12 Nov 2025 Mr Barry Clive Loxston · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 6 Failure to supervise patients taking medication View source Poor patient handling and failure to prevent patients lying in their own excrement View source Lack of a system for direct contact between the transplant team and local on-call nephrology team to exchange clinically relevant patient information View source Failure to review relevant blood tests before surgery and incorporate them into surgical risk assessment and consent View source Lack of investigation of medication maladministration concerns View source Lack of a system mandating review of suitability to remain on the transplant list at each nephrology review 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.
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AI-generated summary
Mr Barry Clive Loxston · 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 Barry Clive Loxston died at St George’s Hospital on 30 July 2023 after complications following renal transplant surgery, including electrolyte imbalance and delayed graft function. The report identifies concerns about failures to recognise his unfitness for surgery, inadequate patient handling, unsupervised medication administration, insufficient investigation, incomplete review of blood tests, and gaps in systems for assessing transplant-list suitability and communication between nephrology teams.
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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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise patients taking medication
Wider context from the report “2. That leaving medication with patients for them to take in their own time rather than supervise the taking of medication by the patient causes drug maladministration issues that may cause or contribute to deaths of patents.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor patient handling and failure to prevent patients lying in their own excrement
Wider context from the report “1. That poor patient handling and allowing patients to lie for hours in their own excrement is detrimental to patient wellbeing and may contribute to 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for direct contact between the transplant team and local on-call nephrology team to exchange clinically relevant patient information
Wider context from the report “6. That there is no system recommending direct contact with the local on call nephrology team by the transplant team to check whether there are clinically relevant matters in relation to the patient and their suitability for transplant that the local team are aware of and the transplant team are not , such as active other chronic illness or abnormal test results.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review relevant blood tests before surgery and incorporate them into surgical risk assessment and consent
Wider context from the report “4. That all relevant blood tests, including albumin level since low albumin may be associated with significant post operative complication risk, are not reviewed prior to surgery and considered as part of the risk/benefit analysis of surgery and the consenting 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of investigation of medication maladministration concerns
Wider context from the report “3. That lack of investigation of the matter outlined in 2 increases the risk to patients of the concern outlined in 2.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system mandating review of suitability to remain on the transplant list at each nephrology review
Wider context from the report “5. That there is no system mandating suitability to remain on the transplant list by the local nephrologist at each nephrology review .
” Open source report
16 Sep 2024 Samuel Finlay Parkin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Inadequate understanding of malrotation symptoms and diagnostic tests View source Failure to obtain fresh specialist review of gastroenterology re-referrals View source Inadequate safety-netting for apparently benign abdominal conditions View source Lack of formal consideration and dissemination of learning points View source Failure of ultrasound reporting to avoid false reassurance regarding malrotation View source Failure of communication between clinical teams and within referrals View source Inadequate understanding of ultrasound limitations in assessing malrotation View source Reliance on informal rather than formal learning about malrotation View source See 5 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
Samuel Finlay Parkin · 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
Samuel Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.
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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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate understanding of malrotation symptoms and diagnostic tests
Wider context from the report “3. Following Sam’s death, St George’s has reduced the “threshold” for requesting of upper GI contrast studies in intermittent abdominal pain and intermittent vomiting. Given the serious nature of the potential risk that malrotation carries (namely of volvulus occurring) I consider action is required across the NHS, following St George’s lead, to ensure that the symptoms of and diagnostic tests for malrotation, particularly in older children is understood . Where the learning in St George’s is informal, I consider action is required to ensure that formal learning takes place within St George’s.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain fresh specialist review of gastroenterology re-referrals
Wider context from the report “5. One of the learning actions taken by St George’s is that re-referrals to gastroenterology are reviewed by another consultant in order that a fresh assessment/second opinion may occur , followed by an MDT discussion and the option of transferring back to the original consultant. St George’s feels this may help increase the detection of atypical/unusual presentation of GI conditions , including a later presentation of malrotation. Action is required so that this learning point is considered across the NHS.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate safety-netting for apparently benign abdominal conditions
Wider context from the report “4. St George’s has implemented a change in ‘safety netting’ advice for those with what is thought to be benign abdominal conditions from Paediatric ED (using QR codes), from wards and outpatient clinic. Advice is given inviting that “benign abdominal diagnosis“ does not exclude conditions requiring urgent surgical/medical review. This action has been taken for the reasons set out above and action should be taken to ensure the wider NHS considers this learning point .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal consideration and dissemination of learning points
Wider context from the report “1. St George’s have noted a number of learning outcomes in the course of their M&M process and the Child Death Analysis Form. Whilst I heard evidence of training and informal discussions amongst colleagues both at St George’s and regionally, I consider that action is required to ensure that those learning points are formally considered and disseminated throughout St George’s and more widely in the NHS.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ultrasound reporting to avoid false reassurance regarding malrotation
Wider context from the report “2. In the course of the evidence it became clear that the inclusion of a comment in the ultrasound report that the SMA/SMV axis was normal gave false reassurance regarding malrotation . The consultant paediatric radiologist was clear that she was not looking for malrotation on the USS (as it was not listed as a potential diagnosis on the ultrasound request), that USS cannot be used to exclude malrotation and that noting that the axis is normal was simply a comment on the anatomy seen and was not the radiologist providing information relating to whether or not malrotation was present. It is recorded in the notes of the M&M meeting which took place following Sam’s death and in the evidence that I heard, that although clinicians understood that USS is not the diagnostic test for malrotation and that malrotation will not be seen on an USS in circa 25% of cases, the recording of the axis being normal gave a false reassurance . St George’s has changed their practice of reporting of USS to avoid potential confusion in the future. I consider action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children, and to avoid any similar confusion regarding the reporting of USS both in St George’s and across the NHS.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between clinical teams and within referrals
Wider context from the report “6. The evidence before me suggested that there may have been a miscommunication or misunderstandings between the surgical, paediatric and paediatric gastroenterology teams regarding what had and had not been considered and excluded by each during Sam’s admission in 2015. In particular, St George’s written answers to Mr and Mrs Parkin’s question regarding whether there was miscommunication between the treating clinicians was simply “yes”. St George’s has therefore implemented an inpatient (written) referral form to the GI service. Action is required by St George’s and the wider NHS to consider/implement ways to minimise the possibility of miscommunication between teams/in referrals of all disciplines.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate understanding of ultrasound limitations in assessing malrotation
Wider context from the report “2. In the course of the evidence it became clear that the inclusion of a comment in the ultrasound report that the SMA/SMV axis was normal gave false reassurance regarding malrotation. The consultant paediatric radiologist was clear that she was not looking for malrotation on the USS (as it was not listed as a potential diagnosis on the ultrasound request), that USS cannot be used to exclude malrotation and that noting that the axis is normal was simply a comment on the anatomy seen and was not the radiologist providing information relating to whether or not malrotation was present. It is recorded in the notes of the M&M meeting which took place following Sam’s death and in the evidence that I heard, that although clinicians understood that USS is not the diagnostic test for malrotation and that malrotation will not be seen on an USS in circa 25% of cases, the recording of the axis being normal gave a false reassurance. St George’s has changed their practice of reporting of USS to avoid potential confusion in the future. I consider action is required to ensure proper understanding of the limitations of USS in looking for malrotation, in particular in older children , and to avoid any similar confusion regarding the reporting of USS both in St George’s and across the NHS.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on informal rather than formal learning about malrotation
Wider context from the report “3. Following Sam’s death, St George’s has reduced the “threshold” for requesting of upper GI contrast studies in intermittent abdominal pain and intermittent vomiting. Given the serious nature of the potential risk that malrotation carries (namely of volvulus occurring) I consider action is required across the NHS, following St George’s lead, to ensure that the symptoms of and diagnostic tests for malrotation, particularly in older children is understood. Where the learning in St George’s is informal, I consider action is required to ensure that formal learning takes place within St George’s.
” 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 Meet with Epsom St Helier clinical leads to discuss the learning and resulting practice changes.
Verbatim wording from the response “We have met with the clinical leads in paediatrics and radiology at Epsom St Helier Trust to discuss this learning and our changes in practice. They presented this to their sonographers and paediatric radiologists at their Radiology Quality meeting on 9th October 2024.” Source location Response from St George's Epsom and St Helier University Hospitals
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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 Reinforce the revised abdominal pain guidance through regular departmental teaching.
Verbatim wording from the response “The reduced threshold for considering an upper GI contrast study for intermittent abdominal pain and vomiting is one of our key learning points, while remaining mindful of the need to avoid excess exposure to radiation and limit iatrogenic harms. Informed by our audit, we recognise the cohort of patients to be most aware of - older children, with episodic or intermittent vomiting associated with abdominal pain. We have rewritten our local guidance on management of abdominal pain in children to include awareness of this situation and ensure the correct imaging is requested. The guidance is currently being ratified through local governance processes. The new guideline will be reinforced through regular departmental teaching.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Formalise the paediatric abdominal reporting standard in local radiology protocols and audit reports for quality assurance.
Verbatim wording from the response “The limitations of the SMA/SMV axis alone as a marker for malrotation, in particular in older children, are part of the shared learning being disseminated locally. This is now a regular topic for departmental training for paediatric radiology registrar level doctors. The change in the paediatric abdominal reporting standard at St George’s is formalised in local radiology protocols, with quality assurance through active audit of reports. This will be part of a presentation during a dedicated malrotation session, organised and led by the St George’s team, at the British Society of Paediatric Radiology meeting in November 2024.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Rewrite local guidance on children’s abdominal pain to identify relevant presentations and ensure appropriate imaging requests.
Verbatim wording from the response “The reduced threshold for considering an upper GI contrast study for intermittent abdominal pain and vomiting is one of our key learning points, while remaining mindful of the need to avoid excess exposure to radiation and limit iatrogenic harms. Informed by our audit, we recognise the cohort of patients to be most aware of - older children, with episodic or intermittent vomiting associated with abdominal pain. We have rewritten our local guidance on management of abdominal pain in children to include awareness of this situation and ensure the correct imaging is requested. The guidance is currently being ratified through local governance processes. The new guideline will be reinforced through regular departmental teaching.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Hold monthly Paediatric Gastroenterology Radiology meetings to discuss complex cases and record outcomes in the electronic patient record.
Verbatim wording from the response “In addition, we now hold a monthly Paediatric Gastroenterology Radiology meeting where complex cases are discussed. This is attended by consultant and resident doctors from paediatric gastroenterology, paediatric surgery and radiology and the outcomes of this meeting are recorded in the electronic patient record. This is leading to improved communication between paediatrics and radiology and allows diagnostic uncertainty to be openly discussed.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Deliver a dedicated malrotation session at the British Society of Paediatric Radiology meeting.
Verbatim wording from the response “The limitations of the SMA/SMV axis alone as a marker for malrotation, in particular in older children, are part of the shared learning being disseminated locally. This is now a regular topic for departmental training for paediatric radiology registrar level doctors. The change in the paediatric abdominal reporting standard at St George’s is formalised in local radiology protocols, with quality assurance through active audit of reports. This will be part of a presentation during a dedicated malrotation session, organised and led by the St George’s team, at the British Society of Paediatric Radiology meeting in November 2024.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Formalise written referrals to paediatric gastroenterology in the patient record.
Verbatim wording from the response “The requirement for thorough, contemporaneous documentation and communication between teams is reinforced in our local resident doctor induction and training. We have now formalised written referrals to paediatric gastroenterology in the patient record and will be rolling this out for all specialty consult requests within the paediatric directorate, with the expectation that a clear referral outcome will be formally documented.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Reinforce thorough contemporaneous documentation and team communication through resident doctor induction and training.
Verbatim wording from the response “The requirement for thorough, contemporaneous documentation and communication between teams is reinforced in our local resident doctor induction and training. We have now formalised written referrals to paediatric gastroenterology in the patient record and will be rolling this out for all specialty consult requests within the paediatric directorate, with the expectation that a clear referral outcome will be formally documented.” Source location Response from St George's Epsom and St Helier University Hospitals
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 children over one year old who underwent malrotation surgery across four regional centres and present the findings regionally.
Verbatim wording from the response “The paediatric surgery department have carried out an audit of all children with malrotation operated on over 1 year of age across 4 surgical centres in South London and Surrey/Sussex to inform broader learning about this rare but important condition. It has been presented at the regional paediatric surgical meeting at King’s College Hospital and will be shared more widely via the national meeting of the British Association of Paediatric Surgeons and the annual meeting for the Royal College of Paediatrics and Child Health in 2025.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Provide regular departmental training on the limitations of the SMA/SMV axis for detecting malrotation.
Verbatim wording from the response “The limitations of the SMA/SMV axis alone as a marker for malrotation, in particular in older children, are part of the shared learning being disseminated locally. This is now a regular topic for departmental training for paediatric radiology registrar level doctors. The change in the paediatric abdominal reporting standard at St George’s is formalised in local radiology protocols, with quality assurance through active audit of reports. This will be part of a presentation during a dedicated malrotation session, organised and led by the St George’s team, at the British Society of Paediatric Radiology meeting in November 2024.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Roll out written referrals with documented outcomes to all specialty consultation requests across the paediatric directorate.
Verbatim wording from the response “The requirement for thorough, contemporaneous documentation and communication between teams is reinforced in our local resident doctor induction and training. We have now formalised written referrals to paediatric gastroenterology in the patient record and will be rolling this out for all specialty consult requests within the paediatric directorate, with the expectation that a clear referral outcome will be formally documented.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Present consolidated learning from the case at St George’s paediatric, paediatric surgery and radiology Clinical Governance meetings.
Verbatim wording from the response “The paediatric and radiology departments at St George’s have worked together to summarise all the learning from Samuel’s case and are presenting this formally at departmental Clinical Governance meetings in paediatrics, paediatric surgery and radiology. These presentations will be completed by the end of January 2025.” Source location Response from St George's Epsom and St Helier University Hospitals
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 Share the malrotation audit findings at national paediatric surgery and paediatrics meetings in 2025.
Verbatim wording from the response “The paediatric surgery department have carried out an audit of all children with malrotation operated on over 1 year of age across 4 surgical centres in South London and Surrey/Sussex to inform broader learning about this rare but important condition. It has been presented at the regional paediatric surgical meeting at King’s College Hospital and will be shared more widely via the national meeting of the British Association of Paediatric Surgeons and the annual meeting for the Royal College of Paediatrics and Child Health in 2025.” Source location Response from St George's Epsom and St Helier University Hospitals
Open published response
26 Apr 2023 Mrs Elsie Leaver · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 5 Failure by SGH doctors to take a reasonable psychiatric history during clerking View source Lack of formal psychiatric liaison cover at QMH View source Omission of pertinent psychiatric history from GP summaries View source Insufficient SGH doctor training on HIE information and access View source Unsafe access pathway requiring physically frail QMH patients to travel by LAS ambulance to SGH A&E for psychiatric advice 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.
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AI-generated summary
Mrs Elsie Leaver · 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 Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.
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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by SGH doctors to take a reasonable psychiatric history during clerking
Wider context from the report “2. That doctors at SGH do not take a reasonable psychiatric history as part of their clerking and thus fail to make a proper holistic assessment of the patient and potentially miss the opportunity to manage risks such as those in this case which may lead to death.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal psychiatric liaison cover at QMH
Wider context from the report “4. That NHS South West London Integrated Care Board has made no formal provision for psychiatric liaison cover at QMH , despite there being such a clear clinical need for this that the team from psychiatric liaison have felt compelled to provide informal telephone advice for the last 10 years.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of pertinent psychiatric history from GP summaries
Wider context from the report “1. That the GP summary did not contain pertinent psychiatric history that would have assisted the hospital clinicians to identify Mrs Leaver’s depression and specifically her suicidality.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient SGH doctor training on HIE information and access
Wider context from the report “3. That doctors at SGH need training on the information available on HIE and how to access it .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe access pathway requiring physically frail QMH patients to travel by LAS ambulance to SGH A&E for psychiatric advice
Wider context from the report “5. That the lack of formal psychiatric advice availability at QMH puts vulnerable patients at increased risk, since the only way to properly access such advice is for them to be sent by LAS ambulance to A&E at SGH , when they are physically frail , given that QMH is a rehabilitation unit .
” Open source report
22 Jun 2020 Bethan Naomi Harris · Prevention of Future Deaths report West London
View report summary
Concerns raised 4 Failure to undertake effective individual and collective reflection and learning View source Failure to address important learning issues View source Failure to complete team debriefs View source Failure to provide specific handover training and update the handover process View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Share anonymised learning from Bethan’s death through maternity meetings, governance study days, PROMPT, newsletters, staff forums, and mandatory fetal monitoring and skills training.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Provide yearly staff training updates through monthly practice-development training sessions, using the case as a reference for ongoing learning.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Revise SBAR handover teaching and use, incorporate practical scenarios into mandatory multidisciplinary training, update admission guidelines, and relaunch the tool.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source
Action
Facilitate team debriefs immediately following serious or adverse incidents.
Stated completedThe respondent said that this action was complete when they made their response on 14 September 2020. View source See 1 more action
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AI-generated summary
Bethan Naomi Harris · 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
Bethan Naomi Harris was born on 16 November 2018 and died at Shooting Star Hospice on 26 November 2018 after sustaining severe brain injury during a rapidly progressing labour. Concerns included inadequate handover arrangements, lack of specific training, an outstanding team debrief, and limited evidence of reflection or learning after her birth and death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake effective individual and collective reflection and learning
Wider context from the report “(4) There was little evidence from the oral evidence given that any effective reflection, reflective discussions or learning had taken place subsequent to Bethan’s birth and then death. I consider it important that organisations seek to ensure individual and collective reflection to seek to avoid repetition. The evidence for this, one year on, was lacking .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to address important learning issues
Wider context from the report “(1) The Inquest was held one year after Bethan Naomi Harris's death. During the course of the oral evidence it emerged that several, in my mind important, learning issues had not been addressed .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete team debriefs
Wider context from the report “(3) At the time of Inquest a team debrief , which I consider to be a source of learning to reduce the risk of serious incident in future was still outstanding .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specific handover training and update the handover process
Wider context from the report “(2) There were issues relating to handover of patients to midwives and at the time of Inquest there had been no further specific training in relation to handover . Indeed it was stated that the process in place at the time of Bethan’s delivery still pertained without alteration . This represented a risk to patients .
” 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 anonymised learning from Bethan’s death through maternity meetings, governance study days, PROMPT, newsletters, staff forums, and mandatory fetal monitoring and skills training.
Verbatim wording from the response “Learning from Bethan’s death has been shared throughout the maternity unit via PROMPT, as outlined above. The case, appropriately anonymised, was presented at the maternity unit meeting on 15 November 2019 and at the Clinical Governance study day on 19 December 2019. Individual reflection and learning has also taken place with the support of the PMA team through verbal discussion and written reflection.” Source location 2020-0133-Response-from-St.-Georges-University-Hospitals-Trust_Redacted.pdf
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 Provide yearly staff training updates through monthly practice-development training sessions, using the case as a reference for ongoing learning.
Verbatim wording from the response “The issues identified have been communicated to staff via the governance newsletter and at staff forums. There is also on-going learning through mandatory training as Bethan’s case is used as a reference during the Fetal Monitoring and Skills and Drills study day. It is a requirement at the Trust that each member of staff attends a yearly training update with the practice development team facilitating monthly training sessions. As of February 2020 more than 90% of the midwives and doctors have attended this training.” Source location 2020-0133-Response-from-St.-Georges-University-Hospitals-Trust_Redacted.pdf
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 Revise SBAR handover teaching and use, incorporate practical scenarios into mandatory multidisciplinary training, update admission guidelines, and relaunch the tool.
Verbatim wording from the response “Following on from the Inquest the maternity governance team undertook an audit of the use of the clinical handover tool Situation Background Assessment Recommendation (SBAR) within the maternity unit. The result demonstrated poor compliance with the SBAR tool. The staff reported they were unclear on when and how to use the SBAR tool. This resulted in a review and update of how the SBAR tool is taught and used. The revised SBAR tool provides clarity on how, when and where the SBAR should be used; practical use of the tool has also been incorporated into the unit mandatory multi-disciplinary training which includes clinical scenarios. The updated version of the SBAR tool is included in the maternity unit Admission Guidelines. The updated version of the SBAR tool was re-launched in May 2020 through various forums including staff meetings, face to face teachings, newsletter and email.” Source location 2020-0133-Response-from-St.-Georges-University-Hospitals-Trust_Redacted.pdf
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 Facilitate team debriefs immediately following serious or adverse incidents.
Verbatim wording from the response “2018. Following the coroner’s Inquest, a team debrief was facilitated by the Professional Midwifery Advocate (PMA) team and a lead midwife for governance with attendance and support from the legal team. The midwives in this case have attended leadership and PROMPT (Practical Obstetric Multi-Professional Training). The Trust recognises the value of this training and registered all staff groups to attend PROMPT.” Source location 2020-0133-Response-from-St.-Georges-University-Hospitals-Trust_Redacted.pdf
Open published response
14 Jan 2020 John David Long · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 4 Failure to provide safe break and relief arrangements during 1:1 care View source Failure to implement, administer and communicate 1:1 care training View source Bed rails allowing patients to fall from their beds View source Lack of clear definitions and operational rules for 1:1 care 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
John David Long · 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
John David Long suffered an unwitnessed fall from his bed in Benjamin Weir Ward at St. George’s Hospital on 4 May 2019, sustaining a head injury that led to his death. The concerns identified relate to the design and suitability of bed rails, the definition and administration of one-to-one care, provision of breaks without leaving the patient alone, and training for one-to-one care.
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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe break and relief arrangements during 1:1 care
Wider context from the report “2. A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means. In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient. Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and how they are relieved from their duties in such circumstances but ensuring the Patient is not left alone at any time .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement, administer and communicate 1:1 care training
Wider context from the report “3.A review is required on how training of 1: 1 (one to one) care is implemented
And administered on a hospital ward and also how such training is communicated to nurses and Carers .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Bed rails allowing patients to fall from their beds
Wider context from the report “1. The bed rails affixed to patients beds allow a patient to fall easily from the patient’s bed and the make and manufacture of bed rails should be reviewed to ensure they are fit for purpose and act to ensure the patient is secure in their bed and also prevent a patient accidentally falling from their bed.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear definitions and operational rules for 1:1 care
Wider context from the report “2. A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means . In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient . Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and how they are relieved from their duties in such circumstances but ensuring the Patient is not left alone at any time.
” Open source report
8 Dec 2017 Roger Albert Saxby · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 7 Insufficient discussion with patients about their care View source Unstructured discussions about patients’ subsequent care View source Failure to consider patients’ best interests before repeat hub-to-hub transfers View source Delays in decisions to transfer patients between vascular hubs View source Delays in starting thrombolysis after arrival at a receiving vascular hub View source Failure to provide urgent clinical decision-making and care View source Failure of a vascular hub to maintain required staffing and resources View source See 4 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
Roger Albert Saxby · 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
Roger Albert Saxby died from natural causes, to which delay in treatment and lack of urgency contributed. Concerns included inadequate staffing and resources at Royal Sussex County Hospital, delays in transfer and thrombolysis, and an unstructured discussion about his subsequent care, including two hub-to-hub transfers within 36 hours.
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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient discussion with patients about their care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unstructured discussions about patients’ subsequent care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured .
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider patients’ best interests before repeat hub-to-hub transfers
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest .
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in decisions to transfer patients between vascular hubs
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in starting thrombolysis after arrival at a receiving vascular hub
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed .
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide urgent clinical decision-making and care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of a vascular hub to maintain required staffing and resources
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Use learning from this case to inform future decisions about similar hub-to-hub transfers.
Verbatim wording from the response “Thank you for raising these concerns which has given us the opportunity to deliberate carefully about future hub to hub transfers. The vascular and interventional radiology” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
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 Accept patients from another hub in similar circumstances, while limiting transfer back to a hub hospital to exceptional cases after due consideration.
Verbatim wording from the response “Going forward, having discussed and reflected on this case, it is the clinicians’ and the trust’s view that to refuse to accept patients from another hub in similar circumstances as that of Mr Saxby will not be in any patient’s best interests, and in fact is more likely to cause patient harm and death. However, once a patient is accepted, a transfer back to a hub hospital will only take place in exceptional circumstances and after due consideration.” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
Open published response
×
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 Care plans and team communication were clear, although lost clinical notes prevented demonstrating that structure.
Verbatim wording from the response “The clinicians involved in Mr Saxby’s care have reiterated that they were clear about the actions and plans. There was good communication within the team and they had conveyed the plan to Mr Saxby at each stage. Most regrettably, as you were made aware at the inquest, the clinical notes made by the vascular team were lost and this lamentable situation has meant that they have been unable to demonstrate that there was clarity and structure in the care plan.” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
Open published response
×
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 Thrombolysis was commenced as promptly as reasonably possible after arrival, without compromising patient safety.
Verbatim wording from the response “Mr Saxby arrived at St George’s at 16:45 hours on Friday 28 July 2017 and underwent thrombolysis at 19:00 hours. Colleagues from both the vascular and interventional radiology (IR) teams have reviewed Mr. Saxby’s pathway and they are absolutely confident that thrombolysis in this case was commenced as soon as it was safe and practical to do so. Mr. Saxby had to be assessed and clerked, and prepared for theatre including being consented for the procedure. Having reviewed the theatre list for 28 July 2017, the IR service has confirmed that the IR suite was not available to take a patient at around 17:00 hours in any event as they had an on-going case at the time. As soon as the case was completed and the IR suite was cleaned and prepared for the next case, the IR on call team sent for Mr. Saxby. Mr Saxby arrived in the IR suite at 18:30 hours.” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
Open published response
×
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 Transfer back to the referring hospital was considered in the patient’s best interests to support rehabilitation and care closer to home.
Verbatim wording from the response “I believe the Brighton trust has provided an explanation for why Mr Saxby needed to be transferred to St.Georges. I will address here the issue of the transfer back to Royal Surrey County Hospital (RSCH). As per the evidence heard at the inquest, the transfer back was discussed with the referring team at RSCH and it was agreed that it would be in Mr. Saxby’s best interests to have the amputation closer to home to prevent a prolonged period in a London hospital. The vascular service has confirmed that the repatriation of patients following amputation is extremely difficult and can take many weeks, and this hinders the commencement of any planning for proper rehabilitation and social care that Mr Saxby would have needed at home.” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
Open published response
×
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 decision not to amputate at the weekend was reasonable given the clinical presentation and rehabilitation planning needs.
Verbatim wording from the response “████████ has reflected deeply on the care provided to Mr. Saxby and discussed this with his peers, including the clinical lead for Vascular Surgery, ████████ accepts that in retrospect, it may appear that there was no sense of urgency at the time, however, in dealing with the reality of what was before him, he did not feel it appropriate at the time to undertake the amputation over the weekend. His peers, including ████████ who has independently reviewed the decision not to amputate at the weekend, agree that this was a reasonable decision taking into consideration Mr. Saxby’s clinical presentation and the plans that had to be made for his on-going rehabilitation needs.” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
Open published response
×
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 Hub-to-hub transfers should not be categorically prohibited because accepting patients may prevent harm; transfers back should occur only exceptionally.
Verbatim wording from the response “A hub to hub transfer is, as you have heard, an uncommon event. In this case, Mr. Saxby’s transfer was accepted by St. George’s because interventional radiology cover was not available at the Royal Surrey County Hospital at the weekend and so transfer was accepted by St. George’s to give Mr.Saxby the best chance of salvaging his leg. However, despite best efforts by the interventional radiology team, it was recognised that he was going to need an amputation and, for the reasons explained above, the decision was made, in conjunction with Mr. Saxby’s cell agreement, for the transfer back to RSCH. The subsequent catastrophic turn of events for Mr. Saxby has been a source of the deepest regret for the clinicians and trust.” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
Open published response
×
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 There were repeated discussions with the patient about amputation, despite lost records preventing corroboration.
Verbatim wording from the response “Prof Loftus has indicated that he saw Mr. Saxby on five occasions over the 48-hour period and Mr. Ben Patterson saw the patient more often than that. ████████ has” Source location 2017-0365-Response-by-St-Georges-Universty-Hospital
Open published response
8 Dec 2016 Mary Patricia MULDOWNEY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Unavailability of intensive care beds for time-critical specialist neurosurgical transfers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mary Patricia MULDOWNEY · 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
Mary Patricia Muldowney suffered a spontaneous subarachnoid haemorrhage caused by a ruptured artery and was admitted to East Surrey Hospital on 20 July 2016. Several hospitals refused urgent transfer to specialist neurosurgical care because intensive care beds were unavailable; she was eventually transferred and underwent surgery, but died after her condition deteriorated during transfer. The principal concern was that the lack of an immediately available intensive care bed delayed time-critical surgery, which the report states she probably would have survived if performed promptly.
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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of intensive care beds for time-critical specialist neurosurgical transfers
Wider context from the report “In the light of the gravity of Ms Muldowney’s situation, with the only definitive treatment being surgery, she required immediate transfer to a specialist neurosurgical unit, yet she was refused transfer by at least three hospitals who said they had no intensive care beds.
She could have been transferred, undergone surgery, spent time in recovery, and then an intensive care bed procured, perhaps even by transferring out a non neurosurgical patient.
If such a bed was still unavailable, she could then have been transferred to a different hospital , at least having undergone the time critical clot evacuation and aneurysm clipping.
With prompt transfer and surgery, Ms Muldowney would probably have survived.
” Open source report
17 Mar 2016 Jacqueline Emma Brown Scott · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 7 Failure of the BIPAP display to keep the battery-power indicator visible during multiple alarms View source Lack of an isolated power supply for ward beds routinely using life-saving equipment View source Failure to train BIPAP staff to recognise battery-power indicators and battery-depletion alarms View source Failure to repair emergency call bells after notification of a fault View source Lack of a system or check to alert ward staff to local mains-power failure View source Failure of the BIPAP alarm system to provide a distinct urgent warning for battery depletion View source Conflict between electrical-safety guidance for clinical risk areas View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Emma Brown Scott · 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
Jacqueline Emma Brown Scott was admitted to hospital on 31 March 2015 with worsening shortness of breath and reduced mobility and was treated with a BIPAP machine. The machine was running on battery because of a failed power socket, but this was not recognised before the battery ran out; she died shortly afterwards. Concerns included the machine’s battery warnings and alarms, staff training, ward power provision and the absence of systems to identify power failures.
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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the BIPAP display to keep the battery-power indicator visible during multiple alarms
Wider context from the report “(i)The BIPAP Trilogy 202 machine had a subtle visual display symbol which denoted when the machine was running on battery power. That symbol is not visible if there are many alert alarms as the alarm messages fill up the screen as they come in pushing the earlier alerts (including low battery) off the screen. In Mrs Scott’s case there had been 17 alert alarms in the space of 50 minutes.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an isolated power supply for ward beds routinely using life-saving equipment
Wider context from the report “(iv) Richmond ward ADU beds was designated as a category 4 area which in this case meant there was no isolated power supply (IPS) provided to the ward notwithstanding life-saving equipment was routinely used .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to train BIPAP staff to recognise battery-power indicators and battery-depletion alarms
Wider context from the report “(iii) Staff who were experienced and trained on the BIPAP machine did not appear to be trained to be alert to the situation or to the significance of a battery symbol showing on the machine when the machine was plugged in to the mains or to any particular alarm which denoted battery depletion rather than mask slippage .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to repair emergency call bells after notification of a fault
Wider context from the report “(vii) The crash bell for bed bay 5 did not work when the emergency arose . However estates management had been notified some days earlier of the broken patient call in the same bay . This was of concern as both emergency bells were on the same circuit and not fixed until 2 April 2014 when by chance the failure of electricity was identified.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system or check to alert ward staff to local mains-power failure
Wider context from the report “(vi)There was no system or check that would alert ward staff to the failure of mains power in any particular area.
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the BIPAP alarm system to provide a distinct urgent warning for battery depletion
Wider context from the report “(ii)The BIPAP Trilogy 202 machine has the same alarm sound for battery depletion as for circuit disconnect (where for example the face mask slipped) which was the more usual and expected reason for an alarm and these two factors separately and together did not have any feature of urgent warning to alert staff to battery depletion .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Conflict between electrical-safety guidance for clinical risk areas
Wider context from the report “(v) Hospital Technical Memoranda (HTM) 06-01 Part A provides advice and guidance and a benchmark standard for electrical installation, maintenance and safety etc in healthcare premises. It is a matter of concern that there is a conflict of advice between clause 4.22 and Clause 6.62 . Clause 4.22 states: “Clinical treatment and patient safety may be compromised ( but not endangered) by any interruption of electrical supply “ whereas Clause 6.62 states: “In clinical risk Category 4 and 5 areas the patient environment should have at least two IPS circuits at the bedhead”
” 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 Incorporate battery depletion and alarm-safety content into training delivered by the practice educator and respiratory specialist nurses.
Verbatim wording from the response “Following this incident staff working in this area have undergone a period of retraining by Phillips which includes the points raised in point 1. These key aspects of training have further been incorporated into the training delivered by the practice educator and specialist nurses. The unit has further employed a dedicated practice educator to work with staff in ADU. All staff other than two new starts have now received training on NIV and this device and competencies are held within the department.” Source location St-Georges-Hospital-Response
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 Retrain NIV staff on battery depletion indicators, alarms and Trilogy ventilator safety, with competencies documented for all staff except two new starters.
Verbatim wording from the response “Following this incident staff working in this area have undergone a period of retraining by Phillips which includes the points raised in point 1. These key aspects of training have further been incorporated into the training delivered by the practice educator and specialist nurses. The unit has further employed a dedicated practice educator to work with staff in ADU. All staff other than two new starts have now received training on NIV and this device and competencies are held within the department.” Source location St-Georges-Hospital-Response
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 Obtain external electrical-infrastructure advice and use it to design Richmond ADU UPS/IPS backup arrangements.
Verbatim wording from the response “The Trust engaged an external expert to advise the organisation on the areas where the electrical infrastructure requires upgrading to comply with HTM 06-01. This advice has” Source location St-Georges-Hospital-Response
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 Progress tendering and installation of the Richmond ADU UPS/IPS backup system to alert staff when mains power fails.
Verbatim wording from the response “formed the basis of the design a UPS/ IPS back up system in the Richmond ADU area. The work has now been put to a tender process with the summer 2016 set as the date for completion of this work due to the co-ordination that is required with clinical areas for this work to be completed. The Trust has set aside sufficient funds for this work to be completed and once installed the designed UPS/IPS back up system will alert staff of any failure in the electricity supply to the mains sockets.” Source location St-Georges-Hospital-Response
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 Staff involved in the incident were appropriately trained on non-invasive ventilation and the Trilogy ventilator, contrary to the concern raised.
Verbatim wording from the response “The panel was satisfied during the investigation that all nursing staff involved in the care of Mrs Scott were appropriately trained on the particular machine and NIV therapy. There was also access to senior help and a practice educator was available on the day when the incident happened. The nurse directly involved in the incident was a trained ITU nurse of six years, who had additional training on the NIV and the Trilogy machine. The panel found, however, that there was no consistent documentary evidence of the training that staff had received.” Source location St-Georges-Hospital-Response
Open published response
20 May 2014 Rainer Wickens · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Potential for serious injury from vulnerable and unsupervised residents accessing stairs View source Delays in remedial action following SUI reports View source Poor verbal communication at handovers between treating doctors View source Failure of communication between junior doctors and radiologists causing delay in CTPA View source Delays in commencing inquiry of SUI reports View source Gaps in medical notes View source Failure to provide timely treatment for clot formation View source See 4 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
Rainer Wickens · 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
Rainer Wickens fell through the roof of a single-storey rear extension while assisting with its demolition, sustaining a thoracic spine fracture. After surgery, concerns arose about low oxygen saturations and possible pulmonary embolism; he suffered a cardiac arrest and died before testing could be completed. The report identifies concerns about delayed treatment for clot formation, gaps in medical notes, poor handover communication, and delays in obtaining a CTPA scan.
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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Potential for serious injury from vulnerable and unsupervised residents accessing stairs
Wider context from the report “I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury .
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in remedial action following SUI reports
Wider context from the report “Delay in commencement of inquiry of the SUI report and the impact of the delay on remedial action re impact on patient treatment
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor verbal communication at handovers between treating doctors
Wider context from the report “Poor verbal communication at handovers between treating doctors
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between junior doctors and radiologists causing delay in CTPA
Wider context from the report “Breakdown in communication between junior doctor and radiologist resulting in avoidable delay of CTPA
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing inquiry of SUI reports
Wider context from the report “Delay in commencement of inquiry of the SUI report and the impact of the delay on remedial action re impact on patient treatment
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Gaps in medical notes
Wider context from the report “Gaps in the medical notes
” 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 St George'S University Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely treatment for clot formation
Wider context from the report “Although Mr Wickens was at risk of clot formation, he remained untreated for clot formation for 10 hours in A&E
” 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 Investigate every case of hospital-acquired thrombosis, undertake root-cause analysis and disseminate the resulting learning.
Verbatim wording from the response “As you are aware, the SI investigation highlighted a number of failures and missed opportunities in the care provided to Mr Wickens. The SI investigation and the learning outcomes have since been shared with the immediate teams who had looked after Mr. Wickens and will continue to be disseminated through various patient safety initiatives as described above. You will also be pleased to hear that we now investigate and undertake root cause analysis and disseminate the learning on all cases of hospital acquired thrombosis.” Source location 2014-0234-Response-by-St-Georges-Healthcare-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 Present Serious Incident actions to the Patient Safety Committee and audit action-plan progress twice yearly.
Verbatim wording from the response “All actions are presented to the Patient Safety Committee and a regular audit of the actions contained within any SI action plan is also presented to the committee on a bi-annual basis. The Patient Safety Committee meets monthly and is a Trust Board sub-committee with the remit of ensuring that actions are implemented and learning is shared.” Source location 2014-0234-Response-by-St-Georges-Healthcare-NHS-Trust
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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 Serious Incident panel’s recommendations through assigned senior leads, completing outstanding actions by 31 July 2014.
Verbatim wording from the response “The SI panel made a number of recommendations in the final report. All actions have been assigned to senior staff to lead on implementation. Some of these actions have been completed with the rest due for completion by 31 July 2014.” Source location 2014-0234-Response-by-St-Georges-Healthcare-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 Existing monitoring and audit processes are considered sufficient to prevent slippage in implementing Serious Incident action plans.
Verbatim wording from the response “I would also like to provide assurance relating to your concern that the timelines for implementation of the actions identified in Mr. Wickens’ case could slip. The trust does have routine and stringent processes in place to ensure that all actions from all SIs are monitored and audited, as described above. I will be very happy to provide you with an update of the actions in August 2014.” Source location 2014-0234-Response-by-St-Georges-Healthcare-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations