17 Jan 2023 Teegan Marie Barnard · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 9 Failure to undertake anaesthetic morbidity and mortality reviews and share learning View source Failure to disseminate institutional learning from unexpected deaths View source Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event View source Failure to investigate potential anaesthetic-related causes of unexpected deaths View source Failure to remove and assess anaesthetic equipment for faults after a suspected equipment-related event View source Lack of a robust system to trigger investigations into unexpected deaths View source Delays in recognition of surgical emphysema during cardiac arrest View source Failure to comply with the Statutory Duty of Candour by sharing investigation findings and prevention steps View source Failure to consider and exclude tension pneumothorax during PEA cardiac arrest View source See 6 more concerns
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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
Teegan Marie Barnard · 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
Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake anaesthetic morbidity and mortality reviews and share learning
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths , and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate institutional learning from unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths .
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated , which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate potential anaesthetic-related causes of unexpected deaths
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure ) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to remove and assess anaesthetic equipment for faults after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault . Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust system to trigger investigations into unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in recognition of surgical emphysema during cardiac arrest
Wider context from the report “2. Surgical emphysema
There was a delay in the recognition of surgical emphysema by clinical attendees at the cardiac arrest (medical specialist registrar, consultant obstetricians, anaesthetic core trainee, anaesthetic specialist registrar and the on call consultant anaesthetist) despite indicative clinical signs of deep cyanosis, gross whole body swelling with the need to remove the increasingly constrictive hospital wrist band and endotracheal tube tie, alongside sub-cutaneous crepitus and an abdominal drainage bag noted to be tense with air .
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with the Statutory Duty of Candour by sharing investigation findings and prevention steps
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
Wider context from the report “1. Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest
I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation . Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces . Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest.
” Open source report
5 Jan 2022 Richard Paul Victor Sanders · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3 Lack of awareness of immersion pulmonary oedema risks among people participating in diving View source Inefficient diver removal methods and techniques at the diving centre View source Failure to give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation 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
Richard Paul Victor Sanders · 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
Richard Sanders, an experienced diver aged 52, became unresponsive during a dive to 45 metres on 11 April 2019 and was pronounced deceased at the scene. The concerns included awareness of immersion pulmonary oedema risks, the need for fitness-to-dive medical certification, and methods for removing divers from the water.
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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of immersion pulmonary oedema risks among people participating in diving
Wider context from the report “1. Whether there is sufficient awareness of the risks & affects of immersion pulmonary oedema by those engaged &/ or participating in the activity of diving.
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Inefficient diver removal methods and techniques at the diving centre
Wider context from the report “3. Whether more efficient methods and/ techniques of diver removal from the water could be employed at the diving centre .
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation
Wider context from the report “2. Whether sufficient consideration has been given to the requirement for a “fitness to dive” medical certificate as a prerequisite to participation in diving activities .
” Open source report
15 Jul 2016 Leilani Chute · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Failure to perform cervical replacement in accordance with standard training View source Failure to take steps to address identified care and service delivery issues View source Failure of Root Cause Analysis investigations to identify care and service delivery problems View source Failure to ensure consultant knowledge of manual cervical replacement View source Failure to provide balanced relevant facts for informed consent 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
Leilani Chute · 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
Leilani Chute was delivered by Caesarean section after an unsuccessful trial of instrumental delivery and was in a moribund condition, with terminal bradycardia and no other signs of life. The inquest concluded that she died shortly after birth from hypoxic brain injury and umbilical cord occlusion. The principal concerns were the use of an unendorsed practice of manually pushing back the cervix and inadequate disclosure of relevant risks when obtaining consent for instrumental delivery rather than proceeding directly to Caesarean section.
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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to perform cervical replacement in accordance with standard training
Wider context from the report “(1) That the practice of manually pushing back the cervix was one adopted by two junior doctors. This practice was not in accordance with standard training and was conducted without the knowledge of the consultant;
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to take steps to address identified care and service delivery issues
Wider context from the report “(3) That neither of the above matters had been identified as a “Care and Service Delivery problem” by the Trust’s Root Cause Analysis investigation and hence no steps had been taken by the Trust to address these issues .
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of Root Cause Analysis investigations to identify care and service delivery problems
Wider context from the report “(3) That neither of the above matters had been identified as a “Care and Service Delivery problem” by the Trust’s Root Cause Analysis investigation and hence no steps had been taken by the Trust to address these issues.
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consultant knowledge of manual cervical replacement
Wider context from the report “(1) That the practice of manually pushing back the cervix was one adopted by two junior doctors. This practice was not in accordance with standard training and was conducted without the knowledge of the consultant ;
” 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 Richard's Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide balanced relevant facts for informed consent
Wider context from the report “(2) That the manner in which consent was sought from women in labour when there was a choice to be made between attempted instrumental delivery and going straight to a CS did not appear to provide them with the relevant facts in order to come to an informed choice , but presented those facts that favoured the doctor’s preferred approach to management .
” 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