26 Aug 2025 Anne Lorraine Dyson · Prevention of Future Deaths report Sunderland
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Concerns raised 2 Failure to provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation View source Failure to ensure interpretation of the whole scan 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
Anne Lorraine Dyson · 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
Anne Lorraine Dyson died at St Benedict's hospice on 24 February 2025 after metastatic lung cancer was diagnosed in November 2024, following investigation for lung disease since September 2021. An incorrect interpretation of a CT scan in March 2024 significantly delayed diagnosis, by which time the cancer had progressed to a terminal stage. Concerns included inconsistent and limited clinical information provided to radiologists, potentially leading to restricted scan interpretation and delayed diagnosis and treatment.
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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 South Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Radiologists with complete and consistent clinical history and symptom information for scan interpretation
Wider context from the report “The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies greatly in quality and level of detail, and there is no consistent approach , with Radiologists often having to create their own medical history from previous scans and reports , if any have been undertaken.
I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided , and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report.
The evidence indicated that Radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period .
I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted - not the whole of the scan, meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure interpretation of the whole scan
Wider context from the report “The evidence revealed that when Radiologists are asked to interpret a scan, the information they are provided with varies greatly in quality and level of detail, and there is no consistent approach, with Radiologists often having to create their own medical history from previous scans and reports, if any have been undertaken.
I am concerned that the evidence was that such requests for interpretation are often focused to a specific area of concern with a limited background history provided, and that this can lead to confirmation bias or satisfaction of search by the Radiologist when providing a report.
The evidence indicated that Radiologists are not provided with a list or a summary of a patient’s symptoms or health complaints which resulted in the scan being commissioned, nor are they provided with details of any new or changed symptoms that have occurred during the investigative period.
I am concerned that this has the potential to restrict the focus of the interpreter resulting in only limited aspects of the scan being interpreted - not the whole of the scan , meaning that potential diagnosis and treatment can then be significantly delayed, if something is missed.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share identified radiology learning with Trust radiologists, emphasising search extent, confirmation bias and comparison of relevant prior imaging.
Verbatim wording from the response “As a Trust we have taken Anne Dyson’s death very seriously and as you heard at the inquest, we’ve taken steps to share the identified learning with relevant Radiologists within the Trust, highlighting the importance of Radiologists being satisfied with the extent of their search, being aware of the risk of confirmation bias and the importance of comparing prior relevant imaging, where appropriate.” Source location Response from South Tyneside and Sunderland 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 Audit compliance with radiology request information standards and provide feedback to individuals and directorates as appropriate.
Verbatim wording from the response “The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.” Source location Response from South Tyneside and Sunderland 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 Update Trust induction training to emphasise clinical details required in radiology requests for safe and accurate reporting.
Verbatim wording from the response “The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.” Source location Response from South Tyneside and Sunderland 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 Develop a work instruction specifying the required clinical information for radiology examinations to proceed.
Verbatim wording from the response “The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.” Source location Response from South Tyneside and Sunderland 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 Issue Trust-wide communication updating current staff about the required clinical information for radiology requests.
Verbatim wording from the response “The Trust’s Radiology department is working to update Trust induction training to emphasise key clinical details which must be consistently included in radiology requests to ensure the safe and accurate reporting of these exams. To deliver this a work instruction will be developed which will detail the required standard of clinical information required for radiology examinations to proceed. This will also be supported by a Trust wide communication to update current staff members and there will be a regular audit of these standards, completed by the Trust’s Radiology department, to ensure compliance, with feedback provided to individuals and whole directorates as appropriate.” Source location Response from South Tyneside and Sunderland NHS Foundation Trust
Open published response
11 Mar 2025 Mr Allan Taylor · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure to escalate non-compliance with Level 2 EICO observation requirements View source Failure to maintain required nurse sight or sound for Level 2 EICO observations 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
Mr Allan Taylor · 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 Allan Taylor was admitted to Sunderland Royal Hospital after an unwitnessed fall at home and later suffered a further unwitnessed fall in hospital, fracturing his right neck of femur. He died in theatre on 1 June 2024 after becoming hypotensive and suffering cardiac arrest during surgery. The report identified that required Level 2 observations were not provided because the side room was not within sight or sound of the nursing station, and the issue was not escalated; it noted that closer observation might have enabled assistance and possibly prevented the fall.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate non-compliance with Level 2 EICO observation requirements
Wider context from the report “1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it.
2. The evidence was that this was not escalated to the Matron or Site Manager , which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations.
3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain required nurse sight or sound for Level 2 EICO observations
Wider context from the report “1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station . It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it.
2. The evidence was that this was not escalated to the Matron or Site Manager, which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations.
3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall.
” 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 Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.
Verbatim wording from the response “This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.” Source location Response from South Tyneside and Sunderland 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 Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.
Verbatim wording from the response “This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.” Source location Response from South Tyneside and Sunderland 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 Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.
Verbatim wording from the response “Our internal investigation identified omissions in care regarding the level of observation in place for Mr Taylor and the lack of escalation of concerns. Actions were undertaken to address this issue; an urgent review of the existing Enhanced Interactive Care and Observation (EICO) guideline took place which has now been amended and renamed Enhanced Therapeutic Observation and Care (ETOC) for patients in line with recent national changes in guidance as recommended by NHS England. In addition to exploring best practice nationally, the review of the guideline also took into consideration how other local Trusts manage safe observation and care of patients.” Source location Response from South Tyneside and Sunderland NHS Foundation Trust
Open published response
Concerns raised 5 Lack of a procedure to record and audit SafeCare training delivery and efficacy View source Failure to provide SafeCare system training to relevant staff View source Failure to ensure staff awareness of the Standard Operating Procedure for Enhanced Care/Observation View source Unsafe positioning of window restrictor fixings on pivot-window sills View source Failure to communicate changes in window restrictor fixing guidance to hospital trusts View source See 2 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
Edward Cockburn · 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
Edward Cockburn died after falling from an upper-storey window in a sluice room at Sunderland Royal Hospital on 15 March 2020, suffering injuries from which he later died. The report identified failures in enhanced-care assessments and observations, an unsecured sluice-room door, a failed window restrictor fixing, and significantly substandard staffing. It also raised concerns about staff training and the communication of updated window-restrictor fitting guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure to record and audit SafeCare training delivery and efficacy
Wider context from the report “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide SafeCare system training to relevant staff
Wider context from the report “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff awareness of the Standard Operating Procedure for Enhanced Care/Observation
Wider context from the report “Staff appeared to be unaware of the Trusts Standard Operating Procedure in relation to Enhanced Care/Observation. Training at that time had not been given to relevant members of staff in connection with the SafeCare system. Whilst training and information had been cascaded there was no procedure in place in relation to any training that could record and thereafter audit the efficacy of that system with particular regard to when the training was delivered and by whom and to whom it was delivered.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe positioning of window restrictor fixings on pivot-window sills
Wider context from the report “The fixing was attached to the sill of the window in accordance with fitting instructions issued by Jacklok and dated July 2017. Subsequent to the installation a data sheet was issued indicating that the fixing should be attached to the window frame only. This change in data/guidance was not highlighted to South Tyneside and Sunderland NHs Trust and presumably other hospital trusts. The position of the fixing on the sill enabled the restrictor to be more readily defeated bearing in mind this was a pivot window
Jacklok have been requested to take action as follows
(a) To ensure that the guidance is changed clarify the necessity to attach the fixing to the frame and proximity to the points of pivot
(b) To ensure that this is effectively communicated to and highlighted with all NHS Trusts and other relevant users using the Jackloc window restrictor system
The relevant Department guidance is Health Building Note 00-10Part D Windows and Associated Hardware
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate changes in window restrictor fixing guidance to hospital trusts
Wider context from the report “The fixing was attached to the sill of the window in accordance with fitting instructions issued by Jacklok and dated July 2017. Subsequent to the installation a data sheet was issued indicating that the fixing should be attached to the window frame only. This change in data/guidance was not highlighted to South Tyneside and Sunderland NHs Trust and presumably other hospital trusts. The position of the fixing on the sill enabled the restrictor to be more readily defeated bearing in mind this was a pivot window
Jacklok have been requested to take action as follows
(a) To ensure that the guidance is changed clarify the necessity to attach the fixing to the frame and proximity to the points of pivot
(b) To ensure that this is effectively communicated to and highlighted with all NHS Trusts and other relevant users using the Jackloc window restrictor system
The relevant Department guidance is Health Building Note 00-10Part D Windows and Associated Hardware
” 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 Create organisational, ward and department reports to monitor and audit completion of SafeCare and EICO training.
Verbatim wording from the response “We have now agreed a mechanism to address these actions by utilising our existing Electronic Staff Record (ESR) system. We are developing E-learning packages for both SafeCare and EICO which will be uploaded to the ESR and easily accessible to staff. Staff who require this training will have an associated competency added to their learning profile and compliance matrix within ESR. This will allow the creation of reports to capture and monitor/audit completion of this E-learning at an organisational level, as well as a ward/department level.” Source location 2021-0415-Response-from-Sunderland-Royal-Hospital_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add required SafeCare and EICO competencies to staff learning profiles and compliance matrices within the Electronic Staff Record system.
Verbatim wording from the response “We have now agreed a mechanism to address these actions by utilising our existing Electronic Staff Record (ESR) system. We are developing E-learning packages for both SafeCare and EICO which will be uploaded to the ESR and easily accessible to staff. Staff who require this training will have an associated competency added to their learning profile and compliance matrix within ESR. This will allow the creation of reports to capture and monitor/audit completion of this E-learning at an organisational level, as well as a ward/department level.” Source location 2021-0415-Response-from-Sunderland-Royal-Hospital_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete remedial estates work by fitting additional window restrictors and swipe-card access to restricted areas across key Trust areas.
Verbatim wording from the response “Our internal investigation identified omissions in care with regard to the level of observation in place for Mr Cockburn and the lack of escalation of concerns around staffing levels. Immediate actions were undertaken to address these issues, along with remedial estates work to fit additional window restrictors and swipe card access to restricted areas in key areas across the Trust, which has now been completed.” Source location 2021-0415-Response-from-Sunderland-Royal-Hospital_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop E-learning packages for SafeCare and EICO and make them accessible to relevant staff through the Electronic Staff Record system.
Verbatim wording from the response “We have now agreed a mechanism to address these actions by utilising our existing Electronic Staff Record (ESR) system. We are developing E-learning packages for both SafeCare and EICO which will be uploaded to the ESR and easily accessible to staff. Staff who require this training will have an associated competency added to their learning profile and compliance matrix within ESR. This will allow the creation of reports to capture and monitor/audit completion of this E-learning at an organisational level, as well as a ward/department level.” Source location 2021-0415-Response-from-Sunderland-Royal-Hospital_Published
Open published response
15 Apr 2019 Mr Thomas Smith Collings · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 2 Failure of the alert algorithm to provide earlier differentiation between detached-lead artefacts and life-threatening ventricular defibrillation View source Lack of timely refresher training on maintenance of monitor lead attachments 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
Mr Thomas Smith Collings · 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 Thomas Smith Collings suffered unexpected ventricular fibrillation at Sunderland Royal Hospital on 2 August 2018 and was found several minutes later without effective cardiac output. The report identified failures to detect the ventricular fibrillation, including ECG monitoring not detecting the rhythm, the crisis alarm not sounding, artefact obscuring the trace, and delays in attendance. The substantive concern was whether improvements to monitoring algorithms could enable earlier alerts and better distinguish artefact from a life-threatening event.
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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 South Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the alert algorithm to provide earlier differentiation between detached-lead artefacts and life-threatening ventricular defibrillation
Wider context from the report “I should be glad to be told about any additional learning arising from the evidence heard at the Inquest especially with regard to the evidence of your engineer ████████ and
In particular, are there any improvements to the algorithm for earlier alerts, especially those that may differentiate sooner between any artefact, such as a detached lead, and a life-threatening event, such as a ventricular defibrillation, recognisable by the human eye?
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of timely refresher training on maintenance of monitor lead attachments
Wider context from the report “Although the letter of 8th February 2019 from the Trust’s Solicitors set out the likely steps to be taken, I should be glad to be told of any additional learning arising from the evidence heard at the Inquest, especially with regard to the evidence of ████████ of GE Healthcare and ████████. In particular, what are the timescales for implementation and refresher training in respect of the importance of maintenance of the lead attachments to ensure optimal performance of the monitors ?
” 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 Deliver comprehensive staff training for the new monitoring system, including alarm classifications, lead attachment maintenance and train-the-trainer provision.
Verbatim wording from the response “The Directorate developed a business case for a new monitoring system for CCU from an alternative supplier. I am pleased to inform you that the Trust approved this business case, the equipment has been purchased and the enabling work for the installation has now commenced. Staff training on the new monitoring equipment has been procured as part of the process and there will be a full and comprehensive training package delivered as part of this changeover. Our estates department is currently installing additional network cabling throughout the unit, so we do not yet have a completion date for the installation of the monitoring system, but we estimate that this will be in the Autumn.” Source location 2019-0260-Response-by-South-Tyneside-and-Sunderland-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A definitive commencement timescale for staff training cannot be provided until enabling works for the new monitoring system are completed.
Verbatim wording from the response “Unfortunately, until we have confirmation of when these enabling works will be completed, I am unable to provide you with the definitive timescales for the commencement of this training, as it needs to be organised around the installation date. However, I have provided a copy of the training programme (please see attached).” Source location 2019-0260-Response-by-South-Tyneside-and-Sunderland-NHS-Trust
Open published response
Concerns raised 4 Failure to obtain definitive diagnostic imaging before discharge View source Failure to act on reported x-ray findings View source Potentially delayed surgical treatment View source Lack of documented protocols for treatment and 24/7 CT scanning and reporting View source See 1 more concern
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
Ms Susan Joan Elliott (Sue) · 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
Ms Susan Joan Elliott died at Sunderland Royal Hospital on 14 September 2017 after a fall, an initially unconfirmed suspected hip fracture, subsequent readmission and surgery. Concerns included that the 4 August x-ray was reportedly ignored, no CT scan was undertaken before discharge, and surgery may have been possible earlier.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain definitive diagnostic imaging before discharge
Wider context from the report “No CT scan was undertaken prior to discharge on 9th August 2017 , so there was no definitive diagnosis and decisions were based on clinical impression .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on reported x-ray findings
Wider context from the report “The orthopaedic surgeon in his evidence confirmed that the x-ray of 4th August 2017 was “reported on and ignored”
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Potentially delayed surgical treatment
Wider context from the report “In all likelihood surgery was an earlier possibility for Sue .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documented protocols for treatment and 24/7 CT scanning and reporting
Wider context from the report “Reference was made to new protocols about the treatment of patients presenting with similar conditions such as Sue (particularly for 24/7 CT scanning/reporting ), but no documents were produced .
” 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 the Emergency Department Injured Elderly NWB Guideline in junior doctor induction and stress discussion of referrals at trauma x-ray meetings.
Verbatim wording from the response “At the inquest, the same witness also made reference to new protocols about the treatment of patients presenting with similar conditions such as Ms Elliott, but did not produce any documents. I would like to assure you that we do have an “Emergency Department Injured Elderly Non-Wight Bearing (NWGB) Guideline” which was developed in 2015. This guideline provides clear recommendations for cross sectional (CT) imaging and reporting, where pain or dysfunction suggests an occult fracture. I have provided a copy of this guideline.” Source location 2018-0275-Response-by-City-Hospital-Sunderland-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 Review and relaunch the injured elderly non-weight-bearing pathway across the Trust to raise clinicians’ awareness.
Verbatim wording from the response “The guideline is now included in the T&O junior doctor induction programme and the importance of all referrals being discussed at the trauma x-ray meeting is also stressed within this training. Our internal investigation has acknowledged that we need to review and relaunch this pathway across the Trust in order to raise clinicians’ awareness and this has been addressed within the action plan.” Source location 2018-0275-Response-by-City-Hospital-Sunderland-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 The radiograph and report were viewed by three medical staff and were therefore not reported and ignored.
Verbatim wording from the response “You will recall that one of the witnesses in his evidence at Ms Elliott’s inquest, suggested that Ms Elliott’s radiograph of 4th August 2017 was “reported and ignored”. I would like to reassure you that following a thorough internal investigation, I can confirm that both the radiograph and the associated radiology report were viewed on our electronic system (Meditech) between 4th and 5th August 2017 by three different members of medical staff who considered the report alongside Ms Elliott’s clinical presentation and status.” Source location 2018-0275-Response-by-City-Hospital-Sunderland-NHS-Trust
Open published response
Concerns raised 2 Lack of clear implementation plans for the Enhanced Care/Observation Standard Operating Procedure View source Failure to provide close supervision in the hospital room following review of the falls risk assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr James Trevor Vinson · 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 James Trevor Vinson, aged 72, was admitted to Sunderland Royal Hospital for rehabilitation after treatment for an acute subdural haematoma. He was found after an unwitnessed fall in his hospital room and later died from an intra-peritoneal bleed associated with splenic tears. The concern was that he was not under the close supervision intended despite his assessed falls risk, and that plans for implementing an enhanced care and observation procedure were unclear.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear implementation plans for the Enhanced Care/Observation Standard Operating Procedure
Wider context from the report “I heard evidence about a draft Enhanced Care/Observation Standard Operating Procedure (SOP) , and copies were provided to me and the family. Although a SOP is to be piloted, I am further concerned that the plans for its implementation are not clear . Hence this Report to you. I emphasised in Court that this Report is not to be construed as any form of censure, but rather a means to clarify the actions to be taken and firm 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 South Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide close supervision in the hospital room following review of the falls risk assessment
Wider context from the report “Although the Splenomegaly (identified in Sunderland Royal Hospital on 16th October 2016) would not have led to any changes in the management of Mr Vinson, I was concerned to hear evidence, that Mr Vinson was meant to be under close supervision in his hospital room, but this was not the case despite a review of the falls risk assessment .
” 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 Ratify and roll out the Enhanced Care SOP across the Trust.
Verbatim wording from the response “As you will note from the enclosed action plan, the Trust is currently developing an Enhanced Care Standard Operating Procedure (SOP) to assess vulnerable adult in-patients’ observation and care requirements. The SOP incorporates an Enhanced Care Risk Assessment Tool and defined criteria for heightened levels of observation. The purpose of this SOP is to ensure our staff maintain an environment which is safe and reduces the risk to patients and others by providing heightened levels of observation for patients within the stated criteria.” Source location 2017-0316-Response-by-City-Hospitals-Sunderland-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 Develop and pilot an Enhanced Care SOP with a risk assessment tool and criteria for heightened observation of vulnerable adult inpatients.
Verbatim wording from the response “As you will note from the enclosed action plan, the Trust is currently developing an Enhanced Care Standard Operating Procedure (SOP) to assess vulnerable adult in-patients’ observation and care requirements. The SOP incorporates an Enhanced Care Risk Assessment Tool and defined criteria for heightened levels of observation. The purpose of this SOP is to ensure our staff maintain an environment which is safe and reduces the risk to patients and others by providing heightened levels of observation for patients within the stated criteria.” Source location 2017-0316-Response-by-City-Hospitals-Sunderland-NHS-Trust
Open published response
Concerns raised 9 Failure to provide longitudinal management of recurring asthma exacerbations View source Failure to recognise deterioration in respiratory condition View source Failure to enable appropriate referrals to the tertiary paediatric service View source Failure to ensure understanding of the purpose and limits of asthma plans View source Lack of a long-term management plan for chronic asthma View source Lack of effective communication between primary and secondary care services View source Lack of a coordinating record of recurrent asthma presentations View source Failure to assign overall clinical management responsibility View source Failure to refer paediatric asthma patients to tertiary respiratory specialists View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tamara Mills · 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
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide longitudinal management of recurring asthma exacerbations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in respiratory condition
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enable appropriate referrals to the tertiary paediatric service
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust . The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure understanding of the purpose and limits of asthma plans
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a long-term management plan for chronic asthma
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes .
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication between primary and secondary care services
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment .
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinating record of recurrent asthma presentations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall clinical management responsibility
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer paediatric asthma patients to tertiary respiratory specialists
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service .
” Open source report
Concerns raised 6 Lack of an inter-trust policy clarifying responsibility and communication channels for referred patients View source Poor direct and indirect communication between medical professionals at different trusts View source Lack of a policy clarifying responsibilities and communication channels between trusts when patients are referred View source Poor understanding between medical professionals of differing practices and procedures View source Poor understanding of differing practices and procedures between trusts View source Poor direct and indirect communication between medical professionals across trusts View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Anne Ferry · 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
Margaret Anne Ferry was admitted to Sunderland Royal Hospital, underwent a planned toe amputation, and subsequently developed deterioration in her skin integrity before dying on 12 May 2015. The report identified unclear responsibilities between hospitals, poor written and oral communication, differing practices and procedures, and a lack of leadership and a cohesive treatment plan.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an inter-trust policy clarifying responsibility and communication channels for referred patients
Wider context from the report “1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor direct and indirect communication between medical professionals at different trusts
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy clarifying responsibilities and communication channels between trusts when patients are referred
Wider context from the report “1. Evidence was given at the Inquest that there was no policy in place between City Hospitals Sunderland NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust clarifying the areas of responsibility and channels of communication between the two when patients are referred .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor understanding between medical professionals of differing practices and procedures
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor understanding of differing practices and procedures between trusts
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor direct and indirect communication between medical professionals across trusts
Wider context from the report “2. Evidence was given that there were poor levels of communication both direct and indirect between medical professionals at each trust and poor understanding of each other’s differing practices and procedures.
” Open source report
Concerns raised 10 Lack of contingency provision for physiotherapy View source Confusion about hoist transfers between bed and chair View source Failure to identify patients with relevant co-morbidities as higher risk View source Failure to submit pressure-ulcer incident reports View source Inaccurate recording or communication of diabetes type View source Unclear toileting arrangements and unmet hygiene needs View source Inconsistent classification of heel injuries View source Confusion about patient fluid restrictions View source Delays in referral to the foot protection team View source Inadequate nursing and care-record documentation View source See 7 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
Leonard Henry Hudson · 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
Leonard Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of contingency provision for physiotherapy
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy ;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion about hoist transfers between bed and chair
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist ;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify patients with relevant co-morbidities as higher risk
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor .
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to submit pressure-ulcer incident reports
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted .
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording or communication of diabetes type
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1 .
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear toileting arrangements and unmet hygiene needs
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met ;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent classification of heel injuries
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable” .
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Confusion about patient fluid restrictions
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson : the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to the foot protection team
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner .
The nursing documentation was not as comprehensive as it ought to have been.
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate nursing and care-record documentation
Wider context from the report “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted.
Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor.
Mr Hudson ought to have been referred to the foot protection team in a more timely manner.
The nursing documentation was not as comprehensive as it ought to have been .
The classification of Mr Hudson’s heel injuries was “variable”.
From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team.
During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: -
1) there were episodes of inadequate record keeping ; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter ; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this ;
2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist;
3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis;
4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy;
5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met;
6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1.
All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding.
However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention.
I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths.
” Open source report
Concerns raised 4 Failure to provide follow-up appointments within the required timeframe View source Missing referral documentation for procedures View source Lack of systems to identify and rectify problems View source Failure to provide urgent procedure appointments within the required timeframe 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
Thomas David Dixon · 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
Thomas David Dixon had bladder cancer and died at St Benedict’s Hospice on 29 March 2014 from metastatic transitional cell carcinoma of the bladder. Concerns included failures to arrange follow-up and an urgent procedure, missing referral documentation, and a lack of systems to identify and rectify these problems, with potential implications for other patients.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide follow-up appointments within the required timeframe
Wider context from the report “(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012
(2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013
(3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014
(4) There appeared to be no systems in place to identify and take action to rectify these problems.
Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up.
I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements.
However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Missing referral documentation for procedures
Wider context from the report “(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012
(2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013
(3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014
(4) There appeared to be no systems in place to identify and take action to rectify these problems.
Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up.
I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements.
However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of systems to identify and rectify problems
Wider context from the report “(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012
(2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013
(3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014
(4) There appeared to be no systems in place to identify and take action to rectify these problems .
Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up.
I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements.
However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide urgent procedure appointments within the required timeframe
Wider context from the report “(1) There was a failure to give Mr Dixon an appointment 6 months after he was seen in August 2012
(2) There was a failure to give Mr Dixon an urgent appointment for a procedure within 4-6 weeks of the 14/08/2013
(3) Important documentation was missing namely the referral form for the procedure that took place on 13/01/2014
(4) There appeared to be no systems in place to identify and take action to rectify these problems.
Although none of the failures caused or contributed to the death of Mr Dixon and although the Consultant Urological Surgeon had identified some of the problems before Mr Dixon’s death I am concerned that these may impact upon other patients not just within the urology department but in other areas of the hospital, particularly screening and follow up.
I heard evidence about an action plan to deal with the issues that had arisen particularly about problems with faxes and the proposed electronic improvements.
However it is nearly 6 months since the problems were identified and it may be that a review of the action plan and the timeliness of its implementation would be beneficial together with any other action that could be taken to deal with these concerns so as to prevent future deaths
” Open source report
Concerns raised 6 Insufficient robustness of systems and compliance controls to deal with human factors View source Delays in completing initial documentation due to process interruptions View source Failure to communicate pharmacy queries effectively View source Failure to effectively review omissions to prescribe prophylactic Dalteparin View source Insufficiently timely implementation of effective change initiatives View source Failure to correct revealed safety failures in a timely way 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
Mrs Jean James · 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 Jean James was admitted to the Acute Medical Unit on 24 December 2013, where prophylactic Dalteparin was intended but not prescribed. A pharmacy query was not effectively communicated, and the omission was not subject to effective review. Mrs James died on 8 January 2014; the post-mortem identified bilateral pulmonary thromboembolism due to deep venous thrombosis, and the inquest concluded: “Natural Causes Contributed to by Neglect”.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient robustness of systems and compliance controls to deal with human factors
Wider context from the report “4) Systems, forms, checklists, policies, procedures and protocols and compliance with them may not be sufficiently robust to deal with human factors .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing initial documentation due to process interruptions
Wider context from the report “1) The time taken to complete the initial documentation was longer than it ought to have been given the interruptions to the process .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate pharmacy queries effectively
Wider context from the report “3) When the pharmacy raised a query, it was not communicated effectively .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively review omissions to prescribe prophylactic Dalteparin
Wider context from the report “2) The omission to prescribe prophylactic Dalteparin had not been subject to any effective review by a clinician or a nurse .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently timely implementation of effective change initiatives
Wider context from the report “The failures revealed without correction from 24 December until Mrs James’ acute deterioration and death on 8 January 2014.
I heard evidence about the number of initiatives that were under way, including increased vigilance. However, I remain concerned that such steps may be insufficient to effect change in a more timely way .
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correct revealed safety failures in a timely way
Wider context from the report “The failures revealed without correction from 24 December until Mrs James’ acute deterioration and death on 8 January 2014 .
I heard evidence about the number of initiatives that were under way, including increased vigilance. However, I remain concerned that such steps may be insufficient to effect change in a more timely way.
” 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 VTE policy to incorporate technical changes to the VTE assessment and prescribing process.
Verbatim wording from the response “4) The Trust has a VTE policy based on NICE guidelines and we are currently reviewing the policy to encompass the technical changes made to the VTE assessment and prescribing process. We will hold a Trust wide clinical symposium in the autumn to ensure staff have the opportunity to discuss current issues regarding the management of patients at risk of VTE.” Source location 2014-0112-Response-by-City-Hospitals-Sunderland
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 Alert clinical teams about the VTE assessment and prescribing system changes through an all-users electronic message and team briefings.
Verbatim wording from the response “The clinical teams will be alerted to this development by:” Source location 2014-0112-Response-by-City-Hospitals-Sunderland
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 pharmacy-team communication and escalation of medication omissions to identify workable solutions.
Verbatim wording from the response “3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions.” Source location 2014-0112-Response-by-City-Hospitals-Sunderland
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 Test and implement automated VTE risk prompts, mandatory thromboprophylaxis prescribing or rationale documentation, and medication administration alerts.
Verbatim wording from the response “1) We have reviewed the hospital information system, known as MEDITECH V6 to find a solution to prevent further risk for patients who on assessment are at risk of developing a venous thromboembolism episode (VTE). The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk.” Source location 2014-0112-Response-by-City-Hospitals-Sunderland
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 Conduct an audit of the VTE system to ensure practice is embedded.
Verbatim wording from the response “I have also directed our Clinical Governance Department to undertake an audit of the system to ensure practice is embedded.” Source location 2014-0112-Response-by-City-Hospitals-Sunderland
Open published response
Concerns raised 5 Failure to communicate relevant postoperative risks and complications to community carers View source Inadequate systematic assessment of physical symptoms View source Failure to measure and record community patients’ vital signs View source Failure of surgical teams to maintain ongoing oversight after discharge View source Lack of a discharge plan for possible pelvic infection View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Keith Fleming · 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
Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.
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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant postoperative risks and complications to community carers
Wider context from the report “The General Practitioner and consequently the nursing staff were not aware of that the anastomosis of the bowel carried out during the original operation ( 2007) had dehised. Nor were they aware of an internal area of abscess adjacent to the repaired stoma site , only discovered on post mortem and together leading to a catastrophic infection within the deceased particularly and significantly in the area of his left buttock. The reality was the infection within the otherwise pelvic area had tracked through the pelvis into the area of the left buttock.
It was the presence of the swelling of this area of the buttock which was to alert the deceased’ wife several days after his discharge home to the growing crisis and resulted in her summoning her husband’s GP Dr.████████. The Doctor immediately recognized the symptoms, arranged for the deceased’ emergency admission to the South Tyneside District Hospital.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate systematic assessment of physical symptoms
Wider context from the report “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded.
Physical symptoms were noted but only on a generalized – impressionistic basis - tiredness, responsiveness to questions and discussion – level of activity and mobility – diet.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to measure and record community patients’ vital signs
Wider context from the report “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded.
Physical symptoms were noted but only on a generalized – impressionistic basis - tiredness, responsiveness to questions and discussion – level of activity and mobility – diet.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of surgical teams to maintain ongoing oversight after discharge
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” 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 Tyneside and Sunderland NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a discharge plan for possible pelvic infection
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” Open source report
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Request correction
Addressed to City Hospitals Sunderland NHS Foundation Trust, now represented here by South Tyneside and Sunderland NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations