalation of any issues identified, ensure senior support is available and appropriate plans implemented to maintain patient safety.” Source location Response from Sherwood Forest Hsopitals 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 Train an Emergency Department adult nurse in paediatric nursing to increase staffing by one whole-time equivalent.
Verbatim wording from the response “• ED Adult Nurse released to complete Paediatric Nurse Training (18 months) due to complete in September 2024. This will increase staffing by 1WTE.” Source location Response from Sherwood Forest Hsopitals 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 Assign the Tier 3 or above doctor to lead specialty and shift-change handovers for children’s care.
Verbatim wording from the response “The changes to the medical model previously described means that there is a designated Tier 3 or above Doctor overseeing the care of all children. The Tier 3 or above doctor will lead and manage handovers between specialties and at shift change, thus reducing the number of handovers required and improving continuity of care.” Source location Response from Sherwood Forest Hsopitals 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 Install live Nervecentre oversight screens to identify elevated or overdue paediatric observations and support senior monitoring.
Verbatim wording from the response “When considering visibility of observations, a further review was undertaken following the Inquest and it was recognised that the methodology to monitor whether patients were receiving observations at the required frequency in real time required improvement. Within both the major’s area and children’s and young people’s area, large screens which provide a Nervecentre oversight dashboard of a specific task have been installed. The location of these was carefully considered to ensure there was no information governance risk, whilst they were in a location easily visible to departmental staff. Each screen is set to live observation view which enables staff at a glance to identify any patient with an elevated PEWS and the time repeat observations are required in line with PEWS escalation guidance.” Source location Response from Sherwood Forest Hsopitals 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 Require accurate contemporaneous clinical records and undertake regular documentation reviews with feedback, education and support where needed.
Verbatim wording from the response “All clinical staff working in ED have been instructed that accurate and contemporaneous record keeping is mandatory, in line with Sherwood Forest Hospitals Clinical Record Keeping Standards Policy (2023). To gain assurance that medical documentation is being completed contemporaneously to a high standard, regular reviews are undertaken, and feedback, education and support provided to any individuals as deemed required.” Source location Response from Sherwood Forest Hsopitals 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 Use attendance data to roster registered children’s nurses during peak paediatric attendance periods.
Verbatim wording from the response “• A profile of when children and young people attend the ED over a 1-year period has been obtained to ensure that RNCs are rostered on at peak times.” Source location Response from Sherwood Forest Hsopitals 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 Require PEWS scores of 6–8 or a single parameter score of 3 to trigger review by a Tier 3 or above doctor, and cascade the guidance to staff.
Verbatim wording from the response “Following the Inquest, the Trust acknowledged the additional concerns raised by HM Coroner and in conjunction the ED team and Paediatric specialty reviewed national guidance regarding whom a child or young person should be escalated to based upon their PEWS score. The Trust PEWS escalation guidance now states a patient with a PEWS between 6-8 or a single observation in one parameter that scores a 3 will trigger a review by a minimum of a Tier 3 or above Doctor that made aware within 30 minutes of escalation. In addition to acting on PEWS scores and clinical concerns, staff are empowered to escalate parental or carer concerns. This has been reflected in the ED Paediatric Triage Documents. Upon completing the review if the Doctor feels additional support and guidance is required there is always a consultant on call accessible.” Source location Response from Sherwood Forest Hsopitals 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 Use Healthroster improvements and additional evening registered-nurse shifts to identify paediatric staffing gaps and support peak attendance.
Verbatim wording from the response “Healthroster, a system for producing rosters which take into account an employee’s skills, is used to proactively maximise the likelihood that each department has the appropriate number of staff whilst ensuring there is a safe skill mix. The ED children’s area rota is produced by the band 7 lead nurse a minimum of 6 weeks in advance. An additional Band 5 RN shift has been added to the roster from 4pm-2am to support ED Children and Young People attendance at peak times. Following the Inquest, improvements have been made locally to the Healthroster system to highlight specific nursing shifts for the children’s area. This change enables clear identification of where there are gaps in RNC cover thus enabling the ED leads to ensure adult nurses with the minimum paediatric competencies are on duty.” Source location Response from Sherwood Forest Hsopitals 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 Recruitment challenges mean the hospital is unable to meet national Registered Children’s Nurse workforce standards despite active recruitment.
Verbatim wording from the response “The Royal College of Paediatrics and Child Health (RCPCH) Facing the Future: Standards for Children in Emergency Care Settings (2018) describe national standards for care applicable to children in Emergency Care settings. Recommendation 10 of these standards states that every Emergency Department (ED) must be staffed with two registered children’s nurses on each shift. However, the Care Quality Commission (CQC) and RCPCH recognise the challenges in recruiting Registered Children’s Nurses (RNC) and are working to support services through provision of guidance and an audit tool kit.” Source location Response from Sherwood Forest Hsopitals NHS Foundation Trust
Open published response
14 Oct 2021 Mr Murray Hyslop · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 4 Failure of senior staff to openly consider and learn from adverse care events View source Lack of expectation for staff to take a broader view when identifying residents in need of medical attention View source Failure to provide sufficiently responsive review of pressure-damage prevention needs View source Failure to effectively cascade medical-assessment training to frontline care staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Murray Hyslop · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Murray Hyslop developed Covid-19, reduced fluid intake and appetite, and became dehydrated, malnourished and affected by acute kidney injury. He was admitted to hospital on 24 December 2020 but did not recover and died from natural disease on 16 January 2021. Concerns included inadequate prevention of pressure damage, failure to identify when he needed medical attention, and a lack of openness about learning from adverse events.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior staff to openly consider and learn from adverse care events
Wider context from the report “(3) Learning from adverse events – the culture within senior staff of obfuscation and denial when issues regarding care are raised was of significant concern to me as it is hard to have confidence that, as they said to me, “lessons will be learned”. It was appropriate for the senior management to be supportive of their frontline staff who, as set out above, worked hard when the care home was understaffed. They were not, however, open minded to consider areas where significant changes in practice and culture needed to take place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of expectation for staff to take a broader view when identifying residents in need of medical attention
Wider context from the report “(2) Identifying a resident in need of medical attention – some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day . The witnesses did not seek to suggest that they usually did this but were unable to during the outbreak and so I consider that it is likely that this was an issue was existed both before and after the outbreak. I was more reassured in this area by “Restore 2” materials and training which provide very clear and helpful guidance to carers. It is not clear to me how this training, which has been completed by the registered manager, has been effectively cascaded to frontline care staff and their evidence to me suggested that this has not happened to date;
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide sufficiently responsive review of pressure-damage prevention needs
Wider context from the report “(1) Prevention of pressure damage – there was a lack of appreciation of the need to consider Mr Hyslop’s extreme vulnerability to pressure damage when he was very unwell, dehydrated, malnourished and largely immobile. Policies and practices supported only monthly review of his needs and that is insufficiently responsive in order to appropriately prevent damage from occurring ;
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively cascade medical-assessment training to frontline care staff
Wider context from the report “(2) Identifying a resident in need of medical attention – some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day. The witnesses did not seek to suggest that they usually did this but were unable to during the outbreak and so I consider that it is likely that this was an issue was existed both before and after the outbreak. I was more reassured in this area by “Restore 2” materials and training which provide very clear and helpful guidance to carers. It is not clear to me how this training, which has been completed by the registered manager, has been effectively cascaded to frontline care staff and their evidence to me suggested that this has not happened to date ;
” Open source report
21 May 2021 Morris REDDINGTON · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to review the electronic Patient Report Form during emergency department handover View source Failure to resolve electronic Patient Report Form access problems View source Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Morris REDDINGTON · 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
Morris Reddington died from a rare stroke involving basilar artery thrombosis, likely caused by dissection of the right vertebral artery. The report identified delays in diagnosis and concerns that electronic ambulance handover records were not routinely reviewed, as well as limited out-of-hours access to mechanical thrombectomy. It also raised concerns about the risk of future deaths from failures in patient-information handover and geographical disparities in access to thrombectomy.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review the electronic Patient Report Form during emergency department handover
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form . The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone .
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution.
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre.
Whilst ever this problem persists without resolution, there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to resolve electronic Patient Report Form access problems
Wider context from the report “The electronic Patient Report Form (‘ePRF’) is an important template which records all of the pre-hospital interaction with the patient. It forms a crucial part of the professional-to-professional handover of care, and is an adjunct to the concise verbal handover that takes place in the Emergency Department.
The Ambulance Service told me they expect the ePRF to be reviewed by ED staff, rather than staff simply relying on the verbal handover, which can be challenging in the context of a busy hospital environment.
At the point of roll out of the new electronic system, Ambulance Service personnel attended the local Emergency Departments to install software that allowed ED staff to access the electronic Patient Report Form hub from their hospital computers. Further to installing software, the Ambulance Service had also provided ED staff with personalised login details and training to ensure they knew how to access the patient information.
I heard evidence from ED staff that despite having logins and having received training, they did not routinely access the system to review the electronic patient report form. The rationale for this omission, was that the software was “clunky” to use and in some cases it could take up 5 minutes to isolate the correct form; time that busy ED staff do not have. Both Trusts accepted that it had become practise not to review the ePRF instead to rely upon the verbal handover alone.
In this case, had ED staff reviewed the ePRF early in the admission, they would have appreciated from that documentation that Mr Reddington had been suspected of having a stroke, rather than a simple a head injury. His care would then have been provided in accordance with the stroke pathway much earlier in the evening.
I am concerned that ignoring a written handover from a fellow medical professional is not a safe or proportionate solution to the difficulties faced of accessing the electronic system.
I am further concerned that this practise of ignoring the written handover appears to have persisted for a long time without the organisations reaching a sensible solution .
While the Ambulance Service are taking steps to upgrade the system at another local hospital, I heard evidence that there was no agreed plan or date for seeking to resolve the system issues at Kingsmill or Queens Medical Centre .
Whilst ever this problem persists without resolution , there is a risk of future deaths due to failures in the handover of patient information at the point of transfer of care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited availability of 24/7 mechanical thrombectomy for acute ischaemic stroke
Wider context from the report “In January 2018, NHS England published its Clinical Commissioning Policy on the use of Mechanical Thrombectomy as treatment for acute ischaemic stroke (all ages).
The aim of the Policy reports to be two-fold; to improve outcomes for adults with stroke, and to improve access to mechanical thrombectomy as soon as possible after the onset of stroke symptoms.
Despite the publication of the policy some 3 years ago, there remains very limited access to 24/7 mechanical thrombectomy . Save for two Trusts in London, and the West Midlands Network, I am not aware of others providing a 24/7 service. There certainly is no such service in the East Midlands .
There is clear geographical disparity in the access to this vital, life-saving service .
Mechanical thrombectomy would likely have avoided Mr Reddington’s death. Instead, because Mr Reddington was unfortunate enough to suffer a stroke outside of the service’s operational hours (Monday to Friday 8am to 4pm), his family were left to watch his deterioration, knowing that a treatment had the potential to save his life, but that such treatment simply was not offered after 4pm .
This is a situation that no family ought to be placed in.
” 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 Enable NUH Digital Services to create EMAS ePRF accounts directly and issue access to staff requiring it.
Verbatim wording from the response “• The NUH Digital Services team have been given access to create EMAS ePRF logins directly for NUH staff, avoiding the need for this to be done by EMAS.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 Reinforce to receiving staff the importance of reviewing EMAS electronic patient report forms alongside verbal handover.
Verbatim wording from the response “In the meantime, each hospital Trust has implemented a less automated workaround in their Emergency Departments and other direct receiving areas, and ePRF data is already more easily available to clinical staff. Staff at both hospital Trusts have been informed of this and reminded of the importance of accessing the ePRF data in addition to receiving a verbal handover from EMAS.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 Implement automated EMAS transmission of draft and final ePRF data to receiving hospital informatics systems without additional logins.
Verbatim wording from the response “However, a technical solution has now been identified and is in the process of being implemented. The details are set out below along with the projected timescale. The solution involves the EMAS IT system automatically pushing out drafts of the ePRF to the receiving hospital as soon as it is chosen. As the two hospital Trusts do not use identical IT systems for record management, each will handle this data in different ways, although the end point – immediate access to the finalised ePRF for clinical staff, and filing of the report within the patient’s hospital record - will be achieved at both Trusts. Once implemented EMAS intend offering this solution to other acute hospitals’ IT services.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 SFH staff with an interim process to access, convert and save EMAS ePRFs into SystmOne after patient arrival.
Verbatim wording from the response “• Immediately after the inquest, as an interim measure whilst awaiting system improvements, ED reception staff were instructed to access the EMAS portal and print the ePRF within 30 minutes of a patient’s arrival, and place this with the patient’s ED record. This has since been refined to a PDF print being produced and saved in SystmOne, which is the medical record system used in SFH ED.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 Develop and implement the SFH ePRF web viewer and automated SystmOne integration for clinical access without additional login.
Verbatim wording from the response “• SFH uses SystmOne for its electronic ED record. Upon receipt by NHIS (SFH’s informatics service provider) the ePRF data will be automatically added to the SystmOne record, and will be accessible to clinical staff without any additional login.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 Install EMAS ePRF access links on NUH clinical desktops and Nervecentre.
Verbatim wording from the response “• An EMAS ePRF system link has been installed on all clinical PC desktops and on the Nervecentre system to increase access to this system.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 Add finalised SFH ePRFs to CareCentric so staff can view records for patients initially taken to either hospital.
Verbatim wording from the response “• As described above, NUH will be using the Nottinghamshire CareCentric Portal as their main conduit for ePRFs. SFH will also automatically add the finalised version of the ePRFs they receive to CareCentric, which will allow clinical staff at each hospital Trust to view ePRF data for patients initially taken to the other Trust.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 Brief NUH Heads of Service to establish processes for reviewing EMAS ePRFs for patients received directly from ambulance crews.
Verbatim wording from the response “• All Heads of Service have been briefed on the importance of having a process for review of the EMAS ePRF system for any patients received directly from ambulance crews.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 Implement NUH integration to transfer finalised EMAS ePRFs into CareCentric and DHR for immediate clinical review and record visibility.
Verbatim wording from the response “• NUH will use the final PDF document following finalisation of the record after handover, and not any of the draft data entered before this process. This removes any risk associated with viewing a record that has not been finalised. These PDF documents will be automatically transferred to CareCentric. This system is directly linked from Medway (the ED clinical system) and is used over 10,000 times per month in NUH to access GP record summaries and other community information. In addition, NUH will automatically ‘push’ the EMAS ePRF documents into DHR (the Trust’s scanned electronic document management system) for immediate clinical review and longer term visibility alongside NUH records. The DHR element of this is anticipated to be live by September 2021, although there is a delay with the CareCentric element. This is anticipated to be resolved before the end of the calendar year.” Source location 2021-0312-Response-from-City-Hospital-Campus_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 SFH cannot control automated ePRF integration because it depends on NHS Digital standards development and subsequent implementation by TPP.
Verbatim wording from the response “• NHIS have a project team working on implementation, with SFH oversight. Whilst there is an effective non-automatic workaround now in place that provides ED staff with easy access to ePRFs, the following timescales for the automated process are envisaged:
o SFH ePRF Web Viewer – end August 2021.
o Automatic integration into SystmOne – this is dependent on NHS Digital (the national NHS IT body) completing their current development of national FHIR standards for document distribution, before TPP (who supply SystmOne) can add the ePRF to patient records. Whilst this is outside SFH’s control, SFH are pushing for the earliest possible resolution (but this may well not be implemented for several months at least). .” Source location 2021-0312-Response-from-City-Hospital-Campus_Published
Open published response
25 Sep 2020 Marian DAY · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 3 Failure to record a clear anticoagulant prescription plan for all staff to follow View source Multiple charts and documents permitting muddled or omitted anticoagulant prescribing View source Lack of senior review of patients for anticoagulant management View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marian DAY · 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
Marian Day died at Kings Mill Hospital on 18 November 2019 after a sudden collapse caused by a massive intra-abdominal haemorrhage. Warfarin was continued and administered despite suspected bleeding and an earlier plan to withhold it; the inquest found that this prescription error made a contribution to the haemorrhage. The report raises concerns about muddled prescribing systems, insufficient senior review, and unclear anticoagulant management plans.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record a clear anticoagulant prescription plan for all staff to follow
Wider context from the report “Whilst there has been a detailed Serious Incident review of the circumstances of Mrs Day’s death conducted by the Trust, it remains unclear as to how and why these prescription errors occurred.
It is my view that a similar prescription error could occur again, as there remains a number of different charts and documents that allow for muddled prescribing of, or omission of, anticoagulants, when there are complex medical conditions and concern re likely bleeding.
Whilst the development of an electronic prescribing system may increase the probability of more clarity in prescription of anticoagulants, this is not in place currently. In addition, this alone in my view will not ensure oversight of anticoagulant management, unless other measures are taken to ensure senior review of patients, and a clear prescription plan recorded for all staff to follow .
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Multiple charts and documents permitting muddled or omitted anticoagulant prescribing
Wider context from the report “Whilst there has been a detailed Serious Incident review of the circumstances of Mrs Day’s death conducted by the Trust, it remains unclear as to how and why these prescription errors occurred.
It is my view that a similar prescription error could occur again, as there remains a number of different charts and documents that allow for muddled prescribing of, or omission of, anticoagulants , when there are complex medical conditions and concern re likely bleeding.
Whilst the development of an electronic prescribing system may increase the probability of more clarity in prescription of anticoagulants, this is not in place currently. In addition, this alone in my view will not ensure oversight of anticoagulant management, unless other measures are taken to ensure senior review of patients, and a clear prescription plan recorded for all staff to follow.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of senior review of patients for anticoagulant management
Wider context from the report “Whilst there has been a detailed Serious Incident review of the circumstances of Mrs Day’s death conducted by the Trust, it remains unclear as to how and why these prescription errors occurred.
It is my view that a similar prescription error could occur again, as there remains a number of different charts and documents that allow for muddled prescribing of, or omission of, anticoagulants, when there are complex medical conditions and concern re likely bleeding.
Whilst the development of an electronic prescribing system may increase the probability of more clarity in prescription of anticoagulants, this is not in place currently. In addition, this alone in my view will not ensure oversight of anticoagulant management, unless other measures are taken to ensure senior review of patients , and a clear prescription plan recorded for all staff to follow.
” 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 Audit compliance with documentation requirements for the immediate warfarin safety actions.
Verbatim wording from the response “6. Pharmacy to audit documentation compliance for the immediate further actions described above. December 2020 Assistant Chief Pharmacist and Medication Safety Officer to Conduct” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 Require senior-doctor discussion and full documentation before changing an existing warfarin plan.
Verbatim wording from the response “2. Changes to existing warfarin plans to be made only following discussion with senior doctors, and fully documented.” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 guidance reminding staff to amend both charts when withholding warfarin doses.
Verbatim wording from the response “5. Further Education and Awareness:” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 Document decisions to change existing warfarin plans on the yellow dosing chart and in the clinical record when made.
Verbatim wording from the response “1. Decisions on changes to existing warfarin plans to be documented on the yellow dosing chart at the time they are made, as well as in the clinical record. This will ensure that all doctors dosing warfarin are aware of the current plan even if they are not part of the treating team.” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 Explore electronic Nervecentre alerts to inform ward doctors when INR results become available.
Verbatim wording from the response “Advancement of laboratory technology including electronic results makes most results available earlier in the day. Dosing before the parent team finish their shift is ideal as they will know their patients’ needs. To achieve this we are working towards:” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include the patient story in junior-doctor training on warfarin prescribing errors.
Verbatim wording from the response “• Add this patient story into training for juniors to highlight the potential outcome of warfarin prescribing errors: Training updated November 2020 for inclusion in August 2021 junior doctor induction and going forwards.” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 Complete a multidisciplinary review of the warfarin prescribing, dosing and supporting-documentation process.
Verbatim wording from the response “I am responding to your Regulation 28 Report to Prevent Future Deaths, issued following the inquest touching the death of Mrs Marian Day. You raised concern about prescription errors that led to Mrs Day receiving two doses of warfarin on consecutive days despite there being a medical plan that it should be withheld. You were concerned that a similar error may occur again in part due to the number of charts involved in the prescribing and dosing of warfarin. In order to address your concerns we have undertaken a multidisciplinary (MDT) review of our warfarin process, prescription and supporting documentation to address these concerns.” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 Consider adding prompts to warfarin documentation addressing thrombosis and bleeding risks during prescribing decisions.
Verbatim wording from the response “4. Consideration of the benefits of prompts in the warfarin documentation with regard to the risks for thrombosis versus the risks of bleeding to aide prescribing decision making. For discussion at Medicine Safety Group December 2020 [Assistant Chief Pharmacist and Medication Safety Officer to Present]” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 expert panel concluded that changing the entire warfarin prescription process would be unlikely to prevent future deaths and could increase prescribing errors.
Verbatim wording from the response “changing the entire process by altering the prescription charts. The differing expertise outlined that if this was conducted then there would be an increased likelihood in prescribing and dosing errors affecting patients. Therefore it was concluded by this expert panel that this would be highly unlikely not to help prevent future deaths. In addition the roll out of EPMA (electronic prescribing) at SFHFT, which includes warfarin prescribing, is expected to pilot in February 2021 and realistically any changes to paper documentation would be highly unlikely to complete Trust governance processes and printing before this time.” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
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 Paper documentation changes could not realistically complete governance and printing processes before electronic prescribing was piloted.
Verbatim wording from the response “changing the entire process by altering the prescription charts. The differing expertise outlined that if this was conducted then there would be an increased likelihood in prescribing and dosing errors affecting patients. Therefore it was concluded by this expert panel that this would be highly unlikely not to help prevent future deaths. In addition the roll out of EPMA (electronic prescribing) at SFHFT, which includes warfarin prescribing, is expected to pilot in February 2021 and realistically any changes to paper documentation would be highly unlikely to complete Trust governance processes and printing before this time.” Source location 2020-0199-Response-from-Kings-Mill-Hospital-Redacted.pdf
Open published response
2 May 2019 Alexander James Davidson · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Delays in updating electronic patient records with NHS 111 triage documents View source Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients View source Variation in admission for observation of paediatric patients returning to the Emergency Department View source Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage View source Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Alexander James Davidson · 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
Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in updating electronic patient records with NHS 111 triage documents
Wider context from the report “(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report “(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Variation in admission for observation of paediatric patients returning to the Emergency Department
Wider context from the report “(5) Patients who make an unscheduled return to the Emergency Department within 72 hours of discharge are required to have a review undertaken by an ED Consultant, or a ST4 trainee or above in the absence of a Consultant on the ‘shop floor’: RCEM Guidance June 2016. Some hospitals will admit returning paediatric patients for observation but practise seems to vary doctor-to-doctor and across Trusts. Consideration ought to be given to a national approach.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report “(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit . Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standard lipase/amylase testing for patients under 18 with relevant abdominal symptoms
Wider context from the report “(4) Adults presenting to their GP or Emergency Department with abdominal symptoms receive a lipase and/or amylase blood test as part of the standard package of blood testing. The levels of each of these enzymes can be used to diagnose pancreatitis. Patients under the age of 18 years are not offered this testing as standard , on the basis that pancreatitis is rare in paediatric patients. I heard anecdotal evidence of some doctors at Kingsmill Hospital now add this test to the standard admission bloods for older teenage patients who present with non-specific abdominal symptoms but the NICE guidance (September 2018) is not explicit in this regard . I heard evidence as to the increasing prevalence of gallstone pancreatitis in young people, in line with an increase in childhood obesity. Consideration ought to be given to a national approach for lipase/amylase testing in young people with relevant symptoms.
” Open source report
9 Dec 2016 Sheila Stokes · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 8 Failure to contact and follow up patients who DNA appointments View source Lack of a clear timetable and named consultant responsibility for custom-made graft final sign-off View source Failure to advise and update patients on custom-made graft timescales View source Witness statements to the coroner omitting relevant trust delay View source Incomplete investigation of events failing to address trust delay View source Failure to copy DNA appointment correspondence to GPs View source Failure to ensure timely receipt and action on RAD alerts View source Lack of a clear pathway for contacting manufacturers and sending scan results View source See 5 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
Sheila Stokes · 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
Sheila Stokes had a large abdominal aortic aneurysm diagnosed in July 2015 and died at home on 26 January 2016 after it ruptured. The report identified delays in arranging appointments, acting on the radiology alert, discussing the case, and sending information needed for a custom-made graft. It also raised concerns about administrative systems, communication, the trust’s investigation, and the completeness of statements provided to the coroner.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact and follow up patients who DNA appointments
Wider context from the report “1. Review of administrative systems for contacting and following up patients who DNA appointments – with such correspondence to be copied to their GPs.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear timetable and named consultant responsibility for custom-made graft final sign-off
Wider context from the report “3. Vascular surgeons based at both KMH and NUH should consider having a clear agreed protocol for obtaining custom-made grafts – to include such matters as :
a. A clear pathway for contacting and sending scan results to manufacturers.
b. Limited no of consultants dealing with these cases.
c. Clear timetable between first contact with manufacturer and final sign off – with responsibility of a named consultant to ensure there is no delay .
d. Advising and updating patients on these timescales.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise and update patients on custom-made graft timescales
Wider context from the report “3. Vascular surgeons based at both KMH and NUH should consider having a clear agreed protocol for obtaining custom-made grafts – to include such matters as :
a. A clear pathway for contacting and sending scan results to manufacturers.
b. Limited no of consultants dealing with these cases.
c. Clear timetable between first contact with manufacturer and final sign off – with responsibility of a named consultant to ensure there is no delay.
d. Advising and updating patients on these timescales .
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Witness statements to the coroner omitting relevant trust delay
Wider context from the report “5. Nature and content of the witness statements provided to the coroner , which again refer only to delay by the manufacturer , which is clearly not the central issue in this case.
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incomplete investigation of events failing to address trust delay
Wider context from the report “4. Adequacy of the trust’s investigation of these events – in particular the morbidity and mortality meeting discussion, which was incomplete , and does not refer to delay by the trust 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to copy DNA appointment correspondence to GPs
Wider context from the report “1. Review of administrative systems for contacting and following up patients who DNA appointments – with such correspondence to be copied to their GPs .
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely receipt and action on RAD alerts
Wider context from the report “2. System for ensuring RAD alerts are received and acted on timeously .
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear pathway for contacting manufacturers and sending scan results
Wider context from the report “3. Vascular surgeons based at both KMH and NUH should consider having a clear agreed protocol for obtaining custom-made grafts – to include such matters as :
a. A clear pathway for contacting and sending scan results to manufacturers .
b. Limited no of consultants dealing with these cases.
c. Clear timetable between first contact with manufacturer and final sign off – with responsibility of a named consultant to ensure there is no delay.
d. Advising and updating patients on these timescales.
” 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 Transfer the legal team into the Governance Directorate to strengthen collaboration with the Clinical Governance Unit and support earlier identification of investigation and witness-evidence deficiencies.
Verbatim wording from the response “The legal team at Sherwood Forest Hospitals NHS FT is soon to be made part of the Governance Directorate, with offices adjacent. This will enable a greater working relationship between the legal team and the Clinical Governance Unit which it is expected will make matters requiring investigation clearer from the outset. Any insufficiency in witness evidence can be addressed at an earlier stage.” Source location 2016-0439-Response-by-Sherwood-Forest-Hospitals-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 Conduct regular audits of the DNA process to verify adherence.
Verbatim wording from the response “A number of managers involved in the Outpatient service carry out DNA audits on a regular basis to ensure that the process is being adhered to. We are happy to provide audits of this process should you require.” Source location 2016-0439-Response-by-Sherwood-Forest-Hospitals-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 Relaunch and standardize the Trust-wide DNA process, including same-day clinician review, documented actions, safeguarding escalation, and GP notification on discharge.
Verbatim wording from the response “The DNA process was re-launched in June 2016 (see the flow chart attached) as it was clear that there was not a consistent approach to dealing with DNAs across the Trust. This process ensures that DNAs are dealt with on the day. Clinic staff will place a DNA sticker into the patient’s notes and ensure this is completed by the clinician who indicates the action to be taken e.g. further appointment within given timescale or discharge. The clinician can also highlight if there are any safeguarding concerns and request the notes to be returned to their Patient Pathway Co-ordinator (PPC) for further action to be taken.” Source location 2016-0439-Response-by-Sherwood-Forest-Hospitals-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 Upgrade EMRAD to provide simultaneous text-message and email alerts to relevant clinicians and referring trusts.
Verbatim wording from the response “A series of upgrades to the EMRAD systems are underway, which will include a facility to electronically alert clinicians via text message to mobile devices and emails simultaneously which should further enhance the alert system. This should be available to alert not just staff at this Trust but also referring clinicians from NUH and other local trusts that are part of the East Midlands EMRAD/PACS consortium. It also allows specialised reporting radiologists at one of the consortium trusts to report directly on images taken at other Trusts.” Source location 2016-0439-Response-by-Sherwood-Forest-Hospitals-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 Pilot scanning DNA reconciliation slips into Medway to create a permanent record of requested actions.
Verbatim wording from the response “The receptionist will input an outcome for the appointment and makes any further appointments as requested by the clinician before sending the notes to the PPC. If the patient is discharged at the clinician’s request a DNA letter will be sent to both the patient and their GP to indicate the discharge has taken place. However, prior to discharging the patient a check is made to ensure that the patient was sent an appointment letter and also that the address for the patient recorded on Medway, matches that on the Summary Care Record. The reconciliation slips which indicate the actions requested by the clinician are destroyed after completion of the task. However, the DNA sticker remains within the case notes permanently and is a record of the request. The Trust is planning to commence a pilot of scanning reconciliation slips into Medway, providing a permanent record.” Source location 2016-0439-Response-by-Sherwood-Forest-Hospitals-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 An earlier vascular appointment could not be provided because clinic capacity was limited during the relevant period.
Verbatim wording from the response “Mrs S did not attend this appointment and this was inputted onto our system as a ‘DNA’ and she was to have a new appointment made (see appendix 3). We believe that our staff telephoned Mrs S the following day (28th July) to make another appointment for her which was for the 14th September and from the comment made, it was noted that she would like to be seen earlier if there was opportunity by reason of a cancellation (see appendix 4). We believe that it is likely that this date of 14 ████████” Source location 2016-0439-Response-by-Sherwood-Forest-Hospitals-NHS-Trust
Open published response
12 Mar 2015 Mrs Elizabeth Ann Cox · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 2 Insufficient overnight ward staffing capacity for patient workloads View source Unavailability of overnight additional staffing resources 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
Mrs Elizabeth Ann Cox · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Elizabeth Ann Cox, who was 84 and had a high risk of falls, fell from her hospital bed on 18 July 2014 after the equipment accepted as necessary—a Hi-Lo bed and crash mats—had not been provided. Her condition deteriorated and she died at Kingsmill Hospital on 10 August 2014; the report found a clear link between the fall and her death. The report also raised concerns about insufficient night staffing and the lack of equivalent additional staffing support during night hours.
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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient overnight ward staffing capacity for patient workloads
Wider context from the report “The evidence of senior nursing staff involved with this ward and with the trust’s internal investigation made it clear that those working on the ward on the night of 17/18 July felt they needed further staff to cope with the demands of the patients they were looking after.
We heard that the ward sister followed hospital protocol to request assistance. When it was clear that no one was available from neighbouring wards, a bank nurse was requested. Unfortunately, the bank nurse cancelled at very short notice. The duty nurse manager was called, but noone was available to assist at short notice.
1. During daytime hours, where additional staff are needed, the Reducing Harm Team can be contacted to provide the necessary resources. I was told, although this is currently under review, that,as matters stand, this (or an equivalent) is not available during the night.
2. It has been suggested as part of a trust-wide review that the number of staff available on the wards at night be reduced – from 3 registered and 2 unregistered currently, to 3 registered and 1 unregistered. I am aware that this is merely a proposal – and not currently in place – but should this come into effect, I am concerned that events like these may re-occur, where staff simply do not have the capacity to look after their patients safely, because of workloads .
” 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 Sherwood Forest Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of overnight additional staffing resources
Wider context from the report “The evidence of senior nursing staff involved with this ward and with the trust’s internal investigation made it clear that those working on the ward on the night of 17/18 July felt they needed further staff to cope with the demands of the patients they were looking after.
We heard that the ward sister followed hospital protocol to request assistance. When it was clear that no one was available from neighbouring wards, a bank nurse was requested. Unfortunately, the bank nurse cancelled at very short notice. The duty nurse manager was called, but noone was available to assist at short notice.
1. During daytime hours, where additional staff are needed, the Reducing Harm Team can be contacted to provide the necessary resources. I was told, although this is currently under review, that,as matters stand, this (or an equivalent) is not available during the night .
2. It has been suggested as part of a trust-wide review that the number of staff available on the wards at night be reduced – from 3 registered and 2 unregistered currently, to 3 registered and 1 unregistered. I am aware that this is merely a proposal – and not currently in place – but should this come into effect, I am concerned that events like these may re-occur, where staff simply do not have the capacity to look after their patients safely, because of workloads.
” 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 Drive a nurse recruitment strategy to recruit the registered nurses required for medical wards to adopt the new staffing model.
Verbatim wording from the response “Our medical wards have not been as successful with nurse recruitment. This is a national problem but the Trust has developed and are currently driving a nurse recruitment strategy to recruit more Registered Nurses. Our medical wards, including the ward in which Mrs Cox was cared for, are currently being maintained on the post Keogh numbers as described below.” Source location 2015-0094-Response-by-Sherwood-Forest-Hospital
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 Monitor staffing levels and their impact on quality and safety through the Trust Board and Quality Committee.
Verbatim wording from the response “Requests for enhanced care and 1-1 support will continue to be supported when required. During this period of change the Trust Board and the Quality Committee continue to robustly monitor the staffing levels and the impact upon quality and safety.” Source location 2015-0094-Response-by-Sherwood-Forest-Hospital
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 assessed enhanced one-to-one care day and night using ward, bank or agency staffing when additional resources are required.
Verbatim wording from the response “1. A risk assessment form is completed on the ward identifying the level of enhanced care that is required.” Source location 2015-0094-Response-by-Sherwood-Forest-Hospital
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 approved nursing staffing model of five registered and two unregistered staff by day and three registered and one unregistered staff by night.
Verbatim wording from the response “New Investment Numbers:
RN Days Numbers: 5
HCA Days Numbers: 2
RN Nights Numbers: 3
HCA Nights Numbers: 1
Overall Numbers: 5+2 Days; 3+1 Nights” Source location 2015-0094-Response-by-Sherwood-Forest-Hospital
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 Medical wards cannot adopt proposed staffing levels until approximately 100 additional registered nurses are recruited, anticipated to take a further 12 months.
Verbatim wording from the response “Our medical wards have not been as successful with nurse recruitment. This is a national problem but the Trust has developed and are currently driving a nurse recruitment strategy to recruit more Registered Nurses. Our medical wards, including the ward in which Mrs Cox was cared for, are currently being maintained on the post Keogh numbers as described below.” Source location 2015-0094-Response-by-Sherwood-Forest-Hospital
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations