Concerns raised 2 Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance View source Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Baby Isabela Suciu · 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
Baby Isabela Suciu was born in hospital and later suffered a cardiac arrest at home after feeding; she did not regain consciousness and died in hospital. Concerns included the failure to escalate low temperatures for paediatric review or start antibiotics, amid conflicting Kaiser Permanente and NICE guidance. The report identified a continuing risk of confusion and avoidable delay in other neonatal units, although the omission was not shown to have caused Isabela’s death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear and consistent guidance when applying the Kaiser Permanente Score and NICE guidance
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment. Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing .
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the Kaiser Permanente Score as part of an overall assessment of the patient
Wider context from the report “If the Newborn Early Warning Trigger and Track score had been followed the hypothermia would have triggered escalation by the midwife to paediatricians at 02.00 when the temperature was 36.3. Paediatrician ████████, advised that the KP score would not alter then, but at 06.20, the temperature of 36.2 should have triggered starting antibiotics. There was agreement amongst experts that antibiotics should have been started at 06.20 on 3rd of November. It is accepted by the doctors and Trust that this should have happened and did not because of conflict between the Kaiser Permanente Score and the NICE guidance. Whilst this omission was not shown to have caused Isabela’s death, it creates a possible risk for other hospitals using the KP scale.
Expert microbiologist ███████████ informed the court that it was not that the KP scale was inferior to NICE recommendations, but rather that there is a risk as the threshold for antibiotics is different, that doctors will think the KP score is gospel and not look at the patient as a whole and therefore miss clinical signs which should trigger starting antibiotics.
████████████████, consultant neonatology expert opined that the evidence for the use of KP pathway was thin, and it was better to follow NICE guidance as KP should only be used as part of an overall assessment . Expert neonatologist █████████████ agreed saying that the use of two guidelines was confusing.
████████ expert opinion was that there was a risk of deaths in other neonatal units and that the expert was not sure how well known the differences and apparent conflict in applying the guidelines was known. The Trust have taken a number of steps to address the risk, but there appears to remain the opportunity for confusion as the revised Newborn Early Warning Trigger and Track score indicates a different response from KP, when late onset symptoms occur after an asymptomatic period, creating a risk of avoidable delay.
” Open source report
Concerns raised 7 Lack of early mental health review View source Lack of early dietician assessment View source Inability to care for mentally unwell patients with physical health problems who are refusing to eat View source Failure to adequately assess under the Mental Capacity Act View source Failure to act on recorded weight loss View source Lack of recognition of serious harm View source Failure to include family members in care View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Terence Robert TUTTLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.
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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of early mental health review
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of early dietician assessment
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to care for mentally unwell patients with physical health problems who are refusing to eat
Wider context from the report “4.Inability to care for a mentally unwell patient with physical health problems , including gastric problems, who is refusing to eat .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess under the Mental Capacity Act
Wider context from the report “3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recorded weight loss
Wider context from the report “2.Inaction when Mr Tuttle was losing weight even though his intake was recorded no-one acted upon 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of serious harm
Wider context from the report “6. Apparent lack of recognition that serious harm did occur for this patient who was described as appearing cachexic .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include family members in care
Wider context from the report “5.Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation.
” Open source report
Concerns raised 11 Absence of patient care plans View source Delays and failures in escalating serious patient deterioration to senior medical staff View source Insufficient nursing knowledge and experience for patients following serious injury View source Failure to carry out regular and timely neurological observations View source Absence of falls planning and prevention View source Failure of hospital systems to identify nurses lacking the competence or training for basic observations View source Failure to follow hospital protocol for neurological observation frequency View source Failure to make contemporaneous nursing records View source Failure of nursing staff to carry out accurate neurological observations View source Failure to maintain nursing observation of high-risk patients View source Failure to use available movement-alert and fall-prevention equipment View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James Charles MALLETT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.
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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of patient care plans
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward . There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in escalating serious patient deterioration to senior medical staff
Wider context from the report “(2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient . The nursing staff, who were described by Sr Snowden as a "junior workforce" did not seem to understand the seriousness of the injury and did not seek senior help from the night team . The nursing staff did not carry out regular and/or timely neurological observations.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing knowledge and experience for patients following serious injury
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett . There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out regular and timely neurological observations
Wider context from the report “(2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient. The nursing staff, who were described by Sr Snowden as a "junior workforce" did not seem to understand the seriousness of the injury and did not seek senior help from the night team. The nursing staff did not carry out regular and/or timely neurological observations .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of falls planning and prevention
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention , there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital systems to identify nurses lacking the competence or training for basic observations
Wider context from the report “5) There do not appear to be systems in place at the hospital which are sufficient to recognise when nurses are so inexperienced and/or lacking in training that they cannot undertake basic observations on a patient following an injury of this kind.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow hospital protocol for neurological observation frequency
Wider context from the report “(3) The nursing staff made no contemporaneous notes for a period of five hours on the system so there was little information about the timings of their actions. The doctor did not arrive until over two hours later but did order an urgent CT scan, however when he had the results he then ordered neurological observations be done every two hours which is not as per hospital protocol .
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make contemporaneous nursing records
Wider context from the report “(3) The nursing staff made no contemporaneous notes for a period of five hours on the system so there was little information about the timings of their actions . The doctor did not arrive until over two hours later but did order an urgent CT scan, however when he had the results he then ordered neurological observations be done every two hours which is not as per hospital protocol.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to carry out accurate neurological observations
Wider context from the report “[1] It became clear during evidence that the nursing staff on duty on 13 November 2016 were not able to understand and carry out proper neurological observations . This became evident when on one set of observations the nurse assessed Mr Mallett's Glasgow Coma scale (GCS) as 3 (lowest score possible) and yet still had equal power in all four limbs which would not have been possible to assess. Some of the observations contradicted each other with no one nurse assessing the patient as 6 on the GCS.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nursing observation of high-risk patients
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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 South London Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use available movement-alert and fall-prevention equipment
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement . The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” Open source report
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Addressed to Queen Elizabeth Hospital NHS Trust, now represented here by South London Healthcare NHS Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations