Southmead Hospital

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First report 17 Nov 2014•Latest report 21 Sep 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Avon

    AI-generated summary

    Annette HILL · 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

    Annette HILL was transported to the emergency department with increasing breathlessness and was assessed under the sepsis protocol before receiving intravenous antibiotics. She suffered an unexpected reaction and died despite advanced CPR; the concern was an unresolved tension between the Sepsis 6 guidelines and the BTS COPD care bundle, as antibiotics were given although she did not appear to require them based on the available 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 Southmead Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Unresolved tension between Sepsis 6 guidelines and the BTS COPD care bundle

    Wider context from the report

    “(1) This patient received IV antibiotics correctly in accordance with the Sepsis 6 guidelines. However, she did not in fact require antibiotics on an overview of the available information. There appears to be an unresolved tension between the Sepsis 6 guidelines and the BTS COPD care bundle for the management of patients with advanced respiratory disease. ”
    Open source report

  2. Avon

    AI-generated summary

    Peter DORNEY · 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

    Peter Dorney was admitted to Frenchay Hospital and deteriorated overnight on 3–4 April 2014 before suffering a cardiac arrest and dying on 4 April from bronchopneumonia. The report identified that required increased observations and notification of a senior staff member were not carried out after his EWS score rose, and noted that EWS training for nurses was not mandatory.

    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 Southmead Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of mandatory EWS training for nurses

    Wider context from the report

    “During the evidence the ward sister gave evidence and she was of the opinion that there should be mandatory training on EWS for nurses. It was clear in the evidence that the protocol in relation to the EWS score was not followed and I was told that the EWS training was not mandatory currently. This case highlights why EWS scores are so important to the well-being of patients ”
    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 Southmead Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow the EWS score protocol

    Wider context from the report

    “During the evidence the ward sister gave evidence and she was of the opinion that there should be mandatory training on EWS for nurses. It was clear in the evidence that the protocol in relation to the EWS score was not followed and I was told that the EWS training was not mandatory currently. This case highlights why EWS scores are so important to the well-being of patients ”
    Open source report
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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