25 Feb 2026 Lesley Marie Krommendijk · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Failure of discharge-safety assessment processes to accurately assess patient mobility View source
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Lesley Marie Krommendijk · 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
Lesley Marie Krommendijk fell at home, fractured her right hip, and was discharged home on 5 June 2025. She was later found on the floor, admitted to hospital with confusion and abnormal clinical findings, and died on 20 June 2025. The principal concern was that discharge-assessment processes may have created an unrealistic impression of her mobility, leading to an unsafe discharge.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge-safety assessment processes to accurately assess patient mobility
Wider context from the report “(1) The current processes for assessing whether or not it is safe to discharge a patient appear to have led to an unrealistic impression of the patient’s mobility .
” Open source report
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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 There was no discrepancy between the discharge referral information and the patient’s function at discharge, so mobility was not unrealistically represented.
Verbatim wording from the response “Mrs Krommendijk was discharged from Ward D5 as planned into her son’s care. At the time of discharge there was no discrepancy between the information within the referral to D2A and her function at the time.” Source location Response from Stockport NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing discharge planning, equipment provision and continuing mobility reviews were considered appropriate and sufficient under usual practice.
Verbatim wording from the response “Following a full review of Mrs Krommendijk’s documentation whilst in hospital, during the discharge planning process and following her return to home, her mobility and function was continually reviewed as would be expected with appropriate equipment in place. Though Mrs Krommendijk declined physically following her discharge from hospital, the Divisional team believes her discharge was appropriately planned for and completed within our usual expectations. The D2A and ICAH team communicated with Mrs Krommendijk’s GP throughout this period, ensuring that she had timely interventions as required.” Source location Response from Stockport NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The discharge information accurately reflected the patient’s function, and the discharge was appropriately planned within usual expectations.
Verbatim wording from the response “Mrs Krommendijk was discharged from Ward D5 as planned into her son’s care. At the time of discharge there was no discrepancy between the information within the referral to D2A and her function at the time.” Source location Response from Stockport NHS Foundation Trust
Open published response
7 Nov 2025 Richard Charles Worswick · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure to maintain a clear, effective and documented communication system for wound management care plans View source Lack of a clear escalation policy for wound care concerns when residents arrive View source Limited documentation of wound care concerns and escalation attempts View source Lack of clarity in wound care plans and wound management instructions View source See 1 more concern
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Richard Charles Worswick · 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 Charles Worswick, who had Parkinson’s disease, frailty and complex health needs, developed an infected spinal wound and died from sepsis at Stepping Hill Hospital on 19 May 2025. The principal concerns were unclear communication and documentation of the wound-care plan between the hospital and care home, together with unclear escalation arrangements and limited documentation of concerns and escalation attempts.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a clear, effective and documented communication system for wound management care plans
Wider context from the report “The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided . As a consequence of this, there was a lack of clarity regarding wound management.
The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management .
The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear escalation policy for wound care concerns when residents arrive
Wider context from the report “The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management.
The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management.
The home did not have a clear escalation policy for actions to be taken when a resident arrived , and their staff were unclear how they were being asked to manage a wound by the hospital . In addition, the documentation surrounding concerns and attempts to escalate was limited.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited documentation of wound care concerns and escalation attempts
Wider context from the report “The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management.
The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management.
The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in wound care plans and wound management instructions
Wider context from the report “The inquest heard evidence that when he was discharged to the care home from the acute hospital that the care home felt that they did not understand what was required regarding wound care because the care plan regarding wound care was not clear .The Trust did not have a copy of what information had been provided. As a consequence of this, there was a lack of clarity regarding wound management .
The Trust did not, the inquest was told have a clear procedure that ensured that there was a clear, effective and documented communication system in relation to care plans that included wound management.
The home did not have a clear escalation policy for actions to be taken when a resident arrived, and their staff were unclear how they were being asked to manage a wound by the hospital. In addition, the documentation surrounding concerns and attempts to escalate was limited.
” 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 Issue a Trust-wide alert requiring two Transfer of Care documentation copies for care-home discharges.
Verbatim wording from the response “The Trust issued a Trust wide alert on 20 November 2025 in relation to Transfer of Care documentation and action required from all areas to ensure two copies of the documentation are printed; one to go with the patient to the care home and one to be placed in the patient’s records. Please find a copy of the Trust wide alert attached.” Source location Response from Stockport NHS Foundation 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 Establish a task and finish group to improve discharge checklist quality and information.
Verbatim wording from the response “During the course of this review, we have also identified that improvements are needed to the quality and information included in the discharge checklist. A task and finish group has been set up for this piece of work and will commence in January 2026.” Source location Response from Stockport NHS Foundation 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 Improve the quality and information included in the discharge checklist through the task and finish group.
Verbatim wording from the response “During the course of this review, we have also identified that improvements are needed to the quality and information included in the discharge checklist. A task and finish group has been set up for this piece of work and will commence in January 2026.” Source location Response from Stockport NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit five care-provider discharges per ward to verify Transfer of Care documentation is retained in patient records.
Verbatim wording from the response “In order to provide assurance that this practice is fully embedded across the Trust, a Trust wide audit will take place. Five patient discharges to other care providers will be audited per ward for discharges which have taken place in December. The audit will be carried out in the first two weeks of February 2026 and will check that there is a copy of the Transfer of Care documentation within the patient’s record.” Source location Response from Stockport NHS Foundation Trust
Open published response
29 Aug 2025 Audrey Newman · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Absence of a formal escalation and referral pathway to the anaesthetic team for difficult or unavailable lumbar punctures View source Lack of competency training enabling ward doctors to undertake lumbar puncture View source
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AI-generated summary
Audrey Newman · 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
Audrey Newman was admitted after a seizure and suspected encephalitis, but a planned lumbar puncture was delayed until 18 November 2024 because of difficulties involving staff competence, patient agitation and lack of consultant ownership. She subsequently developed severe renal failure while receiving acyclovir and antibiotics, and died from recognised risks of antiviral therapy for a suspected life-threatening condition. The principal concern was the absence of a formal pathway for escalating or referring difficult or delayed lumbar punctures to the anaesthetic team, creating a risk of future delays to crucial diagnostic tests and a risk of death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a formal escalation and referral pathway to the anaesthetic team for difficult or unavailable lumbar punctures
Wider context from the report “The evidence of the Trust was that CSF analysis was CRUCIAL for diagnosing meningitis or encephalitis when infection is suspected. Further, acyclovir is well recognised as a drug giving rise to renal injury.
In its LLO the Trust stated that, in recognition of the lack of training to enable ward doctors to undertake lumbar puncture a series of training sessions were held and are to continue.
Within the LLO it is stated,
There is learning in relation to escalation by doctors when a lumbar puncture is needed and hasn’t been done either due to difficulty (eg agitation) or unavailability of competency trained doctors. This has been discussed and case shared at the general medicine teaching sessions in April 2025.
The witness speaking to the LLO said that requests for escalation are still informal and based on goodwill. There is no formal process for requesting assistance.
The issue of concern is that in the absence of a formal pathway or referral process to the anaesthetic team for those cases which fall into the above category there is a significant risk of future delays in carry out crucial diagnostic tests , and a risk of 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of competency training enabling ward doctors to undertake lumbar puncture
Wider context from the report “The evidence of the Trust was that CSF analysis was CRUCIAL for diagnosing meningitis or encephalitis when infection is suspected. Further, acyclovir is well recognised as a drug giving rise to renal injury.
In its LLO the Trust stated that, in recognition of the lack of training to enable ward doctors to undertake lumbar puncture a series of training sessions were held and are to continue.
Within the LLO it is stated,
There is learning in relation to escalation by doctors when a lumbar puncture is needed and hasn’t been done either due to difficulty (eg agitation) or unavailability of competency trained doctors . This has been discussed and case shared at the general medicine teaching sessions in April 2025.
The witness speaking to the LLO said that requests for escalation are still informal and based on goodwill. There is no formal process for requesting assistance.
The issue of concern is that in the absence of a formal pathway or referral process to the anaesthetic team for those cases which fall into the above category there is a significant risk of future delays in carry out crucial diagnostic tests, and a risk of death.
” 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 Train medical staff to use Theatreman to log escalated procedures, provide pending-procedure visibility and create an audit trail.
Verbatim wording from the response “2) A meeting was arranged between senior members of the anaesthetic team and ████████ (Divisional Medical Director for Medicine and Urgent Care) to formalise the process of escalation of difficult LPs to the anaesthetic team:” Source location Response from Stockport NHS Foundation 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 Keep patients awaiting lumbar puncture on the acute medical unit until successful completion, recording agreed escalation in Theatreman before any ward transfer.
Verbatim wording from the response “• Patients awaiting a lumbar puncture to exclude meningitis, encephalitis, or subarachnoid haemorrhage will not be transferred off the acute medical unit until the LP is performed successfully. If there is a need to escalate after failed attempts then this needs to be agreed and logged onto Theatreman before the patient is transferred to another medical ward.” Source location Response from Stockport NHS Foundation 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 Formulate the anaesthetic-escalation process for difficult lumbar punctures into a flow chart.
Verbatim wording from the response “2) A meeting was arranged between senior members of the anaesthetic team and ████████ (Divisional Medical Director for Medicine and Urgent Care) to formalise the process of escalation of difficult LPs to the anaesthetic team:” Source location Response from Stockport NHS Foundation 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 Cascade the difficult-lumbar-puncture escalation flow chart to clinicians across medicine and urgent care.
Verbatim wording from the response “• The process of escalation to anaesthetics is being formulated into a flow chart that will be cascaded to all clinicians in the division of medicine and urgent care.” Source location Response from Stockport NHS Foundation 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 Deliver registrar lumbar-puncture training through completed simulation and ongoing supervised procedural sign-off.
Verbatim wording from the response “1) In conjunction with the postgraduate department and some of the senior doctors within acute medicine, we have enacted a training program for all registrars working on the medical specialty wards to be signed off to perform lumbar punctures.” Source location Response from Stockport NHS Foundation Trust
Open published response
7 Aug 2025 Kenneth Edwards · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to withhold blood-thinning medication while awaiting CT results for brain bleeding View source Failure to identify relevant findings in out-of-hours CT scan reports View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kenneth Edwards · 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
Kenneth Edwards fell twice on 22 and 23 March 2025 and died on 23 March 2025 following traumatic subdural and subarachnoid haemorrhages. The principal concerns were that a subdural haematoma was missed on the first CT scan and that blood-thinning medication was administered while awaiting the results of a second CT scan to identify brain bleeding.
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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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to withhold blood-thinning medication while awaiting CT results for brain bleeding
Wider context from the report “3. The administration of blood-thinning medication whilst awaiting the results of the second CT scan of the head to identify bleeding should not have happened . Whilst the treating clinician/s could not have known about the bleed that had not been identified on the first scan, they should have known that such medications were contra-indicated where the results of the second scan to identify brain bleeding were awaited .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify relevant findings in out-of-hours CT scan reports
Wider context from the report “1. A subdural haematoma was not identified in the report on the first CT scan [18:51 hours on 22nd March 2025, reported at 19:30 hours]. The inquest heard that since this scan took place out of hours (i.e. between 17:00 and 09:00) hours it was dealt with by an out of hours service provided by a company called Medica. The rapid review which identified the haematoma after Kenneth Edwards’s death was conducted by one of the hospital’s own radiologists. Had the haematoma properly been identified at the time the first scan was reported, appropriate steps could have been taken to deal with it at a relatively early stage. Furthermore, this would have identified circumstances at an early stage of Kenneth Edwards’s treatment that militated against the administering of blood-thinning medication.
2. Evidence was given that this was not the first time that detail had been missed on a scan reported upon by Medica .
” 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 Provide targeted education and training for emergency and acute care staff on anticoagulation risks, clinical vigilance and deferring treatment pending imaging.
Verbatim wording from the response “This aspect of care has been subject to internal review and will be addressed through targeted education and training for emergency department and acute care staff. Specific emphasis will be placed on risk stratification, clinical vigilance, and the importance of deferring anticoagulation when intracranial pathology remains a possibility pending imaging confirmation.” Source location Response from Stockport NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an incident review and escalation framework for radiology discrepancies, including those involving external providers.
Verbatim wording from the response “• Maintenance of a robust incident review and escalation framework for radiology discrepancies, including those involving external providers.” Source location Response from Stockport NHS Foundation 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 Complete an internal review of anticoagulation practice while intracranial pathology remains possible.
Verbatim wording from the response “This aspect of care has been subject to internal review and will be addressed through targeted education and training for emergency department and acute care staff. Specific emphasis will be placed on risk stratification, clinical vigilance, and the importance of deferring anticoagulation when intracranial pathology remains a possibility pending imaging confirmation.” Source location Response from Stockport NHS Foundation 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 Continue engaging in REALM meetings to review complex cases and promote diagnostic excellence.
Verbatim wording from the response “• Ongoing engagement in REALM (Radiology Education and Learning Meetings) to review complex cases and promote diagnostic excellence.” Source location Response from Stockport NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing contractual controls, audits, governance, escalation, and acceptable accuracy thresholds are considered sufficient; no outstanding reporting concerns remain.
Verbatim wording from the response “Stockport NHS Foundation Trust maintains a longstanding contractual relationship with Medica for out-of-hours radiology reporting, governed by a Service Level Agreement that includes defined Key Performance Indicators. Medica undertakes regular audits of its reporting output and contributes to shared learning through participation in governance meetings, including REALM (Radiology Education and Learning Meetings).” Source location Response from Stockport NHS Foundation Trust
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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 Medica retains responsibility for its radiology reports; further concerns about their content or conclusions should be directed to Medica.
Verbatim wording from the response “Medica were invited to comment on the discrepancy following Dr ████████ review and concluded that the subdural haematoma was not appreciable on the initial scan and therefore did not amend their report. As Medica retains responsibility for their reports, any further concerns regarding content or conclusions are appropriately directed to them via the Trust’s legal team.” Source location Response from Stockport NHS Foundation Trust
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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 The claim that Medica scan errors had occurred previously may reflect subjective observation, not a comprehensive assessment of reporting standards.
Verbatim wording from the response “We acknowledge that during the inquest, reference was made to previous occasions where details may have been missed in scans reported by Medica. While we are unable to retract this statement, we recognise that it may have reflected a subjective observation rather than a comprehensive or representative assessment of the reporting standards and governance processes currently in place.” Source location Response from Stockport NHS Foundation Trust
Open published response
18 Jul 2023 Christine Mary Dickinson · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to use a single accessible system for recording chemotherapy administration View source Failure to undertake recent audits of record-keeping View source
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
Christine Mary Dickinson · 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
Christine Mary Dickinson, who had follicular lymphoma and was receiving Rituximab, became gravely ill after a final hospital admission in October 2022 and died on 15 November 2022. The inquest raised concerns about multiple systems being used to record chemotherapy administration and the absence of a recent audit of record-keeping on the Laurel Unit, particularly after another patient’s details appeared in Mrs Dickinson’s record.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a single accessible system for recording chemotherapy administration
Wider context from the report “1. During the course of the inquest, the court heard evidence that staff on the Laurel Unit previously used a variety of systems (including one system not routinely accessible by staff elsewhere in the hospital) to record the administration of Chemotherapy .
2. Whilst the Consultant Haematologist told the court the requirement to use a single method of recording administration of Chemotherapy has been reinforced, in view of the above together with the fact that details pertaining to another patient entirely appear to have been entered into Mrs Dickinson’s record from September 2022, it is a matter of concern that no recent audit has been undertaken in respect of record-keeping on the Laurel Unit.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake recent audits of record-keeping
Wider context from the report “1. During the course of the inquest, the court heard evidence that staff on the Laurel Unit previously used a variety of systems (including one system not routinely accessible by staff elsewhere in the hospital) to record the administration of Chemotherapy.
2. Whilst the Consultant Haematologist told the court the requirement to use a single method of recording administration of Chemotherapy has been reinforced, in view of the above together with the fact that details pertaining to another patient entirely appear to have been entered into Mrs Dickinson’s record from September 2022, it is a matter of concern that no recent audit has been undertaken in respect of record-keeping on the Laurel Unit .
” 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 Conduct monthly Laurel Suite record-keeping audits and review results quarterly through the Division of Medicine Quality Group.
Verbatim wording from the response “To further assure you the following actions have also been taken:
- A monthly record keeping audit will be completed for Laurel Suite documentation and the results will be reviewed quarterly at the Division of Medicine’s Quality Group meeting.
- The team will be implementing a day case nursing admission documentation booklet for consistent documentation. This will be a proforma ‘live’ in AdvantisCDS for the nursing staff to add their information to which includes a question relating to any recent new diagnosis or hospital admission that may influence the decision to administer chemotherapy. This is currently in a pilot phase on paper with the intention to go electronic in the future. Whilst being piloted, at the end of each day the paper information is scanned into AdvantisCDS so it is available on the day of administration.” Source location Response from Stockport NHS Foundation 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 Progress joint procurement of a consolidated electronic patient record through external approval and a planned formal procurement exercise.
Verbatim wording from the response “A copy of this template is enclosed with this letter for your information.
- The team have purchased three additional computers on wheels (rather than desk based computers) so nurses are able to complete their documentation at the side of a patient rather than leaving them to work elsewhere. This allows for more timely contemporaneous recording, especially when patients require close observation.
- The Trust has established an electronic patient record (EPR) programme with the aim to procure and implement a single electronic patient solution to replace the majority of the Trust’s clinical systems. This programme is part of a national NHS digital initiative to ensure all Trusts have implemented such a solution by 2026 and associated funding has been made available to support Trusts.” Source location Response from Stockport NHS Foundation 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 Complete a documentation audit of randomly selected Laurel Suite patient records.
Verbatim wording from the response “Matron ████████ has completed a documentation audit following Mrs Dickinson’s inquest. Twenty Laurel Suite patients’ records were randomly selected between March 2023 and August 2023. For all twenty records there was: relevant documentation on AdvantisCDS regarding the attendance, no incorrect patient details present and relevant information on iQemo relevant to the AdvantisCDS record.” Source location Response from Stockport NHS Foundation Trust
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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 The planned electronic patient record will not replace iQemo because its specialist nature requires it to remain in use.
Verbatim wording from the response “A copy of this template is enclosed with this letter for your information.
- The team have purchased three additional computers on wheels (rather than desk based computers) so nurses are able to complete their documentation at the side of a patient rather than leaving them to work elsewhere. This allows for more timely contemporaneous recording, especially when patients require close observation.
- The Trust has established an electronic patient record (EPR) programme with the aim to procure and implement a single electronic patient solution to replace the majority of the Trust’s clinical systems. This programme is part of a national NHS digital initiative to ensure all Trusts have implemented such a solution by 2026 and associated funding has been made available to support Trusts.” Source location Response from Stockport NHS Foundation 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 digital systems make chemotherapy and treatment information available to relevant staff for emergency care decisions.
Verbatim wording from the response “As referenced by ████████, the staff in Laurel Suite also view patient information in Evolve. Evolve is the Trust’s patient record scanning solution which is used to scan any paper records a patient may have. In the absence of an Electronic Patient Record (EPR) system, clinical information written on paper notes during an inpatient stay or outpatient appointment is then scanned into Evolve. This information can be viewed by all hospital staff (subject to appropriate access). Additionally, some key documents from AdvantisCDS are also sent into Evolve for example a patient’s Emergency Department attendance, test results or patient monitoring information. Laurel Suite staff used to record on paper a patient daily care record which was then scanned into Evolve. As stated above, this practice ceased in 2018, when the staff move to direct electronic recording into Advantis CDS.” Source location Response from Stockport NHS Foundation Trust
Open published response
14 Oct 2022 Kenneth Goodwin · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of specific written confirmation of falls-risk handovers between wards View source Inconsistent use of bed signs to identify falls risk to staff View source Delays in completing falls-risk assessments after transfer to a new ward View source
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
Kenneth Goodwin · 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
Kenneth Goodwin was admitted to hospital with severe abdominal pain and was being treated for sepsis from gall stones and cholecystitis. After being transferred between wards at night, he fell before a falls risk assessment had been completed on the new ward, developed an acute subdural haematoma, and died on 9 June 2022. Concerns included the lack of required written confirmation of falls-risk handover, the delay in completing the new ward’s falls risk assessment, and inconsistent use of visual falls-risk signs on beds.
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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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific written confirmation of falls-risk handovers between wards
Wider context from the report “(1) The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of bed signs to identify falls risk to staff
Wider context from the report “(3) The Inquest heard that the use of signs on beds to visually identify falls risk to the staff is not consistently 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in completing falls-risk assessments after transfer to a new ward
Wider context from the report “(2) The falls risk assessment on the new ward was not completed for just over 4.5 hours . The Inquest heard that the target time for this assessment is within 6 hours, a length of time which is of concern for patients transferred at night, displaying signs of confusion, and already identified as a fall risk .
” 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 Audit use of the correct patient handover document through the senior nursing team’s ward audit programme.
Verbatim wording from the response “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.” Source location Response from Stockport NHS Foundation 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 Use the patient handover document in a Chief Nurse-led senior nurse walkround to reinforce communication of risks during transfers.
Verbatim wording from the response “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.” Source location Response from Stockport NHS Foundation Trust
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 Remove all unauthorised patient handover documents from use.
Verbatim wording from the response “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.” Source location Response from Stockport NHS Foundation Trust
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 Relaunch the formal patient handover document across the Trust through weekly bulletin and targeted governance-team emails.
Verbatim wording from the response “Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.” Source location Response from Stockport NHS Foundation Trust
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 Relaunch the maple leaf sign requirement across the Trust through weekly bulletin and targeted governance-team emails.
Verbatim wording from the response “Action – The requirement for the use of the maple leaf sign, identifying patients at risk of falls, was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. The requirement for the use of the maple leaf sign will also be added on all agency staff induction check lists to ensure that their use is explained to staff who are new to the organisation. Completion of the checklists is already included within the audit programme.” Source location Response from Stockport NHS Foundation 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 Add maple leaf sign use to agency staff induction checklists.
Verbatim wording from the response “Action – The requirement for the use of the maple leaf sign, identifying patients at risk of falls, was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. The requirement for the use of the maple leaf sign will also be added on all agency staff induction check lists to ensure that their use is explained to staff who are new to the organisation. Completion of the checklists is already included within the audit programme.” Source location Response from Stockport NHS Foundation Trust
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 six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.
Verbatim wording from the response “The Trust can confirm that there is a six hour standard for risk assessments to be completed following transfer of a patient to a ward. This window allows the receiving team to admit the patient into their care, undertake” Source location Response from Stockport NHS Foundation 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 The Trust’s formal handover document records falls risk for all transferred patients, contrary to the concern that no specific written confirmation is required.
Verbatim wording from the response “The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place.” Source location Response from Stockport NHS Foundation Trust
Open published response
25 Oct 2021 Alan Harry Hunter · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to calculate and identify inaccurate BMI measurements View source Failure to follow and recognise non-compliance with NICE weight-monitoring guidance View source Poor documentation of diet and weight monitoring View source
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. 6
Action
Run Malnutrition Awareness Week activities including MUST audits, nutritional nurse drop-in sessions and speech and language therapy presentations.
Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. View source
Action
Develop and cascade a standardised nutrition and MUST briefing covering malnutrition, assessments, food charts and protected mealtimes.
Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. View source
Action
Provide mandatory MUST screening training at induction and every three years, and report compliance across the Trust.
Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. View source
Action
Operate monthly nutrition and hydration governance with divisional assurance reporting and oversight of MUST, nutrition, hydration and fluid-balance standards.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 November 2021. View source
Action
Deliver ward-based toolbox training on MUST, fluid balance, food charts and specialist referrals.
Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. View source
Action
Conduct twice-weekly Matron quality assurance checks of nutrition assessments, fluid-balance charts and documentation standards.
Stated completedThe respondent said that this action was complete when they made their response on 4 November 2021. View source See 3 more actions
×
AI-generated summary
Alan Harry Hunter · 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
Alan Harry Hunter was admitted to hospital after a fall, with a urinary tract infection, confusion and delirium. He experienced incorrectly calculated BMI and MUST scores, rapid weight loss, increasing frailty, Covid-19 and a further urinary tract infection before dying at Fernlea Care Home; concerns focused on poor documentation and inadequate monitoring of his diet, weight and nutritional risk.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to calculate and identify inaccurate BMI measurements
Wider context from the report “The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently . As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow and recognise non-compliance with NICE weight-monitoring guidance
Wider context from the report “The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor documentation of diet and weight monitoring
Wider context from the report “The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight . The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers.
” 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 Run Malnutrition Awareness Week activities including MUST audits, nutritional nurse drop-in sessions and speech and language therapy presentations.
Verbatim wording from the response “Finally I would like to confirm that in October 2021, the Trust took part in Malnutrition Awareness Week, with a timetable of activities including MUST audit, drop in sessions with the nutritional nurses and a presentation from the speech and language therapy team.” Source location Response from NHS Stockport
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 Develop and cascade a standardised nutrition and MUST briefing covering malnutrition, assessments, food charts and protected mealtimes.
Verbatim wording from the response “A seven minute briefing document has been developed related to nutrition and MUST assessment and cascaded to teams. The seven minute briefing format is a standardised method of communication used at Stockport NHS Trust to provide teams with key information to improve patient and staff safety. The Nutrition and MUST seven minute briefing provides an overview of malnutrition, MUST assessments and the use of food charts, and the importance of protected mealtimes.” Source location Response from NHS Stockport
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 mandatory MUST screening training at induction and every three years, and report compliance across the Trust.
Verbatim wording from the response “I would like to provide assurance that prior to Mr Hunter’s inquest, improvement work related to MUST, nutrition and hydration had already commenced with a number of actions undertaken to improve the care we provide to patients and the way in which we document and evidence that care. The Nutrition and Hydration Steering Group takes place on a monthly basis and is chaired by the Deputy Chief Nurse. This Group reports to the Patient Safety Group chaired by the Medical Director and has oversight of improvements to nutrition and hydration across the Trust. Reports received by the Group include the training compliance position for MUST screening training which is currently reported at 90.76% trust wide, the compliance position for quality metrics standards for nutrition and hydration and fluid balance monitoring undertaken by senior nurses.” Source location Response from NHS Stockport
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 Operate monthly nutrition and hydration governance with divisional assurance reporting and oversight of MUST, nutrition, hydration and fluid-balance standards.
Verbatim wording from the response “I would like to provide assurance that prior to Mr Hunter’s inquest, improvement work related to MUST, nutrition and hydration had already commenced with a number of actions undertaken to improve the care we provide to patients and the way in which we document and evidence that care. The Nutrition and Hydration Steering Group takes place on a monthly basis and is chaired by the Deputy Chief Nurse. This Group reports to the Patient Safety Group chaired by the Medical Director and has oversight of improvements to nutrition and hydration across the Trust. Reports received by the Group include the training compliance position for MUST screening training which is currently reported at 90.76% trust wide, the compliance position for quality metrics standards for nutrition and hydration and fluid balance monitoring undertaken by senior nurses.” Source location Response from NHS Stockport
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 Deliver ward-based toolbox training on MUST, fluid balance, food charts and specialist referrals.
Verbatim wording from the response “Within the investigation report a robust action plan has been provided that gives additional updates on the continuation of improvements across the Trust. This includes the identification of Nutrition and Hydration Champions across wards, tool box training sessions provided across ward areas between July and October 2021 covering MUST, fluid balance, food charts and specialist referrals and the development of Nutrition and Hydration Information Boards in ward areas.” Source location Response from NHS Stockport
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 Conduct twice-weekly Matron quality assurance checks of nutrition assessments, fluid-balance charts and documentation standards.
Verbatim wording from the response “The action plan also describes the audit processes now in place to ensure oversight of the MUST assessment and the completion of food charts. The Quality Assurance Checks completed by Matron twice weekly include a patient care section which looks at completion of nutrition assessment, that the assessment is up to date, and that fluid balance charts are up to date. The documentation section of the Quality Assurance Check audits that the MUST assessments are completed to the required standard and that standards of documentation are upheld, for example that all nursing entries are legible, signed, dated and timed. Alongside regular audit, daily safety huddles with the matron and ward managers take place to review any concerns in regard to patients. This holistic review includes a review of any nutrition and hydration concerns.” Source location Response from NHS Stockport
Open published response
18 Jun 2021 LESLEY MAWBY · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Residual staffing shortages in the dietetic team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
LESLEY MAWBY · 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
Lesley Mawby, who had multiple myeloma, developed severe vomiting and diarrhoea after starting chemotherapy and was admitted to hospital. She subsequently experienced malnutrition, electrolyte disturbances, sepsis and upper gastrointestinal haemorrhage, and died from multi-organ failure on 5 October 2020. The report raised concern about staffing shortages in the dietetic team causing delays in assessments and lack of weekend cover.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Residual staffing shortages in the dietetic team
Wider context from the report “(1) It is a matter of concern that there are residual staffing shortages in the dietetic team leading to delays in assessments on weekdays and meaning weekend cover cannot be provided .
” 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 Review dietetic staffing risks monthly through divisional governance and the Risk Management Committee.
Verbatim wording from the response “Business Case developed – Therapies Staffing
A risk assessment in respect of the dietetic staffing was completed in October 2020 and a detailed review has been completed. The risk to patients due to the staffing establishment and capacity in the team is reviewed monthly by the divisional team and by the executives at the Risk Management Committee.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Develop and progress a business case for increased nutrition and dietetic staffing through Trust governance.
Verbatim wording from the response “A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 weekend out-of-hours enteral and parenteral feeding guidance to ensure patients receive appropriate nutrition pending dietetic review.
Verbatim wording from the response “7 day provision
The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Combine community and acute nutrition and dietetic staffing establishments to enable flexible cross-service working.
Verbatim wording from the response “Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Allocate highest-priority new and follow-up patients to available staff under senior-dietitian oversight.
Verbatim wording from the response “The Dietitian will review the highest priority patients from new and follow up patients and allocate those patients in order based on the criteria and clinical judgement to the staff available. The process is overseen by a senior Dietitian.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Complete a dietitian job-planning exercise and benchmark staffing against British Dietetic Association recommendations.
Verbatim wording from the response “Job planning and benchmarking
There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Review the skill mix and examine non-registered staff roles and responsibilities.
Verbatim wording from the response “Job planning and benchmarking
There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BDA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the roles and responsibilities of non-registered staff being examined.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Recruit to additional nutrition and dietetic posts to address identified staffing needs.
Verbatim wording from the response “A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Use a streamlined referral spreadsheet recording assessment due dates, follow-up review dates and review reasons.
Verbatim wording from the response “Improved process
A new streamlined process has been implemented, where staff add the referrals to a spreadsheet with ‘assessment due date’ documented based on assessment criteria. This new process allows staff to filter the data easily and has improved ways of working. Patients already seen and requiring follow up remain on the spreadsheet with a ‘review date’ documented and reason for review.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Monitor caseloads regularly to ensure patients are prioritised and seen within appropriate timescales.
Verbatim wording from the response “• Caseload management monitored regularly to ensure patients are prioritised and seen in a timely manner.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Combine specialist acute caseloads and prioritise them across the service.
Verbatim wording from the response “Additional measures implemented by the Dietetic Service to mitigate the risk are as follows:” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 Conduct twice-daily senior-dietitian triage and prioritise referrals using referral criteria and clinical judgement.
Verbatim wording from the response “Twice daily triage
There is twice daily triage by a senior dietitian. All referrals for new patients are triaged by the Dietitians and prioritised according to the dietetic referral triaging criteria, ‘The Inpatient ward referral triage criteria’ (Appendix A), details the target times for reviewing referred patients in line with priority category. However, the Dietitians review all referrals in full and use clinical judgement to review a patient sooner if necessary.” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 out-of-hours guidance is considered sufficient to ensure appropriate nutrition and prevent weekend delays without routine dietetic review.
Verbatim wording from the response “7 day provision
The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
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 The dietetic service cannot provide seven-day cover because it is not commissioned to operate seven days.
Verbatim wording from the response “7 day provision
The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients are in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C. The subsequent” Source location 2021-0208-Response-from-Stepping-Hill-Hospital_Published
Open published response
22 Apr 2020 DAVID CRAIG KERR · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to perform clinical observations at appropriate frequency for sick patients View source Inadequate provision of fluids to seriously unwell patients View source Failure to produce a protocol for the frequency of observations in sick patients View source Failure to complete input/output charts for seriously unwell patients View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DAVID CRAIG KERR · 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
David Kerr was admitted to hospital after a fall at home and subsequently sustained a fractured neck of femur in a further ward fall after removing his oxygen. He became increasingly unwell and died on 27 April 2019; the inquest recorded accidental death, with respiratory failure and extensive idiopathic pulmonary fibrosis as the medical cause of death. Concerns included poor care on Ward D2, inadequate hydration and fluid recording, and too few clinical observations for a seriously unwell patient.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform clinical observations at appropriate frequency for sick patients
Wider context from the report “(3) There were few clinical observations on this sick patient . On 26th April, clinical observations were performed at 11.12 (MEWS 1) and 21.06 (MEWS 0). There were no clinical observations thereafter . No protocol was produced regarding the frequency of observations in sick patients on Ward D2.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate provision of fluids to seriously unwell patients
Wider context from the report “(2) Between 24th and 26th April DK was allowed to become increasingly dehydrated ; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce a protocol for the frequency of observations in sick patients
Wider context from the report “(3) There were few clinical observations on this sick patient. On 26th April, clinical observations were performed at 11.12 (MEWS 1) and 21.06 (MEWS 0). There were no clinical observations thereafter. No protocol was produced regarding the frequency of observations in sick patients on Ward D2 .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete input/output charts for seriously unwell patients
Wider context from the report “(2) Between 24th and 26th April DK was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April , despite the fact that he was seriously unwell.
” 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 Deliver ward training on timely and accurate fluid-balance recording.
Verbatim wording from the response “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 Produce daily NEWS2 reports for Matrons and Ward Managers and review whether appropriate action has been taken.
Verbatim wording from the response “• EWS daily reports are produced and sent via email to Matrons and Ward Managers with details for each area of patients who have scored on the NEWS2 which is reviewed to ensure appropriate action has been taken.” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 accurate fluid-balance review and investigation of alternative causes of hypotension.
Verbatim wording from the response “We have discussed his case with consultants across all clinical business groups and agreed the following Trust wide actions:” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 Roll out a Trust-wide fundamental-care framework containing common nutrition and hydration standards.
Verbatim wording from the response “In addition, to ensure that learning is applied across the organisation, we have started the roll-out of a fundamental care framework across the Trust which includes common best practice standards for the management of nutrition and hydration.” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 Speak to staff involved and remind them to record and escalate observations appropriately and promptly.
Verbatim wording from the response “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 Speak to staff involved and remind them to record fluid balances accurately.
Verbatim wording from the response “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 Audit ward fluid-balance recording daily, provide feedback, and obtain external peer reviews for objectivity.
Verbatim wording from the response “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 Deliver ward training on observation recording and escalation under Trust policies and procedures.
Verbatim wording from the response “In order to ensure compliance with best practice standards in Ward D2, the following actions are being taken:” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 Carry out a Trust-wide quality-improvement project covering hydration and nutrition using recognised improvement methodology.
Verbatim wording from the response “In addition, to ensure that learning is applied across the organisation, we have embarked on a Quality Improvement Project focussed on all aspects of hydration and nutrition. This will be supported by the transformation team using recognised quality improvement methodology to achieve rapid and sustainable change.” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
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 records showed positive, though declining, fluid balance, so the response disputes that the patient became increasingly dehydrated.
Verbatim wording from the response “Between 24th and 26th April 2019, Mr Kerr was allowed to become increasingly dehydrated; on 24th April he received a total of 300mls of fluid and the input/output chart was not filled in on 25th/26th April, despite the fact that he was seriously unwell.” Source location 2020-0100-Response-from-Stockport-NHS-Foundation-Trust_Redacted-1
Open published response
10 Jan 2019 Mr Malcolm Marshall Shaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Unavailability of a revised training programme for patient safety investigators View source Failure to conduct rigorous patient safety investigations View source Lack of guidance for frontline staff on promptly capturing evidence after falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Malcolm Marshall Shaw · 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 Malcolm Marshall Shaw was admitted to Stepping Hill Hospital following a general decline in his condition and later sustained an unobserved fall, resulting in a fractured right femur. He developed bronchopneumonia and died on 20 February 2018; the inquest recorded that his death was contributed to by underlying lung disease. The principal concerns were that the Trust’s original investigation into the fall was fundamentally flawed, that revised investigation training had not yet been introduced, and that frontline staff lacked guidance on promptly capturing evidence about falls.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a revised training programme for patient safety investigators
Wider context from the report “Whilst the court heard evidence of significant improvements the Trust has made to the way it undertakes investigations, it is a matter of residual concern that the organisation has yet to launch a revised programme of investigation training for those who undertake patient safety investigations .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct rigorous patient safety investigations
Wider context from the report “In view of the fundamental importance of rigorous patient safety investigations whose conclusions are capable of withstanding logical analysis to improving care, it is a matter of concern that the Trust’s original investigation into the circumstances of Mr Shaw’s fall (which had presumably passed through the Trust’s own quality assurance mechanisms) was manifestly and fundamentally flawed .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for frontline staff on promptly capturing evidence after falls
Wider context from the report “Specifically in relation to cases involving falls, it remains of concern that frontline staff do not appear to have been provided with any guidance as to how to capture the best available evidence as to the circumstances of the fall as soon as reasonably possible after the incident . This is a matter of particular concern bearing in mind the potential benefits such an approach would bring to the Trust’s ongoing efforts to understand the causes of falls on wards with a view to trying to prevent as many of them as possible.
” 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 Hold a training session for Executive Directors to improve consistency in investigation oversight and scrutiny.
Verbatim wording from the response “• A training session is to be held with the Executive Directors on 12 March 2019, this will support consistency of overview and scrutiny of investigations.” Source location 2019-0007-Response-by-Stockport-NHS-Trust
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 Run the Safer Mobility Collaborative, including immediate post-fall assessment, staff statements and patient discussions to confirm safety actions.
Verbatim wording from the response “• In June 2018 the Trust launched a Safer Mobility Collaborative aimed at reducing inpatient falls by March 2019. Part of the collaborative included the launch of an immediate assessment of the circumstances of the fall, taking statements from staff and talking with the patient to assess that all actions to ensure patient safety are in place.” Source location 2019-0007-Response-by-Stockport-NHS-Trust
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 in-depth training on gathering and writing investigation statements.
Verbatim wording from the response “• In September 2018 the Trust introduced training sessions with an in-depth focus on statement gathering and writing.” Source location 2019-0007-Response-by-Stockport-NHS-Trust
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 Implement a checklist for final investigation panels to verify key investigation requirements, including team training.
Verbatim wording from the response “• In February 2019 the Trust has implemented a check list to be completed at the time the panel meet to hear the final investigation report. The check list, advocated as best practice by NHS Improvement, supports the Executive Director in identifying if the key requirements for a good investigation have been met during the investigation. The checklist includes identification of the training status of the investigation team; that is whether they have received appropriate training” Source location 2019-0007-Response-by-Stockport-NHS-Trust
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 Launch revised patient safety investigation training and widen participation beyond the small specialist team.
Verbatim wording from the response “The launch of the revised programme of investigation training for those who undertake patient safety investigations” Source location 2019-0007-Response-by-Stockport-NHS-Trust
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 quarterly Root Cause Analysis training through the Quality Governance Team.
Verbatim wording from the response “I can confirm that programme of investigation training has been developed and launched. We have the following programme in place:” Source location 2019-0007-Response-by-Stockport-NHS-Trust
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 Use thrice-weekly Quality Safety Leadership Summits to monitor falls, confirm investigations have started and verify inclusion of immediate statements.
Verbatim wording from the response “• In January 2019, the Trust further enhanced its approaches to monitoring falls via our Quality Safety Leadership Summit, held three times a week. At this meeting, senior nurses are able to ensure that full investigations have started and include immediate statements. The Trust is pleased to report that it continues to be on target to reduce the number of falls within the organisation.” Source location 2019-0007-Response-by-Stockport-NHS-Trust
Open published response
25 Jul 2018 Robert Thomas Wrinch · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Incompatibility of pathology information technology systems between hospital trusts View source Lack of tracking of pathology samples and reports View source Failure of departments to track outstanding pathology reports View source Backlogs delaying pathology sample analysis View source Reliance on delayed paper delivery of pathology reports View source Failure to document conversations with other clinicians 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.
×
AI-generated summary
Robert Thomas Wrinch · 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
Robert Thomas Wrinch deteriorated with severe back pain and reduced mobility associated with an undiagnosed metastatic spinal malignancy, and developed bronchopneumonia. The report raised concerns about delays and inadequate tracking in pathology sample processing and reporting, reliance on paper reports, inconsistent departmental tracking systems, incompatible information technology systems between trusts, and pathology backlogs linked to shortages of pathologists.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Incompatibility of pathology information technology systems between hospital trusts
Wider context from the report “4. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other . This meant that transfer of information between trusts to obtain a second opinion were more difficult .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of tracking of pathology samples and reports
Wider context from the report “1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples . As a result, it was unclear when samples had been received and analysis had taken place . There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events. Transmission dates of the sample to another Trust were unclear . It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician . It was unclear if these issues are specific to the pathology department of the Trust or more widespread.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of departments to track outstanding pathology reports
Wider context from the report “3. At the Trust, some departments such as the respiratory department had clear tracking systems to identify outstanding pathology reports. Other departments such as orthopaedics did not . As a result, clinicians could not readily identify where there was delay in receipt of information required to assess and diagnose a patient .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Backlogs delaying pathology sample analysis
Wider context from the report “5. The Inquest heard that the delay in analysis of the sample taken was due to a backlog . The backlog was not unique to the Trust and such backlogs were prevalent across pathology departments nationally due to a local and national shortage of pathologists.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on delayed paper delivery of pathology reports
Wider context from the report “2. The Trust had a system of issuing reports digitally to clinicians to speed up receipt. In addition the Inquest were told that due to preferences of clinicians paper copies were also produced and sent via internal mail to the treating clinicians . The Inquest heard that the responsible orthopaedic consultant relied on wholly on the paper system although this built in delay .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document conversations with other clinicians
Wider context from the report “1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples. As a result, it was unclear when samples had been received and analysis had taken place. There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events . Transmission dates of the sample to another Trust were unclear. It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician. It was unclear if these issues are specific to the pathology department of the Trust or more widespread.
” Open source report
16 Jul 2018 Sheila Winifred Ridgway · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments 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
Sheila Winifred Ridgway · 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
Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
Wider context from the report “1) Communication between specialty consultants – lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks when specialty specific treatments are being contemplated or planned for the different specialities simultaneously
” Open source report
31 Jul 2017 Michael Bingham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of clarity and consistency in head and neck injury guidelines for considering CT scans in older people with dementia or cognitive impairment View source Lack of consistent regulatory or guidance requirements for assessing fall risks from emergency door release panels View source Failure to provide alarms indicating when internal secure doors become insecure across the service View source Inadequate inspection procedures for Registered Persons’ compliance with internal secure door safety and security requirements 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
Michael Bingham · 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
Michael Bingham fell down stairs at Hilltop Court Care Home on 22 September 2016 after an emergency door release caused internal secure doors to open. He sustained C1/C2 fractures, was not diagnosed with a CT scan, later developed aspiration pneumonia, and died on 24 September 2016; concerns included door security alarms, guidance and inspection procedures, clarity about CT scans for older people with cognitive impairment, and the resulting risk of further deaths.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity and consistency in head and neck injury guidelines for considering CT scans in older people with dementia or cognitive impairment
Wider context from the report “I am concerned that the current Guidelines for Head/neck injuries (as amended) may continue to provide a lack of clarity as to when CT scans should be considered in those over 65 and with dementia or other cognitive impairment . The word ‘confusion’ remains under the general guidance (bullet point 5) but has been changed to ‘dementia’ under the guidance for those who are already being subject to a head scan . I ask that you consider reviewing your guidelines to ensure clarity and consistency of their clinical application.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent regulatory or guidance requirements for assessing fall risks from emergency door release panels
Wider context from the report “I accept that on the present Regulations it is for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, I ask you to review, in light of the evidence I have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel . I also ask you to review your inspection procedures in respect of a Registered Person’s compliance with the Regulations in respect of the safety and security of internal secure doors.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide alarms indicating when internal secure doors become insecure across the service
Wider context from the report “It was accepted by you during the inquest that there was a ‘blind spot’ in the risk assessment of the internal secure doors , in that you were not required by any regulatory body to have an alarm to alert staff when secure doors became insecure by virtue of the use of the green emergency door release or otherwise.
I accept that you have now implemented an alarm system in Hilltop Court Care home that will indicate when the internal doors become insecure and have fitted auditory alarms in relation to the external doors. You indicated that you are in the process of implementing similar systems in the other care homes owned by Harbour Healthcare. I am concerned that without the implementation of these alarms across your service provision there would continue to be circumstances that create a risk of other deaths . I would be grateful for an indication of when you expect this implementation to be completed by way of response.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate inspection procedures for Registered Persons’ compliance with internal secure door safety and security requirements
Wider context from the report “I accept that on the present Regulations it is for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, I ask you to review, in light of the evidence I have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel. I also ask you to review your inspection procedures in respect of a Registered Person’s compliance with the Regulations in respect of the safety and security of internal secure doors .
” Open source report
26 Apr 2017 John Davies · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Failure to identify a suitable nursing home placement when the care home no longer met residents’ needs View source Insufficient communication and information sharing between the care home and District Nursing Team View source Insufficient detail in care home notes View source Failure by District Nurses to seek advice when experiencing difficulties examining a patient View source Failure to involve the District Nursing Team in discussions when residents’ status changed View source Lack of continuity of care by the District Nursing Team View source Failure to follow the correct procedure when trigger points for pressure-relieving strategies were reached View source Failure to complete District Nursing Team patient records within required timescales View source Lack of a process for completing risk assessment plans when residents’ needs changed from care to nursing needs while awaiting a bed View source Insufficient detail in patient records completed by the District Nursing Team View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John Davies · 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 Anthony Davies had Lewy body dementia and Parkinson’s disease and died on 23 October 2016 after deterioration following an infected pressure sore. Concerns included inadequate risk assessment when his care needs changed, poor communication and information sharing, incomplete records, lack of continuity of care, difficulties securing a suitable nursing home placement, and failures relating to pressure-relieving strategies.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify a suitable nursing home placement when the care home no longer met residents’ needs
Wider context from the report “7. A suitable nursing home placement could not be identified once it had been agreed that the Care Home was no longer the best place to meet the needs of Mr Davies
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient communication and information sharing between the care home and District Nursing Team
Wider context from the report “5. There was little evidence of communication and information sharing between the care home and the District Nursing Team
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in care home notes
Wider context from the report “6. The Care Home notes were lacking in detail
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by District Nurses to seek advice when experiencing difficulties examining a patient
Wider context from the report “8. Advice was not sought by the District Nurses when they had difficulties examining Mr Davies
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve the District Nursing Team in discussions when residents’ status changed
Wider context from the report “2. The District Nursing Team were unaware of the change in status and there was no system in place to involve them in discussions .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care by the District Nursing Team
Wider context from the report “4. There was no continuity of care provided by the District Nursing Team .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the correct procedure when trigger points for pressure-relieving strategies were reached
Wider context from the report “9. The correct procedure was not followed on previous occasions when a trigger point was reached in relation to pressure relieving strategies .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete District Nursing Team patient records within required timescales
Wider context from the report “3. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a process for completing risk assessment plans when residents’ needs changed from care to nursing needs while awaiting a bed
Wider context from the report “1. There was no process in place for risk assessment plans to be completed when a resident’s needs changed from care to nursing needs and a bed was awaited .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail in patient records completed by the District Nursing Team
Wider context from the report “3. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales.
” 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 Address District Nursing documentation deficiencies with staff and facilitate a reflective session on nursing care.
Verbatim wording from the response “Patient records complete by the District Nursing Team lacked detail and were not completed in the required timescale.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 continuity through Named Nurse visits, structured handovers, and Caseload Holder oversight.
Verbatim wording from the response “The Named Nurse for each care home will undertake all visits to the residents within their allocated home; however, when not on duty, the Named Nurse will hand over any relevant information to whichever nurse is assigned to visit.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 Remind District Nursing staff to follow the pressure-ulcer prevention guideline and pressure-relieving trigger procedures.
Verbatim wording from the response “The correct procedure was not followed on previous occasions when a trigger point was reached in relation to pressure relieving strategies” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 Appoint a Named Nurse for the residential home.
Verbatim wording from the response “A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients’ care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 Implement a multi-agency risk assessment for residents awaiting transfer from residential to nursing care.
Verbatim wording from the response “There was no process in place for risk assessment plans to be completed when a resident’s needs changed from care to nursing needs and a bed was awaited.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 Book new District Nursing staff onto mandatory pressure-ulcer training covering trigger points and pressure-relieving strategies.
Verbatim wording from the response “The Trust has a Prevention and Management of Pressure Ulceration Guideline (2015). All members of staff in the District Nursing team have been reminded of the requirement to adhere to this guidance and new staff have been booked on to the mandatory pressure ulcer training which includes how to identify trigger points and provide pressure relieving strategies.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 residential-home care meetings and share key information at District Nursing Time Team meetings.
Verbatim wording from the response “A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients’ care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 Audit District Nursing patient notes and repeat the audit to confirm improvements are sustained.
Verbatim wording from the response “The Trust accepts that the patient’s District Nursing notes did lack detail especially around the deterioration of the patient’s physical and mental health and were not completed in the required timescale. This has been addressed with the team and a reflective session has been facilitated regarding the patient’s nursing care. An audit of the team’s patients’ notes has been carried out by the DN Clinical Lead and improvements have been noted. The Patient Records audit is being repeated to ensure that the improvements have been sustained.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 home notes are the care home's responsibility, so the concern should be forwarded to the care home.
Verbatim wording from the response “The Care Home notes are not the responsibility of the Trust, and we respectfully request that this concern is forwarded to the Care Home.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
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 Nursing-home placement is not the District Nursing Team's responsibility, so the concern should be addressed by the CCG's Funded Nursing Care team.
Verbatim wording from the response “Locating and assessing Nursing Home placements is not the responsibility of the District Nursing Team, and we respectfully request that this concern is forwarded to the Stockport Clinical Commissioning Group’s Funded Nursing Care team to be addressed.” Source location 2017-0138-Response-by-Stockport-NHS-Trust
Open published response
23 Mar 2017 Marian Dale · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to ensure retrieval of patient notes after death View source Lack of a contemporaneous central record of patient condition and treatment 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
Marian Dale · 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
Marian Dale injured both legs in separate accidents, developed cellulitis in both legs, and was admitted to Stepping Hill Hospital. She developed sepsis and died there on 17 November 2016. The report raised concerns that the District Nursing Team could not evidence the condition of her legs and treatment because records were not held centrally or retrieved 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure retrieval of patient notes after death
Wider context from the report “Marian Dale had been visited on a regular basis by the District Nursing Team. However, they were unable to give evidence of the condition of her legs and treatment on their visits prior to her death. This was due to the fact that all notes were retained at the patient’s address until a sheet in the hand held notes was completed. There was no system for a contemporaneous record to be held centrally. Her notes had not been retrieved after her death and there was no system in place to ensure that happened .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a contemporaneous central record of patient condition and treatment
Wider context from the report “Marian Dale had been visited on a regular basis by the District Nursing Team. However, they were unable to give evidence of the condition of her legs and treatment on their visits prior to her death . This was due to the fact that all notes were retained at the patient’s address until a sheet in the hand held notes was completed . There was no system for a contemporaneous record to be held centrally . Her notes had not been retrieved after her death and there was no system in place to ensure that happened.
” Open source report
20 Jun 2016 Michael Guy Hutchence · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Unnecessary transfers between hospital wards View source Shortage of Braun’s Frames for safe leg elevation View source Failure to record accurate patient weights consistently View source Failure to use a sufficiently refined method for anticoagulant dose assessment View source Insufficient availability of trained nursing staff View source Failure to provide appropriately specialist and supervised nursing care View source Failure to maintain accurate nursing and medical notes View source Failure to provide usable sterile surgical kits 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
Michael Guy Hutchence · 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
Michael Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unnecessary transfers between hospital wards
Wider context from the report “1. For no other reason than the convenience of the hospital bed-managers, he was moved at least four times from ward to ward in the hospital .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Shortage of Braun’s Frames for safe leg elevation
Wider context from the report “6. I was told that the ideal way of elevating a patient’s leg is by using a Braun’s Frame. There was (and apparently still is) a shortage of these within the hospital , such that his leg was at all times elevated by using pillows . This was a potential for causing or contributing to the formation of DVT’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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record accurate patient weights consistently
Wider context from the report “4. In addition to the above problem, the body weight was recorded on some occasions in metric and others in imperial weights . This can and does lead to confusion . On one page of the notes, the predicted weight was shown as 15stone 10lbs which was in fact the actual weight and NOT the predicted weight . For the purpose of the accurate delivery of many drugs including anti-coagulants, accurate weight recording is essential .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a sufficiently refined method for anticoagulant dose assessment
Wider context from the report “3. He was administered his anti-coagulant simply on the basis of his body weight . He weighed 99.8Kg and the difference between a daily dose of 40mg of Clexane and a twice daily dose of 40mg of Clexane is arbitrarily set at a body weight of 100Kg . Should there not be a rather more refined way of assessing the dose required ?
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of trained nursing staff
Wider context from the report “5. There was a shortage of trained nurses in the hospital , and this may have led to at least one of the “ward moves”. Ward D2 was closed due to lack of staff .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriately specialist and supervised nursing care
Wider context from the report “2. The quality and accuracy of the nursing and medical notes left much to be desired and it was noted that he was cared for by non-specialist nurses on a number of occasions and even when he was in the I.T.U. he was looked after by a trainee nurse .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate nursing and medical notes
Wider context from the report “2. The quality and accuracy of the nursing and medical notes left much to be desired and it was noted that he was cared for by non-specialist nurses on a number of occasions and even when he was in the I.T.U. he was looked after by a trainee nurse.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide usable sterile surgical kits
Wider context from the report “7. The patient was taken to theatre for the operation and this could not be started as the “kit” for the operation was found to have a non-sterile status as the outer wrapping had been breached . The operation was delayed whilst another kit was obtained but this was also found to be defective . The operation was then aborted and put off for a further two days , during which time the patient was immobile and the risk of DVT and PE was inevitably increased.
” 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 Undertake monthly live spot audits of 30 inpatient records to improve written-record quality during the electronic-record rollout.
Verbatim wording from the response “The EPR will improve patient safety and outcomes by standardising pathways underpinned by best practice, it will remove issues relating to the illegibility of written records and will also assist with the completion of important documents, as the system will employ a ‘force function’, meaning the record cannot be left incomplete. The roll out for the system will be completed in 2017. In the meantime we will continue to try to improve our written records by undertaking monthly ‘live’ spot audits of 30 inpatient records across the wards.” Source location 2016-0228-Response-by-Stockport-NHS-Trust
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 Install and roll out an electronic patient record integrating healthcare information and standardising documentation and care pathways.
Verbatim wording from the response “The Trust is currently in the process of installing an electronic patient record (EPR) system, which is a computerised version of the entire healthcare record. Instead of hospital staff using a mixture of paper and electronic records, information will be available to them online in one place. We already use a variety of electronic systems to help staff look after our patients, but the EPR will bring all this information together.” Source location 2016-0228-Response-by-Stockport-NHS-Trust
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 Merge D2 staff with the Short Stay Surgical Unit and increase weekend capacity to 32 patients, providing additional emergency capacity and redeploying spare staff to staffing gaps.
Verbatim wording from the response “D2 (an elective inpatient ward) was closed following NHS England advice for us not to undertake any elective work, apart from day case work, due to winter bed pressures throughout the NHS at that time. As a result of this we merged the staff from D2 with SSSU which was open 7 days a week and increased to 32 patients at a weekend, giving us extra capacity for emergencies. Any spare staff were utilised to support gaps in staffing on other areas.” Source location 2016-0228-Response-by-Stockport-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 Continue an awareness drive requiring staff to record patient weight and height using metric measurements.
Verbatim wording from the response “There is currently an ongoing awareness drive to ensure all staff are recording weight and height in the metric format.” Source location 2016-0228-Response-by-Stockport-NHS-Trust
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 Purchase and provide four additional Braun frames for Ward D1, increasing the hospital total to eight.
Verbatim wording from the response “I can advise that four new Braun frames have since been purchased and were delivered to Ward D1 on 25 July 2016; we now have 8 in total. There is still a potential that outlying trauma patients, in the very busy winter period, may still have pillows utilised as an elevation method.” Source location 2016-0228-Response-by-Stockport-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 Critical-care patients were supervised by qualified staff, and the patient was never solely cared for by an unqualified nurse.
Verbatim wording from the response “2) The quality and accuracy of the nursing and medical notes left much to be desired and it was noted that Mr Hutchence was cared for by non-specialist nurses on a number of occasions and even when he was in the I.T.U. he was looked after by a trainee nurse.” Source location 2016-0228-Response-by-Stockport-NHS-Trust
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 Evidence and manufacturer guidance do not support routine anticoagulant dose adjustments for overweight patients without evidence of efficacy and safety.
Verbatim wording from the response “3) Mr Hutchence was administered his anti-coagulant simply on the basis of his body weight. He weighed 99.8 Kg and the difference between a daily dose of 40 mg. of Clexane and a twice daily dose of 40mg of Clexane is arbitrarily set at a body weight of 100 Kg. Should there not be a rather more refined way of assessing the dose required?” Source location 2016-0228-Response-by-Stockport-NHS-Trust
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 Proceeding with surgery when instrument-tray sterility was uncertain was unacceptable, requiring postponement until safe equipment was available.
Verbatim wording from the response “Mr. Hutchence was scheduled for surgery on the trauma list for open reduction and internal fixation of fractured left tibia and fibula on 19th January 2016. It has not been possible to identify a particular cause for the breaches in the wrappings. Great care and attention is given to maintaining the integrity and sterility of the instrument tray wrappings. It is standard theatre practice that careful and thorough checking of every instrument tray wrapping is undertaken by the theatre practitioner prior to use. In this case, the routine checking identified the breaches and an appropriate action was taken to re-sterilise the instrument trays.” Source location 2016-0228-Response-by-Stockport-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 There is no direct evidence that limb elevation reduces venous thromboembolism, and the elevation method does not affect that risk.
Verbatim wording from the response “6) I was told the ideal way of elevating a patient’s leg is by using a Braun’s frame. There was (and apparently still is) a shortage of these within the hospital such that Mr Hutchence’s leg was at all times elevated by using pillows. This was a potential for causing or contributing to the formation of D.V.T’s” Source location 2016-0228-Response-by-Stockport-NHS-Trust
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 Ward moves were often necessary to create bed capacity and meet emergency access targets, rather than being solely for bed-manager convenience.
Verbatim wording from the response “1) For no other reason, other than the convenience of hospital bed managers, Mr. Hutchence was moved at least four times from ward to ward within the hospital.” Source location 2016-0228-Response-by-Stockport-NHS-Trust
Open published response
13 May 2016 Geoffrey Ellis · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to complete important clinical documents View source Illegible clinical records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Geoffrey Ellis · 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
Geoffrey Ellis was admitted for a left-sided laparoscopic nephro-ureterectomy, which was completed by open laparotomy. He died in hospital on 8 September 2015; the inquest concluded that misadventure contributed to by neglect contributed to his death. The principal concern was that illegible clinical records or incomplete important documents could cause communication breakdown and misinformation in a patient’s care pathway.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete important clinical documents
Wider context from the report “Illegible clinical records and/or a failure to complete important documents creates a serious risk of a breakdown in communication and misinformation within a patient’s care pathway.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Illegible clinical records
Wider context from the report “Illegible clinical records and/or a failure to complete important documents creates a serious risk of a breakdown in communication and misinformation within a patient’s care pathway.
” 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 Undertake monthly live spot audits of 30 inpatient records to improve written record quality and communication.
Verbatim wording from the response “In the meantime we will continue to endeavour to improve written records and communication by undertaking monthly ‘live’ spot audits, of 30 records per audit, relating to inpatients on our wards.” Source location 2016-0186-Response-by-Stockport-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 Complete the rollout of the TrakCare electronic patient record system to consolidate patient information and prevent incomplete or illegible records.
Verbatim wording from the response “The Trust is currently in the process of installing an electronic patient record system (EPR); this is a computerised version of the entire healthcare record. Instead of hospital staff using a mixture of paper and electronic records, information will be available to them online in one place. We already use a variety of electronic systems to help staff look after our patients but the EPR will bring all this information about our patients together into one system for better and safer care.” Source location 2016-0186-Response-by-Stockport-NHS-Trust
Open published response
4 Mar 2016 Marjorie Booth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to routinely perform CT scans in circumstances where impacted or undisplaced fractures may be present 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
Marjorie Booth · 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
Marjorie Booth fell at home on 21 September 2015 and was initially discharged from hospital after an X-ray failed to identify an impacted hip fracture. The fracture was identified by CT scan the following day, but she subsequently deteriorated and died on 19 October 2015; the report raises concern about the apparent policy of not routinely performing CT scans in such circumstances.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely perform CT scans in circumstances where impacted or undisplaced fractures may be present
Wider context from the report “1. I was told that a CT scan is not routinely asked for in these circumstances , even though it is really the only way to be sure that there is no impacted or un-displaced fracture , because of the risk of exposing the patient to additional levels of radiation. The doctor giving this evidence agreed with me that the minimal risk of the radiation (in a patient over 90 years old) did not compare with the considerable risk of missing such fractures.
2. Can the Trust explain why there is apparently a policy not to perform scans in such circumstances and whether in fact this policy could be amended.
” Open source report
28 Feb 2016 Antony Edmund Briggs · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure of Buxton local GPs to act on unavailable urologist information View source Failure to make Buxton urology test results viewable at Stepping Hill 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
Antony Edmund Briggs · 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
Antony Edmund Briggs developed a very aggressive bladder tumour, with delays in treatment; the inquest recorded natural causes and a medical cause involving pulmonary embolism, deep venous thrombosis, immobility and pelvic obstruction due to bladder carcinoma, with ischaemic heart disease. Concerns included differences between the Buxton and Stepping Hill information systems, failure of information to be acted on, and the infiltrating adenocarcinoma not being identified as soon as it could have been.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Buxton local GPs to act on unavailable urologist information
Wider context from the report “1. The “system” which operates at Buxton is different from that at Stepping Hill Hospital, and therefore he cannot look at the test results on his screen at Stepping Hill.
2. The urologists see patients at Stockport, Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to be viewable at Stepping Hill, save and except for Buxton.
3. When the Urologist’s view is not available on screen at Stepping Hill, it should, apparently, fail to the Local GP's in Buxton to act on the information, but they either cannot or do not, thus the patient falls into a lacuna and no action is pursued. This is always of importance, but especially so with a very aggressive malignancy.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make Buxton urology test results viewable at Stepping Hill
Wider context from the report “1. The “system” which operates at Buxton is different from that at Stepping Hill Hospital, and therefore he cannot look at the test results on his screen at Stepping Hill.
2. The urologists see patients at Stockport, Tameside, Macclesfield and Buxton. At all of these locations, the data can be input so as to be viewable at Stepping Hill, save and except for Buxton.
3. When the Urologist’s view is not available on screen at Stepping Hill, it should, apparently, fail to the Local GP's in Buxton to act on the information, but they either cannot or do not, thus the patient falls into a lacuna and no action is pursued. This is always of importance, but especially so with a very aggressive malignancy.
” Open source report
23 Feb 2016 Freda Weston · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Insufficient nursing staffing capacity View source Failure to allow sufficient time to assess tolerance of a newly started drug before discharge View source Failure to ensure staff knowledge and adherence to IBleep escalation guidelines View source Failure to retain ward handover sheets for reference View source Delays in administering prescribed antibiotics View source Insufficient medical staffing capacity for patient review View source Failure to provide precise drug and potential side-effect information when dispensing medication 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
Freda Weston · 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 Weston was treated for septic arthritis in a replacement knee and died in hospital on 29 April 2015. The report states that Septrin led to disseminated intravascular coagulation and identifies concerns including delays in antibiotics, insufficient time to assess whether the new drug suited her, inadequate staffing, and failures in communication and escalation procedures.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staffing capacity
Wider context from the report “7. There was an acknowledged shortage of nurses at the 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allow sufficient time to assess tolerance of a newly started drug before discharge
Wider context from the report “1. She was discharged from hospital after being started on the Septrin without allowing sufficient time to ensure that the new drug “suited” her .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff knowledge and adherence to IBleep escalation guidelines
Wider context from the report “6. The “Escalation guidelines for the IBleep system were either unknown to the staff or were not adhered to .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain ward handover sheets for reference
Wider context from the report “9. The handover sheets on the ward are “shredded by the nurses” immediately after handover . Why cannot these be kept in a folder on the ward for at least 14 days should they be needed for reference purposes? I was told of the transition from paper to electronic notes. This seems to have been happening for a very long time and one wonders when it will be complete.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in administering prescribed antibiotics
Wider context from the report “2. She was advised for teicoplanin on the 8th April at 17.10 hours yet she had not even been given the first dose thereof by 15.56 hours on the 9th April .
3. There was a 48 hour delay in her being given any antibiotics .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical staffing capacity for patient review
Wider context from the report “4. The junior doctor gave evidence that s/he was unable to “get round to seeing” this patient as there was insufficient doctor-time to do so on that shift . The doctor went on to say “this is not an uncommon situation”. The hospital as a whole was being covered by one FY1 doctor and two SHO’s , one of whom was “clerking in” the new patients. This meant that the FY1 was covering 13 wards of the hospital . Clearly an impossible task .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide precise drug and potential side-effect information when dispensing medication
Wider context from the report “8. The pharmacy staff did not give precise details of the drug which they were dispensing and the potential side effects thereof .
” 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 Recruit additional nursing staff, including European and international registered nurses, through quarterly cohorts to increase Medicine Business Group capacity.
Verbatim wording from the response “Nursing staff levels has been a concern, particular within the Medicine Business Group over the last 18 months. I can confirm that we are actively recruiting to nursing posts within the Trust. We are also proactively recruiting European and International nurses as part of our 5 year plan.” Source location Weston-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 Update and approve the iBleep escalation procedure to specify escalation by staff placing calls and reinforce registered-nurse judgement and frequent escalation.
Verbatim wording from the response “Please see enclosed the current standard operating procedure for the Escalation of iBleep jobs which is to be used by the iBleep Co-ordinator. This guides the staff monitoring the iBleep system to escalate to senior staff as and when required.” Source location Weston-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 Provide patient information leaflets for each medicine supplied in monitored dosage systems, including generic medicine information and access to drug advice.
Verbatim wording from the response “Patients who are discharged with their medicines supplied in a monitored dosage system will have a Patient Information Leaflet supplied with the dosage system for each medicine” Source location Weston-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 Provide electronic handover access across Medicine Business Group wards, enabling retrospective access to patient handover information.
Verbatim wording from the response “I can confirm that all wards in the Medicine Business Group have access to an electronic handover. Staff print these for each shift so they can be viewed as they move around the wards. The handover sheets are shredded at the end of each shift to make sure information is not taken home by staff, which would compromise patient confidentiality and make sure that incorrect information is not used on the ward. The information, per patient, can be accessed electronically retrospectively.” Source location Weston-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 Intravenous antibiotics were not indicated during the 48-hour period because the patient was clinically well and revision surgery was not planned.
Verbatim wording from the response “In Mrs Weston’s case she was clinically well, showing no signs of generalised sepsis and therefore giving intravenous antibiotics would have had no clear benefit for her at that time. ████████ had already ruled out the option of revision surgery and therefore the Trauma and Orthopaedic registrar made the decision to withhold intravenous antibiotic treatment until a definitive long term plan had been discussed with ████████ the outcome of which was likely to involve a joint washout to reduce the microbial load followed by long term oral antibiotics. ████████ Consultant Orthopaedic Surgeon, confirmed this plan with ████████ the following day and clearly documented that IV antibiotics were not indicated, as the plan was for washout followed by long term infection suppression with oral antibiotics and that IV antibiotics would only be indicated if Mrs Weston became clinically unwell.” Source location Weston-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 Electronic handover records can be accessed retrospectively, so retaining shredded paper handover sheets is unnecessary and risks confidentiality and outdated information.
Verbatim wording from the response “9) The handover sheets on the ward are “shredded by the nurses” immediately after handover. Why cannot these be kept in a folder on the ward for at least 14 days should they be needed for reference purposes? I was told of the transition from paper to electronic notes. This seems to have been happening for a very long time and one wonders when it will be complete.” Source location Weston-Response
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 Patient information leaflets supplied with monitored medicines provide drug and side-effect information, supplemented by generic medicine leaflets.
Verbatim wording from the response “Patients who are discharged with their medicines supplied in a monitored dosage system will have a Patient Information Leaflet supplied with the dosage system for each medicine” Source location Weston-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 Out-of-hours staffing arrangements, including prioritisation and access to senior clinicians, were considered adequate for urgent reviews and emergencies.
Verbatim wording from the response “There is no on-call national guidance with regards to staffing numbers and broadly the total number of on-call doctors in Stepping Hill Hospital is the same for most district general hospitals of a similar size. Out of hours on-call work is primarily for urgent reviews and emergencies.” Source location Weston-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 The Trust considers post-initiation hospital observation unnecessary because serious Septrin adverse events are more likely after prolonged treatment.
Verbatim wording from the response “The Surgical and Critical Care Team do not feel that a period of observation in hospital after starting Septrin would be beneficial, as the most serious adverse events that can occur while taking Septrin are more likely to occur after being on Septrin for a more prolonged period. The advice recommended by the various manufacturers of Septrin is to monitor the patient’s blood results monthly, therefore the Trust will continue to abide by this recommendation. Notwithstanding this, Mrs Weston remained on the ward for a further week, prior to her discharge on 22 April 2015 and was well at the time of discharge.” Source location Weston-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 The patient did not receive Teicoplanin during this admission; oral Doxycycline followed the subsequent knee washout.
Verbatim wording from the response “On 8th April our Microbiology department contacted the Trauma and Orthopaedic registrar to advise that the aspirate taken from the knee was growing an organism, although they were unclear as to what the organism was. They therefore recommended to the registrar that the patient be given intravenous Teicoplanin (as they normally would for an infected joint).” Source location Weston-Response
Open published response
20 Jan 2016 Steven Leslie Rogers · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to administer prescribed long-acting insulin as scheduled View source Failure to assess patients and ensure medical and social factors are in place before discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven Leslie Rogers · 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
Steven Leslie Rogers was admitted to Stepping Hill Hospital on 20 August 2015 with reduced consciousness and confusion and a history of unstable type 1 diabetes. His long-acting Levemir insulin was accidentally omitted during his admission, and he was discharged by a consultant who had not seen him; he was found dead at home two days later, having died from diabetic keto-acidosis. The substantive concerns were the discharge process and the omission and subsequent alteration of his insulin regimen.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed long-acting insulin as scheduled
Wider context from the report “2. During his stay in the hospital, the staff had erroneously omitted to administer his Levemir long acting insulin . This was then given later but this meant that his regime had been altered and he would have to re-set the regime 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess patients and ensure medical and social factors are in place before discharge
Wider context from the report “1. The doctor who discharged the patient from the hospital as being “medically fit for discharge” did so without ever seeing the patient . In his statement to the inquest he says “I am afraid I have never seen Mr Rogers.......... he was seen by two consultant colleagues........... I was asked if he could go home by one of the nurses.....was shown the notes ..... asked the nurse to follow the team’s pre-arranged plan i.e. to discharge the patient. It is noted that Mr Rogers went home by bus”. The fact that a doctor not only discharges a patient in this way but also has no compunction in saying that he has done so in a statement to a Coroner, suggests a fundamental lack of understanding as to the importance of ensuring that all factors are in place for discharge, including medical and social issues .
” 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 Review the medication-chart interface problem and develop an effective interim solution through the specialist Task and Finish Group.
Verbatim wording from the response “A risk assessment is already in place within the Trust regarding this issue and staff are reminded on all wards to check for any paper charts. The Trust is moving towards a Trust wide electronic patient record (EPR) which should resolve this issue, but in the meantime, I can confirm that there is a specialist “Task & Finish Group” in place to further review this issue and develop an effective interim solution. This group reports to the Trust’s Risk Management Committee and through this to the Quality Governance Committee and the Quality Assurance Committee, which reports directly to the Board of Directors.” Source location Steven-Rogers-Response
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 Establish a specialist Task and Finish Group to oversee the interim medication-chart solution.
Verbatim wording from the response “A risk assessment is already in place within the Trust regarding this issue and staff are reminded on all wards to check for any paper charts. The Trust is moving towards a Trust wide electronic patient record (EPR) which should resolve this issue, but in the meantime, I can confirm that there is a specialist “Task & Finish Group” in place to further review this issue and develop an effective interim solution. This group reports to the Trust’s Risk Management Committee and through this to the Quality Governance Committee and the Quality Assurance Committee, which reports directly to the Board of Directors.” Source location Steven-Rogers-Response
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 consultant-led written discharge plan was followed, providing sufficient arrangements for discharge despite the discharging doctor not personally seeing the patient.
Verbatim wording from the response “It is normal practice for all patients to have a written plan by a consultant in relation to their discharge.” Source location Steven-Rogers-Response
Open published response
19 Jan 2016 Irene Anne Pearson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to define the terms “prolonged” and “hot” in the hot-bath warning View source Failure to reconcile prescribed opiate patches with the patient’s actual possession View source Failure to maintain clear and sufficiently detailed electronic clinical notes View source Failure to provide a full report of the patient’s care View source Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches View source Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch View source Lack of liaison with the GP Practice over regulation of additional opiate pain-control 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
Irene Anne Pearson · 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
Irene Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to define the terms “prolonged” and “hot” in the hot-bath warning
Wider context from the report “2. Even when the said warning phrase is reached in the leaflet, it then refers to “a prolonged hot bath” without in any way defining the words “prolonged” or “hot”. These terms are easily open to subjective interpretation, which may lead to an unsafe usage environment. (Takeda UK)
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile prescribed opiate patches with the patient’s actual possession
Wider context from the report “5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain clear and sufficiently detailed electronic clinical notes
Wider context from the report “5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a full report of the patient’s care
Wider context from the report “6. When HM Coroner asks for a full report of the care of the patient from the General Practitioner, it is insufficient (as in this case), for the practice simply to photocopy part of the patient’s records. (Churchgate 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Provision of potentially dangerous bath-removal advice for exhausted Matrifen patches
Wider context from the report “3. I heard evidence that the Macmillan Nurses had advised the deceased to take a bath when preparing to remove the ‘exhausted’ patch so as to aid removal. The toxicologist point out that even when due for changing the patch contains (and therefore can release) a very considerable level of the drug. The advice to use this method of removal would therefore be inherently potentially dangerous. (Macmillan Cancer Care)
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prominently communicate the danger of taking a hot bath whilst wearing the patch
Wider context from the report “1. The package leaflet of advice on the use of Matrifen is very extensive running to several pages of closely printed words. It is not until half way down the eighth page (and then contained in the middle of a 4th bullet point) that there is reference to the danger of taking a hot bath whilst wearing the patch. The Forensic Consultant Toxicologist gave evidence to me that heating of the body will cause an onrush of the delivery of the drug. (Takeda UK)
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of liaison with the GP Practice over regulation of additional opiate pain-control
Wider context from the report “4. I was told that the Macmillan Nurses will prescribe additional opiate pain-control, but there seemed little or no liaison with the GP Practice as to the regulation of this. (Macmillan Cancer Care)
” 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 Disseminate a Trust Alert to hospital and community staff reminding them not to submerge fentanyl patches or advise bathing for removal.
Verbatim wording from the response “The Macmillan team have provided assurance that they would not advise anyone to take a bath to aid removal of an exhausted patch or indeed to submerge the patch in water. In response to the information you have shared we have sent a ‘Trust Alert’ out to all hospital and community staff to ensure they are reminded of this risk.” Source location I-Pearson-Response2
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 faxing practice within 24 hours and GP record scanning are considered sufficient liaison for medication changes.
Verbatim wording from the response “I was told that the Macmillan Nurses will prescribe additional opiate pain control, but there seemed little or no liaison with the GP Practice as to the regulation of this.” Source location I-Pearson-Response2
Open published response
27 Aug 2015 Frederick Sutton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to read nursing notes accurately View source Lack of nursing and medical staff understanding of cardiac-arrest response View source Lack of staff training in prescribed-drug administration View source Failure to understand or implement staff-shortage escalation procedures View source Failure to maintain accurate next-of-kin information View source Failure of Emergency Department and hospital note-keeping systems to interoperate View source Insufficient hospital staffing levels 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
Frederick Sutton · 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
Frederick Sutton fell and broke his hip at home on 3 February 2015, may have suffered a myocardial infarction, and died approximately 12 hours after admission to hospital. The concerns included hospital staffing levels, escalation procedures, failures to read nursing notes, incompatible computerised record systems, inadequate staff training, response to cardiac arrest, medication administration, and inaccurate next-of-kin information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to read nursing notes accurately
Wider context from the report “(3) There was clear evidence that a nurse had failed to read (or read properly) the nursing 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of nursing and medical staff understanding of cardiac-arrest response
Wider context from the report “(5) The patient required the administration of cyclizane and there was an obvious problem with the (lack of) training of the staff in this regard.
(6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to .
(7) There seemed to be a lack of training amongst the staff as to the administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training in prescribed-drug administration
Wider context from the report “(5) The patient required the administration of cyclizane and there was an obvious problem with the (lack of) training of the staff in this regard .
(6) The patient suffered a cardiac arrest and there was a lack of understanding amongst nursing and medical staff as to how this ought to have been responded to.
(7) There seemed to be a lack of training amongst the staff as to the administration of certain prescribed drugs, both as to the appropriate amount thereof and the method of delivery .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand or implement staff-shortage escalation procedures
Wider context from the report “(2) Whilst there is a procedure for escalation of the shortage of staff , this was either not fully understood or not properly put into effect .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate next-of-kin information
Wider context from the report “(8) There was a general lack of care as to the accuracy of the information held by the hospital as to next-of-kin details , where the wife of the deceased was shown as n.o.k when in fact she had died in 2008 .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Emergency Department and hospital note-keeping systems to interoperate
Wider context from the report “(4) The computerised note keeping system used in the Emergency Department is not able to “talk to” the system which covers the rest of the hospital .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient hospital staffing levels
Wider context from the report “(1) The staffing levels in the hospital during his stay seemed to be less than optimal .
” Open source report
23 Mar 2015 Pamela Pattison · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Failure of nurses to recognise and escalate deteriorating diabetic care View source Failure of doctors in training to administer every dose of long-acting insulin View source Failure to ensure staff access to and knowledge of required cardiac monitoring equipment View source Delays in transferring patients to the appropriate ward View source Failure to provide specialist diabetes outreach cover during absence View source Under-resourcing of diabetes care View source Unavailability of specialist diabetes outreach nurse advice View source Deficient nurse training on Type 1 Diabetes View source Unavailability of additional diabetes consultant cover View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Pamela Pattison · 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
Pamela Pattison was admitted to hospital after falling at home and fracturing her hip. Her insulin was intentionally omitted following a mistaken assessment, and concerns were raised about sub-optimal diabetic care, inadequate staff training and escalation, insufficient specialist diabetes support, equipment and resourcing problems, and delay in transferring her to an appropriate ward. The medical cause of death was recorded as aspiration pneumonia following nausea and vomiting consequent upon unstable diabetic control, with brittle diabetes and a fractured neck of femur also recorded.
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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nurses to recognise and escalate deteriorating diabetic care
Wider context from the report “1. From the evidence it was apparent that nurse training on wards M4 and A11 was deficient and their understanding of the importance and danger of Type 1 Diabetes seemed to be limited at best. The nurses were unable to say why they had not escalated her care on a number of occasions .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of doctors in training to administer every dose of long-acting insulin
Wider context from the report “2. ALL the doctors in training need to be aware that they should not omit any dose of 'long-acting insulin' . The consultant expressed the 'hope' that they would know this, but the evidence suggested the contrary .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff access to and knowledge of required cardiac monitoring equipment
Wider context from the report “6. There was either a lack of equipment or a lack of understanding by the staff as to what equipment was needed by them . The staff indicated that they were unable to find 'ketone dipsticks', for diabetic urine sampling. I was told that in fact these are unnecessary in that ketone blood tests are now routine. Similarly I was told they could not find any or sufficient cardiac monitors on the ward . Further evidence revealed there are in excess of 240 such monitors in the hospital but the relevant staff seemed unaware of this . They were also unaware that they could have used the ward based defibrillator for the same purpose .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients to the appropriate ward
Wider context from the report “7. There was a considerable delay of approximately 12 hours in moving her to ward A3 after she had been deemed the appropriate place for her to be . No reason for this delay was offered.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide specialist diabetes outreach cover during absence
Wider context from the report “5. The specialist outreach Nurse Practitioner for diabetes was booked off sick for one month, and no 'cover' was in place to cover his absence .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Under-resourcing of diabetes care
Wider context from the report “8. It was conceded by the ‘Head of Risk’ for the Trust, that there was a general under resourcing within the Trust for the care of patients with Diabetes .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist diabetes outreach nurse advice
Wider context from the report “3. It was evident that the nursing staff on, for example, the surgical wards, did not have any specialist outreach nurse advice on such things as diabetes .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficient nurse training on Type 1 Diabetes
Wider context from the report “1. From the evidence it was apparent that nurse training on wards M4 and A11 was deficient and their understanding of the importance and danger of Type 1 Diabetes seemed to be limited at best . The nurses were unable to say why they had not escalated her care on a number of occasions.
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of additional diabetes consultant cover
Wider context from the report “4. There was an obvious need for additional consultant cover for Diabetes . I was told that funding has been put in place to cover this, but as yet no one has been appointed to fulfil this vital role .
” 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 Commission and complete a diabetes-care Task and Finish Group review, producing an approved action plan.
Verbatim wording from the response “One of our most important actions was the internal commissioning of a “Task and Finish Group” whose remit was “to review the current situation regarding diabetes care to ensure safe and ████████ for all patients with diabetes in hospital”. This was chaired by ████████ Head of Risk and Customer Services, and included senior medical staff, experienced diabetes specialists (both nursing and medical) and senior nurses from across the Trust. I understand the action plan from this group was also shared with you during the inquest.” Source location 2015-0108-Stockport-NHS-Trust
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 Put a sickness-cover and backfill plan in place for the specialist outreach nurse post.
Verbatim wording from the response “This planned sickness had been identified and the manager recognised the need for additional cover and backfill for this post. A plan had been put in place to commence on the 27th January 2014, which is sadly the day Mrs Pattison died.” Source location 2015-0108-Stockport-NHS-Trust
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 Amend the Trust Training Needs Analysis to require diabetes training for nurses and doctors.
Verbatim wording from the response “a. The Trust Training Needs Analysis (TNA) has been amended to include diabetes training as an essential requirement for all nurses and doctors (see below).” Source location 2015-0108-Stockport-NHS-Trust
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 Purchase and incorporate an NHS England-recommended diabetes e-learning module into the Training Needs Analysis.
Verbatim wording from the response “b. An E-Learning module has been purchased by the Trust (one recommended by NHS England) completion of which is included in the TNA.” Source location 2015-0108-Stockport-NHS-Trust
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 Improve the Diabetes Microsite and increase availability of Diabetes Specialist Nurses to support diabetes management.
Verbatim wording from the response “Ensuring that all doctors are aware of the appropriate management of diabetes has been addressed both by training (see above) and by an improved ‘Diabetes Microsite’ and improved availability of Diabetes Specialist Nurses.” Source location 2015-0108-Stockport-NHS-Trust
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 Deliver bespoke diabetes-care training to nursing staff on wards M4 and A11.
Verbatim wording from the response “c. Bespoke training has been delivered to nursing staff on both M4 and A11 in the care of diabetic patients.” Source location 2015-0108-Stockport-NHS-Trust
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 Identify ward link nurses and provide specialist training so they can deliver local diabetes training.
Verbatim wording from the response “Nurses/Midwives/Allied Health Professionals, Assistant Practitioners, Clinical Community Professionals (See key below): Covered on Essentials for all. Registered Nurses and Midwives and all APs also to complete module ‘Safe use of insulin’ 3 yearly. Tool box training by link nurses – annually” Source location 2015-0108-Stockport-NHS-Trust
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 specialist insulin-prescribing and diabetes-management training to medical staff when they commence.
Verbatim wording from the response “Medical staff in training: On bespoke induction and complete eLearning module for ‘Safe use of insulin’ every three years” Source location 2015-0108-Stockport-NHS-Trust
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 Add diabetes and insulin management to mandatory three-yearly Essentials training for all staff.
Verbatim wording from the response “d. ‘Essentials’ training (that which is mandatory for all staff every three years) now includes a session on diabetes and insulin management.” Source location 2015-0108-Stockport-NHS-Trust
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 Review the Capacity and Flow Escalation Policy to define bed-allocation prioritisation based on clinical need.
Verbatim wording from the response “However the bed management team are aware that they need to balance priority of bed allocation based on clinical needs of all patients regardless of their location and any concerns could have been raised through the appropriate out of hours’ management structure. The Trust is in the process of reviewing its Capacity and Flow Escalation Policy which will reflect the bed allocation prioritisation process.” Source location 2015-0108-Stockport-NHS-Trust
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 Implement an electronic inpatient referral form for requesting diabetes review and support across wards.
Verbatim wording from the response “The Trust has also implemented an electronic inpatient referral form for patients needing review, which provides a more robust method for all ward areas to request help or support in managing patients with diabetes.” Source location 2015-0108-Stockport-NHS-Trust
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 additional consultant diabetes cover through an agency locum and a Consultant of the Week model.
Verbatim wording from the response “An agreement was reached to expand the consultant cover within Diabetes & Endocrinology in July 2014. This subsequently went out to advert but unfortunately we have failed to recruit on” Source location 2015-0108-Stockport-NHS-Trust
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 Design bespoke diabetes training for senior nurses covering night and out-of-hours care, and begin its delivery.
Verbatim wording from the response “Diabetes management advice: Bespoke training session; Hospital and night nurses and those undertaking professional cover; N/A; N/A; N/A” Source location 2015-0108-Stockport-NHS-Trust
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 Appoint an additional Diabetes Specialist Nurse and a Diabetes Practice Educator to support the whole Trust.
Verbatim wording from the response “Since this incident there has been a merger of community and hospital teams and the appointment of a further Diabetes Specialist Nurse and a Diabetes Practice Educator, who support the whole Trust.” Source location 2015-0108-Stockport-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 Orthopaedic wards need not provide cardiac monitoring because patients requiring it can be transferred to wards with appropriately trained staff.
Verbatim wording from the response “b. Cardiac monitors/ward defibrillator
Cardiac monitors are available on the diabetes speciality ward. It is accepted that there were none available for the orthopaedic ward; staff on these wards are not trained to interpret the output from a cardiac monitor so the most appropriate course of action would be to transfer those patients requiring cardiac monitoring to a ward where staff are trained to interpret and respond to the output from a cardiac monitor. In this instance the plan was to move Mrs Pattison as soon as possible; unfortunately this was not as timely as I would have hoped. This matter should then have been escalated through the appropriate out of hours’ management structure to ensure that her move was facilitated as soon as possible.” Source location 2015-0108-Stockport-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 A sickness-cover plan for the specialist outreach nurse had already been put in place before the patient's death.
Verbatim wording from the response “This planned sickness had been identified and the manager recognised the need for additional cover and backfill for this post. A plan had been put in place to commence on the 27th January 2014, which is sadly the day Mrs Pattison died.” Source location 2015-0108-Stockport-NHS-Trust
Open published response
11 Mar 2015 Neil Thomas Westerman · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to record and account for equipment and materials used during procedures View source Insufficient junior doctor staffing to cover patient needs View source Failure to ensure the operating consultant is informed of vital information during pre-operative assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Neil Thomas Westerman · 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 Thomas Westerman attended Stepping Hill Hospital for an elective cholecystectomy on 2 July 2014, after which a bile leak caused septicaemia. Concerns included the pre-operative assessment being conducted by a junior doctor, incomplete operation notes about equipment and materials, and insufficient junior doctors available in practice, particularly at night.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and account for equipment and materials used during procedures
Wider context from the report “2. The operation notes did not contain details of the equipment and materials used during the procedure and it was agreed that this should be the case and that all such items should be fully recorded and accounted for at the conclusion of the procedure.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient junior doctor staffing to cover patient needs
Wider context from the report “3. I heard evidence, as I have on previous occasions, that there were simply too few junior doctors on duty to cover the needs of the patients, especially at night . It was not suggested that the numbers were not in compliance with the set guidelines, but rather that in practice there simply weren’t enough doctors available .
” 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 Stockport NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the operating consultant is informed of vital information during pre-operative assessment
Wider context from the report “1. During the course of the inquest I heard evidence that the pre-operative assessment was performed by a junior doctor and not by the consultant who was to perform the procedure . This meant that the consultant was unaware of certain vital information .
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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 Take steps with the operating surgeon to prevent recurrence of consultant-unaware pre-operative assessment.
Verbatim wording from the response “A concern regarding the pre-operative assessment being carried out by a junior doctor and not the consultant who was to perform the operation, meaning the consultant was unaware of vital information.
This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation. The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment.” Source location 2015-0091-Response-by-Stockport-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 Consider broadening advanced nurse practitioner roles to undertake basic junior doctor duties.
Verbatim wording from the response “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients.
We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.” Source location 2015-0091-Response-by-Stockport-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 Reiterate across Surgery and Critical Care the requirement to record equipment and material details in operative notes.
Verbatim wording from the response “The operating notes did not contain details of the equipment and materials used during the procedure.
In this case this was an error; it is standard practice to document and record all relevant information for the related surgery, including the recording of equipment and the numbers of items used. In this case there was clearly an omission to record such details and the requirement for vigilance in this respect has been reiterated across the Surgery and Critical Care Business Group.” Source location 2015-0091-Response-by-Stockport-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 Discuss the case at General Surgery Morbidity and Mortality meetings and with the assessing junior doctor.
Verbatim wording from the response “A concern regarding the pre-operative assessment being carried out by a junior doctor and not the consultant who was to perform the operation, meaning the consultant was unaware of vital information.
This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation. The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment.” Source location 2015-0091-Response-by-Stockport-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 Review general surgical junior doctor rotas, including surgical assessment unit presence and distribution across the working week.
Verbatim wording from the response “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients.
We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.” Source location 2015-0091-Response-by-Stockport-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 Increase junior doctor presence on the surgical assessment unit and distribute doctors more evenly across the working week.
Verbatim wording from the response “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients.
We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.” Source location 2015-0091-Response-by-Stockport-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 Junior doctors conducting pre-operative assessments is not standard organisational practice and was unique to the operating surgeon concerned.
Verbatim wording from the response “A concern regarding the pre-operative assessment being carried out by a junior doctor and not the consultant who was to perform the operation, meaning the consultant was unaware of vital information.
This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation. The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment.” Source location 2015-0091-Response-by-Stockport-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 Omitting equipment and material details from operating notes was an error; standard practice requires recording all relevant surgical information.
Verbatim wording from the response “The operating notes did not contain details of the equipment and materials used during the procedure.
In this case this was an error; it is standard practice to document and record all relevant information for the related surgery, including the recording of equipment and the numbers of items used. In this case there was clearly an omission to record such details and the requirement for vigilance in this respect has been reiterated across the Surgery and Critical Care Business Group.” Source location 2015-0091-Response-by-Stockport-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