2 Jul 2025 Neil John Clarke · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Inaccurate handover communications for patients returning from HDU to the main ward View source Failure to consider more conservative measures for elderly patients undergoing surgical procedures View source Inadequate documentation and guidance on different treatment choices 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
Neil John Clarke · 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
Neil John Clarke, aged 81, died at Stepping Hill Hospital on 26 February 2024 after vomiting, aspiration and a cardiac arrest following a right hemicolectomy. The report raises concerns about the safety and wellbeing considerations for surgical procedures involving elderly patients, documentation and guidance about treatment choices, and the accuracy of handover communications when patients return to the main ward from HDU.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Inaccurate handover communications for patients returning from HDU to the main ward
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices.
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU .
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to consider more conservative measures for elderly patients undergoing surgical procedures
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices.
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU.
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentation and guidance on different treatment choices
Wider context from the report “The considerations given to the appropriateness, from a safety and well-being perspective, of surgical procedures involving elderly patients who may benefit from more conservative measures and the associated documentation and guidance advising patients of different treatment choices .
My second concern arising from this interest was the accuracy of hand over communications between clinical staff in respect of patients returning to the main ward from HDU.
” Open source report
1 Oct 2024 Ryan James Richard Campbell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital 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
Ryan James Richard Campbell · 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
Ryan Campbell experienced persistent chest pain and underwent medical investigations, but further cardiac imaging was still awaited when he died. The report identified delays associated with the absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms, and the need to switch treatment centres.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital
Wider context from the report “The absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms , contributes to delays in diagnosis for patients and the risk of delays is heightened by having to switch treatment centres. This lack of a range of equipment is inconsistent with providing a full cardiology service to patients .
” Open source report
Concerns raised 3 Failure to establish whether care at home could be safely provided View source Failure to alert a doctor to significant deterioration before discharge home View source Failure to record fluctuations in presentation relevant to diagnosis and pre-discharge review 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
Charles Henry DANIELS · 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
Charles Henry Daniels was admitted to Stepping Hill Hospital in January 2024 after a fall and was later discharged home in March despite being described as clearly unwell. He returned to hospital with an acute on chronic subdural bleed and died on 21 March 2024. Concerns included inadequate nursing record-keeping, failure to alert a doctor to his deterioration before discharge, and the distress caused by his condition and discharge arrangements at home.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether care at home could be safely provided
Wider context from the report “3) He arrived home by ambulance to his family in physically poor condition and clearly very unwell, on a stretcher in a hospital gown and incontinent, causing considerable distress to the family, particularly after a nurse, the paramedics and his carer questioned how they would cope with his care at home .
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to alert a doctor to significant deterioration before discharge home
Wider context from the report “2) Neither the discharging nurse nor North West Ambulance Service personnel attending Stepping Hill on 6 March 2024, for the purposes of his discharge home, appear to have alerted a doctor to the significant deterioration in Mr Daniel’s condition since last assessed by a doctor on 4 March.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record fluctuations in presentation relevant to diagnosis and pre-discharge review
Wider context from the report “1) Record keeping by the nursing team at Stepping Hill Hospital did not record the fluctuations in presentation relevant to the diagnosis of intracranial hypotension or to enable or confirm a review of his condition prior to discharge .
” Open source report
24 Jul 2019 Xander Curran-Pass · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Lack of guidance on pethidine use with significant reduced fetal movement View source Inconsistent fundal-height measurement and recording View source Lack of national provision for sharing maternity induction-of-labour learning View source Poor quality of admission documentation View source Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour View source Lack of clear guidance for managing a prolonged episode of reduced fetal movement View source Inconsistent and unclear diarising, prioritisation and management of induction of labour View source Failure to closely observe a concerning cardiotocograph View source Failure to review cardiotocography after induction of labour commenced View source Failure to advise return to triage for further monitoring during ongoing reduced fetal movement View source See 7 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
Xander Curran-Pass · 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
Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on pethidine use with significant reduced fetal movement
Wider context from the report “6. Xander's mother was given pethidine. There was no guidance on issues to be considered in terms of advisability of pethidine where there was already significant reduced fetal movement ;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Inconsistent fundal-height measurement and recording
Wider context from the report “5.Xander had his fundal height measured by tape measure by midwives in the community. There was a significant discrepancy between the recorded measurements of two different midwives , which altered where he was on the centile chart significantly ;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of national provision for sharing maternity induction-of-labour learning
Wider context from the report “1.The inquest was told that there was a growing challenge to maternity units from the rise in Induction of Labour and the pressure to ensure that timescales set out in NICE guidance were met. In this case and since the death of Xander the trust have taken steps to reconfigure their IOL process to reduce risk but no provision to share such learning nationally existed ;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor quality of admission documentation
Wider context from the report “7. The quality of documentation on admission was poor ;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour
Wider context from the report “4. A review by an obstetrician did not take place on admission despite RFM and delayed IOL . The trust guidance did not require such a review . Such a review may have identified growing concern about condition of Xander;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance for managing a prolonged episode of reduced fetal movement
Wider context from the report “2.In the inquest reference was made to the guidance from the Royal College on reduced fetal movement. The guidance references individual episodes of RFM but does not give clear guidance on the approach to be taken where in effect there is one prolonged episode rather than multiple episodes of RFM ;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and unclear diarising, prioritisation and management of induction of labour
Wider context from the report “8. The triage and IOL diary were poorly kept and used in different ways by staff . The trust has since changed the way records are kept to ensure consistency and improved its audit process. It is unclear if nationally there is clarity on the way in which IOLs are diarised, prioritised and managed ;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to closely observe a concerning cardiotocograph
Wider context from the report “9. The CTG at 07.09 was concerning from the early stages but the evidence suggested that it was not closely observed ;
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review cardiotocography after induction of labour commenced
Wider context from the report “10. The second CTG after IOL commenced was not reviewed .
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to advise return to triage for further monitoring during ongoing reduced fetal movement
Wider context from the report “3. Xander's mother was not told it would be advisable to return to triage for further monitoring in light of the ongoing reduced fetal movement. The inquest was told that this would have been advisable given the prolonged nature and the fact that it was unclear when she would be offered a slot for IOL;
” Open source report
1 Mar 2018 George French Russell · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to seek guidance during rapidly evolving labour situations View source Lack of structured and direct information sharing between hospital and ambulance services View source Lack of paramedic experience in managing footling breech deliveries View source Failure to provide or seek continuing expert support during footling breech deliveries 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
George French Russell · 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
George French Russell was born prematurely at 35 weeks and 1 day following a footling breech birth on 11 January 2017, in poor condition and with severe brain damage. He died on 23 January 2017 after being transferred for neonatal care. Concerns included inadequate information-sharing between services and a lack of sustained expert input during the breech delivery.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to seek guidance during rapidly evolving labour situations
Wider context from the report “1. During the inquest it became clear that during the telephone conversation between EMAS and George’s mother her labour was rapidly developing. There was no evidence of the call taker seeking guidance on how to deal with a rapidly evolving situation other than to update the ambulance crew who were on route. (EMAS)
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of structured and direct information sharing between hospital and ambulance services
Wider context from the report “2. The way in which information was exchanged between Stepping Hill Hospital and EMAS meant that all those involved in making decisions were not in possession of key facts. There was no structure to how information was shared and it was passed 3rd hand .
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of paramedic experience in managing footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery . Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought.
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or seek continuing expert support during footling breech deliveries
Wider context from the report “3. During labour EMAS were present. The paramedics did not have the experience to deal with a footling breech delivery. Expert input was given for a brief period by a registrar but when that conversation terminated there was no further support given or sought .
” Open source report
7 Sep 2017 Glenys Pollitt · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Unclear process for escalation to consultant level and critical care View source Lack of an ongoing programme for reinforcing clinical lessons View source Inconsistent use of high-resolution screens for viewing x-rays View source Failure to assess the whole x-ray image rather than only expected findings 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
Glenys Pollitt · 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
Glenys Pollitt was admitted to Stepping Hill Hospital with community acquired pneumonia, but surgical emphysema and an oesophageal rupture were not identified on an initial x-ray and subsequent reviews. She underwent emergency surgery after the rupture was identified, deteriorated, and died from multi-organ failure on 16 February 2017. Concerns included inconsistent use of high-resolution x-ray screens, unclear reinforcement of clinical learning, and unclear escalation processes to consultant and critical care levels.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Unclear process for escalation to consultant level and critical care
Wider context from the report “3. The process for escalation to consultant level and critical care was unclear.
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of an ongoing programme for reinforcing clinical lessons
Wider context from the report “2. At the inquest, the evidence given was that the clinicians had seen what they expected to see on the x ray rather than seeing the whole picture shown on the x ray. It was unclear what ongoing programme was in place for reinforcing the lessons learnt from this case amongst 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of high-resolution screens for viewing x-rays
Wider context from the report “1. It was accepted during the evidence that the x ray should ideally be viewed on a high-resolution screen rather than an standard screen. This increased the likelihood of significant abnormalities being detected. There are a number of such high-resolution screens for viewing of x rays. The evidence indicated that there was differing practice across the hospital as to when such screens were used and by whom.
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the whole x-ray image rather than only expected findings
Wider context from the report “2. At the inquest, the evidence given was that the clinicians had seen what they expected to see on the x ray rather than seeing the whole picture shown on the x ray . It was unclear what ongoing programme was in place for reinforcing the lessons learnt from this case amongst clinicians;
” Open source report
26 Aug 2016 Maureen Patricia FLYNN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to complete required falls risk assessments View source Failure of patient safety investigations to identify incomplete required assessments View source Lack of alerts to staff when required patient safety assessments are incomplete 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
Maureen Patricia FLYNN · 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
Maureen Patricia FLYNN was admitted to hospital with a urinary tract infection and later suffered a fall from her bedside chair, fracturing her left hip. She underwent surgery, subsequently developed a chest infection that did not respond to antibiotics, and died on 7 May 2016. Concerns included the incomplete falls risk assessment, staff not being alerted to this, and the Patient Safety Investigation not identifying the omission.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required falls risk assessments
Wider context from the report “The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA.
It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed . It is clear that the HCA was unaware. It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed?
It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed. My concern extends to any other assessment required for a patient’s safety and well-being.
I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed.
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of patient safety investigations to identify incomplete required assessments
Wider context from the report “The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA.
It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed. It is clear that the HCA was unaware. It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed?
It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed. My concern extends to any other assessment required for a patient’s safety and well-being.
I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed .
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of alerts to staff when required patient safety assessments are incomplete
Wider context from the report “The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA.
It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed . It is clear that the HCA was unaware . It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed?
It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed . My concern extends to any other assessment required for a patient’s safety and well-being .
I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed.
” Open source report
Concerns raised 1 Failure to carry out falls risk assessments during hospital admission and transfer 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
Laura Hill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Laura Hill was admitted to Stepping Hill Hospital with acute abdominal pain and sepsis due to cholangitis, fell from her bed and sustained a left hip fracture, and died on 8 October 2013. The principal concern was that Falls Risk Assessments were not carried out on admission or after transfers between wards, despite relevant training being in place.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out falls risk assessments during hospital admission and transfer
Wider context from the report “Despite training being in existence in relation to the carrying out of Falls Risk Assessments there was a missed opportunity throughout the time Mrs Hill was in hospital for this to be carried out . There was no assessment on her admission to Ward C3 nor when she was transferred to Ward B6 .
” Open source report
Concerns raised 1 Failure to access and read all relevant information across nursing and clinical records 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
Russell James Felstead · 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
Russell James Felstead, who had severe learning disabilities, epilepsy and a history of falls, was found unresponsive on the floor of his room on 7 January 2013 and died on 28 January 2013 after a subdural haematoma was identified and operated on. Relevant information about his falls and helmet was available in the hospital records from 7 January but was not noted by doctors until 11 January, when an urgent CT scan was requested.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to access and read all relevant information across nursing and clinical records
Wider context from the report “Doctors must ensure that all relevant information is accessed and read even if this is in the Nursing notes as opposed to the Clinical records. It is clear that the information which prompted an urgent CT scan on the 11th January had been available in Mr Felstead’s medical records since the 7th January and his helmet had in fact been at the hospital.
” Open source report
Concerns raised 3 Delays in cardiology review for patients proposed for surgery View source Failure to include surgeons’ input in theatre booking View source Insufficient surgeon capacity for laparoscopic surgery and urgent patient assessment 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
Jennifer Elsie RUSHWORTH · 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
The circumstances of Jennifer Elsie Rushworth's death are not included in the supplied text. Concerns raised at the inquest included delays in cardiology review and surgery, insufficient surgical staffing, and questions about surgical clips used to clip blood vessels.
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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in cardiology review for patients proposed for surgery
Wider context from the report “The first of the issues that he raised was the fact that it is quite normal for cardiology review to take anything up to six months to come through to the surgeon proposed to operate on the patient . In this particular instance the first consultation with the surgeon took place on 5 July 2012 and in view of her cardiac history he referred her to the cardiologist for cardiac optimisation review. Report back from the cardiologist came on 28 January 2013 . It seems to me unsatisfactory that this length of time should elapse for cardiology reviews in these circumstances .
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to include surgeons’ input in theatre booking
Wider context from the report “Secondly the surgeon indicated that the booking of theatres and follow-up therefrom is dealt with by the management and not from any input from the surgeons themselves . ████████ indicated that it was for this reason that there was a delay in booking this lady in to surgery and that delay may have had a bearing on her wellbeing at the time of surgery but more particularly during the recovery period. Again I would have thought that an input from the surgeons would have been the prime consideration that bed managers should be looking at when booking theatres , etc.
” 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 Stepping Hill Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient surgeon capacity for laparoscopic surgery and urgent patient assessment
Wider context from the report “Thirdly ████████ indicated that there are simply not enough surgeons dealing with this type of laparoscopic surgery and to deal with the number of patient's requiring their care . They are simply unavailable to perform these operations and therefore the operations are later than would often be desirable and this can of course have quite devastating effects.
Finally he also indicated that they needed to be seeing this type of patient more urgently and again they cannot do this simply because there are insufficient surgeons available for the number of cases that they are expected to deal with .
” 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