Recipient

Southampton General Hospital

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First report 20 Mar 2017•Latest report 20 Mar 2017

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Southampton General Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Portsmouth and South East Hampshire

    AI-generated summary

    Scott Douglas Hooper · 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

    Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.

    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 Southampton General Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record who made significant clinical decisions and why

    Wider context from the report

    “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight. 2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why. In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held. In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning. Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms. I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category. The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication. ”
    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 Southampton General Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of agreed use of beds with weight-indicating scales to support accurate medication dosing

    Wider context from the report

    “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight. 2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why. In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held. In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning. Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms. I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category. The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication. ”
    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 Southampton General Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to disseminate and implement weight-estimation learning and training for clinical staff treating high-risk patients

    Wider context from the report

    “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight. 2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why. In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held. In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning. Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms. I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category. The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication. ”
    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 Southampton General Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately record or obtain patient weight for weight-dependent anticoagulant dosing

    Wider context from the report

    “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight. 2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why. In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held. In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning. Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms. I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category. The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026