10 May 2022 Freda Mary Lennox · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Failure to inform the consultant anaesthetist about patients and their medical co-morbidities before admission View source Unavailability of designated permanent room space for a high-risk anaesthetic pre-operative assessment clinic View source Lack of funding for a dedicated high-risk consultant-led anaesthetic pre-operative assessment clinic with necessary equipment View source Lack of secretarial input to type reports for high-risk patients View source Failure to complete requested pre-operative echocardiographic assessment for pulmonary hypertension or Cor Pulmonale View source Failure to provide recent consultant orthopaedic review before admission for elective surgery 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
Freda Mary Lennox · 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
Freda Mary Lennox, an 86-year-old woman with significant idiopathic pulmonary fibrosis and other medical comorbidities, was admitted for an elective total hip replacement and died on 4 November 2020 after experiencing a cardio-respiratory arrest at the end of the procedure. Concerns included incomplete pre-operative assessment, a lack of recent orthopaedic and anaesthetic review before admission, and inadequate resources for a dedicated high-risk anaesthetic assessment service.
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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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to inform the consultant anaesthetist about patients and their medical co-morbidities before admission
Wider context from the report “3. The consultant anaesthetist was not informed about Mrs Lennox and her medical co-morbidities prior to her admission . Nonetheless the consultant anaesthetist undertook a thorough pre-operative assessment on the day of surgery and Mrs Lennox consented for surgery.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of designated permanent room space for a high-risk anaesthetic pre-operative assessment clinic
Wider context from the report “5. There was no designated (permanent) room space to set up such a clinic and no secretarial input to type reports for high-risk patients which led to a significant delay in providing a timely service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of funding for a dedicated high-risk consultant-led anaesthetic pre-operative assessment clinic with necessary equipment
Wider context from the report “4. Evidence was heard that there was a lack of funding for a dedicated high-risk consultant led anaesthetic pre-operative assessment clinic with the necessary equipment to be able to suitably risk assess patients prior to any potential surgery.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of secretarial input to type reports for high-risk patients
Wider context from the report “5. There was no designated (permanent) room space to set up such a clinic and no secretarial input to type reports for high-risk patients which led to a significant delay in providing a timely service.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete requested pre-operative echocardiographic assessment for pulmonary hypertension or Cor Pulmonale
Wider context from the report “1. Mrs Lennox had previous pre-operative assessments in 2018 and 2019 and a respiratory review in February 2020. Following a telephone consultation in September 2020 an echocardiogram was requested to look for pulmonary hypertension and/or the development of Cor Pulmonale but this had not been carried out prior to her surgery .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide recent consultant orthopaedic review before admission for elective surgery
Wider context from the report “2. Mrs Lennox had not been recently reviewed by the consultant orthopaedic surgeon prior to her admission on 2nd November 2020 despite her medical co-morbidities having given rise to concerns as to her suitability for an elective total hip replacement.
” Open source report
1 Dec 2020 Peter James Michael Unsworth · Prevention of Future Deaths report Surrey
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Concerns raised 2 Failure to document received specialist advice and confirm understanding View source Failure to confirm and record specialist advice 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.
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AI-generated summary
Peter James Michael Unsworth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter James Michael Unsworth had a history of deep vein thromboses and was taking long-term anticoagulant medication before a right hip replacement. After developing an infected hip and undergoing surgery, his anticoagulant dose was reduced following haematological advice that was not recorded in writing; he subsequently developed pulmonary emboli and died at home on 29 July 2018. The principal concern was that the lack of written records may have led to a misunderstanding of the advice given and its significance.
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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document received specialist advice and confirm understanding
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm and record specialist advice
Wider context from the report “The evidence showed that:
1. The advice provided by the Consultant Haematologist related to a very complex medical situation. It was not recorded in writing. The Consultant Orthopaedic surgeon did not record it in the patient’s records nor email his understanding of the advice to the Consultant Haematologist for confirmation of what he understood the advice to be.
2. The Consultant Haematologist did not confirm her advice in writing or make any record of the advice given.
3. As a consequence, there may have been a misunderstanding of the basis on which the advice was sought and/or given, and of the import of the advice.
” Open source report
19 Oct 2017 June Evelyn Evans · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Failure to staff wards at correct staffing levels View source Failure to implement prescribed nutritional advice View source Delay in informing treating clinicians about hospital-acquired grade 3 pressure sores View source Failure to refer hospital-acquired grade 3 pressure sores to the tissue viability nurse 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
June Evelyn Evans · 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
June Evelyn Evans was admitted to St Peter’s Hospital with diarrhoea and was assessed as being at high risk of pressure sores. She developed a severe hospital-acquired pressure sore that became infected, and she died of sepsis on 1 July 2016. The principal concerns were failures to prevent and promptly refer and treat the pressure sore, inadequate nutrition, clinicians’ delayed awareness of the sore, and understaffing across the wards.
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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to staff wards at correct staffing levels
Wider context from the report “4. Mrs Evans was nursed on 3 wards from the 4th to the 30th June. The wards were not staffed according to the levels identified as correct staffing levels by the hospital which detracted from the ability of the nursing staff to undertake the tasks required to protect Mrs Evans from pressure sores and ensure she received adequate nourishment .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to implement prescribed nutritional advice
Wider context from the report “3. Dietician’s advice in respect of the quantity of nutrition required by Mrs Evans was not implemented by the nursing staff . Naso- gastric feeding was advised by both the treating doctor and the dietician on the 14th June 2016. This advice was not followed and there was no evidence of why this did not occur. Mrs Evans was not provided with adequate nutrition .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Delay in informing treating clinicians about hospital-acquired grade 3 pressure sores
Wider context from the report “2. The treating clinicians were unaware that Mrs Evans had developed a grade 3 hospital acquired pressure sore, noted on the 8th June 2016, until the 15th June 2016 . They were therefore unable to make informed decisions as to her treatment, including the antibiotic regime to be followed .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to refer hospital-acquired grade 3 pressure sores to the tissue viability nurse
Wider context from the report “1. The evidence showed that failure to refer the hospital acquired grade 3 pressure sore to the tissue viability nurse on the 8th June 2016 was as a result of the employment of an agency nurse who was unfamiliar with the Trust’s Policy on the Prevention of Pressure Sores. If the referral had been made to the tissue viability nurse on the 8th June 2016 it would not have deteriorated as it did.
” Open source report
1 Jun 2016 Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to accurately record routine observations, fluid balance and gastrointestinal losses View source Failure to make specific obstetric care plans for pregnancy and labour after bariatric surgery View source Failure to provide timely obstetric consultant supervision after emergency admission View source Lack of specific clinical guidance on obstetric care after bariatric surgery View source Failure to act on markedly abnormal urine glucose findings View source Delays in undertaking appropriate investigations for unexplained abdominal pain View source Failure to consider surgical causes of abdominal symptoms after bariatric surgery View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rhi anne Anoushka Florence BARTON · 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
Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.
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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record routine observations, fluid balance and gastrointestinal losses
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart . No accurate records were kept with regard to fluid intake and urine output . It was not possible to assess the amount, frequency and volume of the vomitus . There was no evidence of diarrhoea despite a diagnosis of gastroenteritis . A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to make specific obstetric care plans for pregnancy and labour after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery . I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely obstetric consultant supervision after emergency admission
Wider context from the report “1. Rhi anne’s named obstetric consultant was not informed of her emergency admission . Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of specific clinical guidance on obstetric care after bariatric surgery
Wider context from the report “5. The obstetric consultant made no specific plans with regard to the obstetric care that Rhi anne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery. I also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to act on markedly abnormal urine glucose findings
Wider context from the report “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking appropriate investigations for unexplained abdominal pain
Wider context from the report “3. I also heard evidence that whilst the rarity of an omental band may make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause , by undertaking appropriate investigations in a timely fashion .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider surgical causes of abdominal symptoms after bariatric surgery
Wider context from the report “2. No consideration was given to excluding a surgical cause of Rhi anne’s symptoms despite the history of sudden onset of upper abdominal pain in the knowledge that she had had bariatric surgery . I heard evidence that bariatric surgery can, not infrequently, result in an omental/internal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more women are becoming pregnant following bariatric surgery.
” Open source report
21 Jan 2014 Mrs Nutbeam · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of a procedure for transferring patient information between different Trusts View source Failure to provide patients with a letter accompanying them to subsequent appointments View source Failure to communicate vomiting symptoms to the anaesthetist and surgeon View source Failure to routinely ask patients about vomiting within the previous twenty-four hours before surgery View source Failure to record vomiting symptoms in nursing notes View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Nutbeam · 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 Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.
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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for transferring patient information between different Trusts
Wider context from the report “(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were once aware that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with a letter accompanying them to subsequent appointments
Wider context from the report “(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were once aware that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate vomiting symptoms to the anaesthetist and surgeon
Wider context from the report “(2) Despite clear evidence from the family that Mrs Nutbeam was vomiting on the ward shortly before her debridement procedure, there is no reference in the nursing notes and this information was not made known to the Anaesthetist nor Surgeon . The fact that she was vomiting prior to a surgical procedure should have been a matter of serious concern.
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely ask patients about vomiting within the previous twenty-four hours before surgery
Wider context from the report “(4) It was also given in evidence at the Inquest that, when the Anaesthetist visited Mrs Nutbeam prior to the surgery and explained the procedure, the risks and took her consent, he did not ask her if she had vomited within the last twenty four hours . The evidence was that this is not a standard question to ask of patients ahead of surgery .
” 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 Peter's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record vomiting symptoms in nursing notes
Wider context from the report “(2) Despite clear evidence from the family that Mrs Nutbeam was vomiting on the ward shortly before her debridement procedure, there is no reference in the nursing notes and this information was not made known to the Anaesthetist nor Surgeon. The fact that she was vomiting prior to a surgical procedure should have been a matter of serious concern.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations