Recipient

Southend University Hospital

First report 6 Jun 2014•Latest report 2 Nov 2015

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: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Southend University Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

2 Nov2015
Essex
Concerns raised5
1. Lack of up-to-date knowledge among general practitioners about epiglottitis in adults
2. Lack of effective training of ambulance staff on when to convey a patient to hospital
3. Failure to learn from prior events
1. Lack of effective training of ambulance staff in use of the sepsis screening tool
2. Ineffective use of the sepsis screening tool by ambulance staff
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

Steven David Jackson · 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

Steven David Jackson attended Southend Hospital on 5 March 2014, was later taken there by ambulance after collapsing, and died at 14:26. The inquest recorded acute epiglottitis as the cause of death and identified very serious failings in the care provided by ambulance staff. Concerns also included an out-of-hours general practitioner’s apparently outdated knowledge of epiglottitis in adults.

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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of up-to-date knowledge among general practitioners about epiglottitis in adults
Wider context from the report
“1. The general practitioner, employed by the out of hours service IC24, seemed to have out of date knowledge of the incidence of epiglottitis generally. He seemed to be under the impression that it was still very much a condition found among children and would not be expected in an adult such as Mr Jackson. ”
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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective training of ambulance staff on when to convey a patient to hospital
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to 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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to learn from prior events
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to 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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective training of ambulance staff in use of the sepsis screening tool
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to 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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Ineffective use of the sepsis screening tool by ambulance staff
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”
Open source report
16 Jul2014
Essex
Concerns raised3
1. Lack of formal training in good record-keeping practice
2. Poor record keeping
3. Unavailability of a blood fridge on the ward for immediate access to matched blood
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

Julie Ann Robertson · 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

Julie Ann Robertson died on 11 May 2013 from complications following an operation for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. The inquest narrative described delays in escalation, obtaining blood and starting surgery, as well as poor record keeping and unclear timings. The report raised concerns that matched blood was not immediately available on the ward and that there was insufficient formal training in record keeping.

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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of formal training in good record-keeping practice
Wider context from the report
“2) Record keeping was poor and this was acknowledged in the Root Cause Analysis report. Although I heard evidence that there had been some training instigated there is no formal training and indeed witnesses at the inquest still seemed unaware of good practice as to record keeping. ”
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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Poor record keeping
Wider context from the report
“2) Record keeping was poor and this was acknowledged in the Root Cause Analysis report. Although I heard evidence that there had been some training instigated there is no formal training and indeed witnesses at the inquest still seemed unaware of good practice as to record keeping. ”
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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of a blood fridge on the ward for immediate access to matched blood
Wider context from the report
“1) The possible need for blood had been anticipated as early as 4:40am. If there had been a blood fridge on the ward then the matched blood could have been brought to the ward so that when a transfusion was called for it would have been instantly available on the ward. The blood eventually arrived at 6.55am by which time Mrs Robertson was unfit for surgery. ”
Open source report
30 Jun2014
Essex
Concerns raised1
1. Risk of uterine rupture and associated obstetrical complications from Propess use in patients with previous caesarean section or uterine surgery
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

Jessica Hope Bond · 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

Jessica Hope Bond suffered significant brain injury following a uterine rupture during her mother's labour, which necessitated an emergency caesarean section, and she died seven months later. The report raises concern that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery because of the potential risk of uterine rupture and associated obstetrical complications.

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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Risk of uterine rupture and associated obstetrical complications from Propess use in patients with previous caesarean section or uterine surgery
Wider context from the report
“(1) Independent expert opinion has drawn attention to the fact that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery given the potential risk for uterine rupture and associated obstetrical complications. Uterine rupture has been reported in association with the use of Propess ”
Open source report
6 Jun2014
Essex
Concerns raised3
1. Delays between readmission and arrival in theatre
2. Lack of input from senior clinical staff at patient presentation
3. Failure to conduct root cause analysis and develop lessons learned and an action plan
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

Frances Margaret Ann Bell · 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

Frances Margaret Ann Bell presented at Southend Hospital with abdominal pain on 30 March 2012, was discharged shortly after midnight, readmitted the next day, underwent abdominal surgery on 1 April, and died on 13 April 2012. The report identified very serious failings in her care, including no senior clinical input at presentation and an unacceptable delay before surgery, and noted that no Root Causes Analysis Investigation was carried out.

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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Delays between readmission and arrival in theatre
Wider context from the report
“(3) There was an unacceptable delay between Mrs Bell’s readmission on the 31 March and her arrival in theatre on 1 April ”
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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Lack of input from senior clinical staff at patient presentation
Wider context from the report
“(2) There was no input from senior clinical staff at the time of Mrs Bell’s presentation on 30 March ”
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 Southend University Hospital; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct root cause analysis and develop lessons learned and an action plan
Wider context from the report
“(1) There was no Root Causes Analysis Investigation carried out which would have identified lessons learned and an action plan ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised5

Lack of up-to-date knowledge among general practitioners about epiglottitis in adults

Lack of effective training of ambulance staff on when to convey a patient to hospital

Failure to learn from prior events

Lack of effective training of ambulance staff in use of the sepsis screening tool

Ineffective use of the sepsis screening tool by ambulance staff

Concerns raised3

Lack of formal training in good record-keeping practice

Poor record keeping

Unavailability of a blood fridge on the ward for immediate access to matched blood

Concerns raised1

Risk of uterine rupture and associated obstetrical complications from Propess use in patients with previous caesarean section or uterine surgery

Concerns raised3

Delays between readmission and arrival in theatre

Lack of input from senior clinical staff at patient presentation

Failure to conduct root cause analysis and develop lessons learned and an action plan