29 Jan 2015 John Michael Matthews · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to provide the doctor with access to the complete computerised system View source Failure to make the PRF available to the doctor providing emergency care View source Failure to institute neurological observations View source Failure to make the ambulance Patient Report Form available to the triage nurse before triage View source Delays in sending patients for a head CT scan View source See 2 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
John Michael Matthews · 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 Michael Matthews died from natural causes, with the medical cause recorded as aspiration pneumonia associated with haemorrhagic hydrocephalus and spontaneous subarachnoid haemorrhage. Concerns included triage without the ambulance Patient Report Form, a locum doctor’s inability to access the complete computerised system, failure to institute neurological observations, and an unnecessary and partly unexplained delay in obtaining a head CT scan.
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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 provide the doctor with access to the complete computerised system
Wider context from the report “2. The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system .
” 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 the PRF available to the doctor providing emergency care
Wider context from the report “2. The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system.
” 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 institute neurological observations
Wider context from the report “3. It was agreed by the ED consultant giving evidence that neurological observations ought to have been instituted, but they were not .
” 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 the ambulance Patient Report Form available to the triage nurse before triage
Wider context from the report “1. Whilst in the Emergency Department at Stepping Hill Hospital, he was triaged without the triage nurse having seen the ambulance Patient Report Form .
” 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 sending patients for a head CT scan
Wider context from the report “4. There was an unnecessary and to some extent unexplained delay in sending him for a CT scan of his head .
” 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 learning about vital information handover and neurological observations through meetings, safety huddles and the ED Quality Newsletter.
Verbatim wording from the response “The ED Matron has re-iterated to all nursing staff that vital information must be passed on to the doctors. This has formally been discussed in the sisters’ meeting and at safety huddles. Safety Huddles are times when nurses and doctors meet for handover at the beginning or end of each shift. At these times information is shared about current patients along with any specific department information or to highlight any learning identified following investigations into incidents or complaints. Neurological observation needs have been discussed during these safety huddles, at Sisters’ meetings and shared within the ED Quality Newsletter which is sent to all ED staff.” Source location 2015-0034-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 Institute ED checklists preventing patients from leaving before requested investigations and treatments are completed.
Verbatim wording from the response “For the future, to avoid a reoccurrence of this incident, we have instituted a system of checklists whereby a patient cannot leave the ED without all the investigations and treatments being completed. The investigations requested are clearly shown on Advantis ED therefore the nurse caring for the patient and the shift co-ordinator will be aware of investigations requested.” Source location 2015-0034-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 The ambulance information system worked: the PRF was scanned before the doctor assessed the patient.
Verbatim wording from the response “In his statement to you, ████████ states that “Paramedic notes were not available to me.” What is clear on review of the events is that the triage nurse received a verbal handover as per usual practice. A review of the electronic system has been undertaken which shows that the ambulance document (PRF) was scanned and was added to the system within 13 minutes of arrival and ten minutes prior to the doctor seeing the patient so it is apparent that the system in place to link the paper document with the electronic document worked. I am unable to explain why the locum doctor did not review this information but am assured he was given the training to enable him to do so.” Source location 2015-0034-Response-by-Stockport-NHS-Trust
Open published response
9 Sep 2014 ROSALIND ANN ADSHEAD · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Insufficient ambulance availability during normal working hours View source Failure to avoid transferring severely ill patients in the early hours of the morning View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
ROSALIND ANN ADSHEAD · 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
Rosalind Ann Adshead had previously undergone a total gastrectomy and was later found to have severe adhesions causing strictures. During treatment for an anastomotic leak, she was transferred between hospitals in the early hours of 21 March 2014 while severely ill. Concern was raised that the timing of the transfer was unsafe and added anxiety and distress, and that ambulance shortages during normal working hours were not a valid justification.
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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 Insufficient ambulance availability during normal working hours
Wider context from the report “During the course of her treatment at Stepping Hill Hospital it was considered that she needed to be moved to Manchester Royal Infirmary for her further care. She had developed an anastomotic leak from the site of the operation and needed to have a covered oesophageal stent to block the leak. She was a very severely ill lady at this stage, yet the move between hospitals took place in the very early hours of the 21st March 2014. The consultant surgeon into whose care she was transferred told me in evidence that “it is not safe to transfer such a patient in the early hours of the morning”, that the transfer at this time “did add to the anxiety and distress in the middle of the night” and that “the shortage of ambulances in the normal working day is not a valid excuse” .
” 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 avoid transferring severely ill patients in the early hours of the morning
Wider context from the report “During the course of her treatment at Stepping Hill Hospital it was considered that she needed to be moved to Manchester Royal Infirmary for her further care. She had developed an anastomotic leak from the site of the operation and needed to have a covered oesophageal stent to block the leak. She was a very severely ill lady at this stage, yet the move between hospitals took place in the very early hours of the 21st March 2014. The consultant surgeon into whose care she was transferred told me in evidence that “it is not safe to transfer such a patient in the early hours of the morning” , that the transfer at this time “did add to the anxiety and distress in the middle of the night” and that “the shortage of ambulances in the normal working day is not a valid excuse”.
” Open source report
15 May 2014 Gary Bradshaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 12 Incomprehensive and inefficient hospital notes View source Misinterpretation of blood or urine test results communicated to the General Practitioner View source Discharge before completion of full investigations View source Prescribing and administering Bendroflumethiazide before blood test results were known View source Subjective interpretation of Early Warning Scores View source Failure of the laboratory to flag blood-calcium levels from 3.0mmol/l View source Failure to keep fluid balance charts properly View source Failure of the electronic system to reveal notes of a previous admission View source Failure to consider referral to an endocrine surgeon View source Delay in initial diagnosis of kidney stones View source Failure of ward-to-ITU patient escalation View source Failure to complete or report ordered blood tests View source See 9 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
Gary Bradshaw · 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
Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.
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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 Incomprehensive and inefficient hospital notes
Wider context from the report “10. Hospital notes and especially those in the E.D. (on the ADVANTIS SYSTEM) seem to have been less than comprehensive and efficient. The emergency doctor fed the patient’s ‘number’ into the computer but it did not reveal the notes of the previous admission.(Stockport NHS Trust)
” 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 Misinterpretation of blood or urine test results communicated to the General Practitioner
Wider context from the report “4. There was a misunderstanding or misinterpretation of the results to the General Practitioner as to whether these results related to blood or urine tests .(Stockport NHS Trust)
” 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 Discharge before completion of full investigations
Wider context from the report “5. The patient was discharged from the hospital on the 27th June 2012 rather than being retained as an in-patient whilst full investigations were carried out ; again a practice which the expert witness felt to be inappropriate (Stockport NHS Trust)
” 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 Prescribing and administering Bendroflumethiazide before blood test results were known
Wider context from the report “3. The above blood tests were ordered but the patient was prescribed and administered Bendroflumethiazide before the results were known , something which the expert witness described as contra-indicated .(Stockport NHS Trust and The Secretary of State)
” 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 Subjective interpretation of Early Warning Scores
Wider context from the report “12. There seemed to have been a very subjective interpretation of the EWS at the hospital by using the ‘manual’ assessment method. I was told that an electronic version is being rolled out. I would hope that this can be sooner rather than later as it will give a far better and more objective assessment of the Early Warning Scores. (Stockport NHS Trust and The Secretary of State)
” 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 the laboratory to flag blood-calcium levels from 3.0mmol/l
Wider context from the report “8. The hospital laboratory only ‘flag-up’ the blood-calcium levels exceed 3.5mmol/l or more of serum calcium. The expert witness opined that this should occur at levels of 3.0mmol/l , and that this should be the National standard.(Stockport NHS Trust and The Secretary of State)
” 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 keep fluid balance charts properly
Wider context from the report “7. Fluid balance charts were not kept, or not kept properly , on various occasions during the in-patient stays (Stockport NHS Trust)
” 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 the electronic system to reveal notes of a previous admission
Wider context from the report “10. Hospital notes and especially those in the E.D. (on the ADVANTIS SYSTEM) seem to have been less than comprehensive and efficient. The emergency doctor fed the patient’s ‘number’ into the computer but it did not reveal the notes of the previous admission .(Stockport NHS Trust)
” 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 consider referral to an endocrine surgeon
Wider context from the report “6. During the subsequent admission on the 29th June no consideration was given to referring Mr Bradshaw to an endocrine surgeon . (Stockport NHS Trust)
” 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 Delay in initial diagnosis of kidney stones
Wider context from the report “1. There was a considerable delay in the initial diagnosis that he was suffering with kidney stones, between May 2011 and March 2012. (Stockport NHS Trust)
” 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 ward-to-ITU patient escalation
Wider context from the report “9. The system of escalation of patients from the wards to the ITU did not seem to be in place or alternatively did not seem to have worked as it ought to have done when the ward sister wanted to send the patient to the ITU (Stockport NHS Trust).
” 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 or report ordered blood tests
Wider context from the report “2. At the consultation in March 2012 both blood and urine tests were ordered but apparently only the urine tests were done and /or reported , thus his hypercalciuria was seen but not his hypercalcaemia (Stockport NHS Trust)
” 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 Enable clinicians to electronically check all outpatient tests ordered in their name.
Verbatim wording from the response “3. The above blood tests were ordered but the patient was prescribed and administered Bendroflumathiazide before the results were known, something which the expert witness described as contraindicated
████████ accepted at inquest that it should not have prescribed Bendroflumathiazide without knowing the serum calcium results and will not do so in the future. He had expected to review the results within a week and review his decision but unfortunately that did not happen as he expected.” Source location 2014-0232-Response-2
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 Introduce Patientrack alert functionality in the planned second rollout phase.
Verbatim wording from the response “12. There seemed to have been a very subjective interpretation of the EWS at the hospital by using the manual assessment method. I was told that an electronic version is being rolled out. I would hope that this can be sooner rather than later as it will give a far better and more objective assessment of the Early Warning Scores.
“Patientrack” is the electronic track and trigger system purchased by the Trust and this system generates an urgent alert to Doctors and other clinicians of potentially deteriorating patients. This system has been piloted and evaluated on one ward in the Trust and is due to be rolled out across the Trust. Phase one of the rollout, which will focus on the input of vital signs only, has commenced and is being introduced on a ward by ward basis, with the alert functionality activated in phase two, planned to commence in January 2015.” Source location 2014-0232-Response-2
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 investigation and referral for acute severe hypercalcaemia within 72 hours under revised Trust guidance.
Verbatim wording from the response “6. During the subsequent admission on the 29th June no consideration was given to referring Mr Bradshaw to an endocrine surgeon.
████████ has reviewed this question and states that all of his actions in the care of Mr Bradshaw were to prepare him for Surgery. Our Endocrine/ Parathyroid Surgeon is ████████ at Manchester Royal Hospital. ████████ had not discussed urgent surgery with ████████ as he was well aware that Mr Bradshaw would not be able to have a general anaesthetic until a myocardial infarction had been completely excluded (we were awaiting an echocardiogram). ████████ had considered possible treatment with Cinacalcet which was also mentioned by the external expert, but he had dismissed this option due to previous experience with a patient with worsening of kidney injury secondary to vomiting precipitated by this medication.” Source location 2014-0232-Response-2
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 Improve fluid-balance documentation through contemporaneous recording, two-hourly chart review during intentional rounding, and checks before shift handover.
Verbatim wording from the response “7. Fluid balance charts were not kept, or kept properly on various occasions during the in-patient stays.
A conversation has been held with the ward manager of A11 with regard to the poor documentation on the fluid balance charts. The ward manager has reiterated with her staff the importance of contemporaneous record keeping and the importance of documenting each event as it happens, i.e. each time a patient has completed / consumed a drink, IV fluids are completed or changed or a patient has passed urine.” Source location 2014-0232-Response-2
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 Include cross-disciplinary prescribing-alert capabilities in discussions of requirements with advanced electronic patient-record suppliers.
Verbatim wording from the response “11. I was told that a new electronic system of note keeping is being introduced at Stockport and throughout the NHS. I would consider it helpful if the system had a built in flag which highlighted to a doctor that he or she was prescribing drugs before the requested blood/urine test result had been received.
Electronic records have moved on considerably since 2011 for example we now have Advantis ED (The Emergency Department electronic record), EPMA (Electronic prescribing and recording of medication administration) and Advantis Ward (ward electronic records in its pilot stage). It is however not possible at present to create a flag or a rule for the circumstance as described i.e. across disciplines (Laboratory/Medication Administration). It is unlikely to be possible in the vast majority, if not all Trusts in the UK.” Source location 2014-0232-Response-2
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 Escalate serum calcium results above 3 mmol/L through Trust laboratory processes.
Verbatim wording from the response “8. The hospital laboratory only “flag up” blood results if the blood calcium levels exceed 3.5mmol/L or more of serum calcium. The expert witness opined that this should occur at levels of 3.0mmol/L and that this should be a national standard
The escalation of serum calcium levels above 3mmol/L was introduced into Trust processes in March 2014.” Source location 2014-0232-Response-2
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 Require consultants to follow up, or establish systems to follow up, every blood test and other investigation they order.
Verbatim wording from the response “Action
All consultants have been given clear instruction that it is their responsibility to ensure that they follow up, or ensure that they have systems in place to follow up, any blood tests or any other investigation that they order.” Source location 2014-0232-Response-2
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 Patientrack phase one across wards for electronic vital-sign input.
Verbatim wording from the response “12. There seemed to have been a very subjective interpretation of the EWS at the hospital by using the manual assessment method. I was told that an electronic version is being rolled out. I would hope that this can be sooner rather than later as it will give a far better and more objective assessment of the Early Warning Scores.
“Patientrack” is the electronic track and trigger system purchased by the Trust and this system generates an urgent alert to Doctors and other clinicians of potentially deteriorating patients. This system has been piloted and evaluated on one ward in the Trust and is due to be rolled out across the Trust. Phase one of the rollout, which will focus on the input of vital signs only, has commenced and is being introduced on a ward by ward basis, with the alert functionality activated in phase two, planned to commence in January 2015.” Source location 2014-0232-Response-2
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 Urgent endocrine surgery could not proceed until myocardial infarction was excluded and an echocardiogram was obtained.
Verbatim wording from the response “6. During the subsequent admission on the 29th June no consideration was given to referring Mr Bradshaw to an endocrine surgeon.
████████ has reviewed this question and states that all of his actions in the care of Mr Bradshaw were to prepare him for Surgery. Our Endocrine/ Parathyroid Surgeon is ████████ at Manchester Royal Hospital. ████████ had not discussed urgent surgery with ████████ as he was well aware that Mr Bradshaw would not be able to have a general anaesthetic until a myocardial infarction had been completely excluded (we were awaiting an echocardiogram). ████████ had considered possible treatment with Cinacalcet which was also mentioned by the external expert, but he had dismissed this option due to previous experience with a patient with worsening of kidney injury secondary to vomiting precipitated by this medication.” Source location 2014-0232-Response-2
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 cross-disciplinary electronic alert for prescribing before test results are available cannot currently be created and is unlikely across most UK trusts.
Verbatim wording from the response “11. I was told that a new electronic system of note keeping is being introduced at Stockport and throughout the NHS. I would consider it helpful if the system had a built in flag which highlighted to a doctor that he or she was prescribing drugs before the requested blood/urine test result had been received.
Electronic records have moved on considerably since 2011 for example we now have Advantis ED (The Emergency Department electronic record), EPMA (Electronic prescribing and recording of medication administration) and Advantis Ward (ward electronic records in its pilot stage). It is however not possible at present to create a flag or a rule for the circumstance as described i.e. across disciplines (Laboratory/Medication Administration). It is unlikely to be possible in the vast majority, if not all Trusts in the UK.” Source location 2014-0232-Response-2
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 hospital record system links both hospital numbers, while searching with the NHS number displays all associated records.
Verbatim wording from the response “The Advantis system has been checked to try to replicate ████████ issues: if the search is his F number Mr Bradshaw’s details appear as well as all his records under both the F number and the J number which is his actual patient number. If the search is for the J number then both the J number records and the F number records are shown.” Source location 2014-0232-Response-2
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 Discharge was considered appropriate because pain was controlled, there was no sepsis or obstruction, and a management plan existed.
Verbatim wording from the response “5. Mr Bradshaw was discharged from the hospital on the 27th June rather than being retained as an inpatient whilst full investigations were carried out; again a practice which the expert witness felt to be inappropriate.
Mr Bradshaw presented to the ED with renal colic and worsening of his kidney function; therefore the plan for that emergency admission was to control his pain and rule out urinary tract obstruction secondary to the known kidney stones as a cause of worsening of his kidney function. Mr Bradshaw had an urgent US scan of the urinary tract on the 26/6 and this showed previously known kidney stones with no evidence of hydronephrosis. The renal colic was controlled and Mr Bradshaw became symptomatically better; a management plan for the kidney stones had been made.” Source location 2014-0232-Response-2
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 clear ward-to-intensive-care escalation process existed, but no evidence showed that the Ward Sister followed it.
Verbatim wording from the response “9. The system of escalation of patients from the wards to the ITU did not seem to be in place or alternatively did not seem to have worked as it should have done when the ward sister wanted to send the patient to the ITU.
There is a clear process for the escalation of patients from wards who require Intensive Care input / transfer. If a member of staff is concerned regarding a patient’s condition that Intensive Care input is required then representation should be made to the clinical team looking after the patient. If it is agreed that such input is required then the team should make the referral in person to the on call Intensive Care team who will discuss and review the patient and make arrangements for transfer as required. During our investigations we were unable to find any evidence that the Ward Sister followed this process.” Source location 2014-0232-Response-2
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 Non-obstructing kidney stones were considered incidental and the follow-up interval was intended to assess changes affecting management.
Verbatim wording from the response “As these stones were not causing any obstruction they were deemed to be ‘incidental findings’ and were not responsible for his groin pain. It was felt important to follow up the stones but by leaving a period of time between the Ultrasound Scan and follow up, this would assist in determining whether there was any significant change in the size of the stones which would influence their management.” Source location 2014-0232-Response-2
Open published response
17 Sep 2013 Margaret Theresa CORRIGAN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to diagnose fractures in the Emergency Department View source Failure to transfer patients with medical problems from orthopaedic wards to medical teams View source Ineffective and unclear communication between medical and nursing staff View source Issuing out-patient orthopaedic clinic appointments to hospital in-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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Theresa CORRIGAN · 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
Margaret Theresa Corrigan fell at home on 18 January 2013 and fractured her odontoid peg; the inquest concluded that her death was accidental and recorded medical causes including infarction, vertebral artery dissection, peg fracture and Clostridium Difficile infection. Concerns included ineffective communication, failure to diagnose the fracture promptly, failure to transfer her to a medical team when appropriate, and issuing an outpatient orthopaedic appointment while she was an inpatient.
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 diagnose fractures in the Emergency Department
Wider context from the report “2. The patient was seen in the Emergency Department and it was agreed in evidence that the fracture ought to have been diagnosed at that time but it was not , thus meaning the patient was left for a further two days in additional pain and at risk of further spinal damage.
” 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 transfer patients with medical problems from orthopaedic wards to medical teams
Wider context from the report “3. The patient remained on the orthopaedic ward when she was suffering at that stage from medical problems and ought properly to have been transferred to a medical 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 Ineffective and unclear communication between medical and nursing staff
Wider context from the report “1. Communication between and among medical and nursing staff at your hospital was ineffective and lacked clarity.
” 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 Issuing out-patient orthopaedic clinic appointments to hospital in-patients
Wider context from the report “4. Whilst she was an in-patient in the hospital, she was issued with an out-patient appointment to attend an orthopaedic clinic.
” Open source report
17 Sep 2013 Alva JULLIEN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of communication between health professionals View source Failure to make a discharge decision 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
Alva JULLIEN · 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
Alva Jullien was admitted to hospital after a fall at home but remained there without a home assessment despite being considered medically fit for discharge. During her hospital stay she became recumbent and developed pneumonia; the inquest conclusion stated that missed opportunities during her care might have optimised her chances of survival. The principal concerns were communication and decision-making failures affecting discharge, and the decision to make her nil by mouth and place her on the Liverpool Care Pathway with, in the coroner’s view, insufficient evidence.
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 communication between health professionals
Wider context from the report “There was clear evidence at the Inquest that ████████ daughter of the deceased, was not only able but willing to look after her mother in the home environment had her mother been discharged and it seemed clear to me from the evidence on a balance of probabilities that the deceased might well have survived had she have been discharged from hospital much earlier and that this discharge did not take place simply because of a lack of communication between the various health professionals and the want of a decision for discharge being taken.
” 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 a discharge decision
Wider context from the report “There was clear evidence at the Inquest that ████████ daughter of the deceased, was not only able but willing to look after her mother in the home environment had her mother been discharged and it seemed clear to me from the evidence on a balance of probabilities that the deceased might well have survived had she have been discharged from hospital much earlier and that this discharge did not take place simply because of a lack of communication between the various health professionals and the want of a decision for discharge being taken .
” Open source report
7 Jan 2013 Andrew John Fallon · Prevention of Future Deaths report Manchester South
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Concerns raised 1 Insufficient Emergency Department staffing to manage patient volume View source
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Andrew John Fallon · 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
Andrew John Fallon was admitted to Stepping Hill Hospital on 9 November 2012 after four days of vomiting and abdominal pain, suffered a cardiac arrest later that day, and died on 15 November after severe neurological damage and withdrawal of ventilator support. Concerns included Emergency Department staffing levels, delays in treatment, and the proposed use of a primary care facility for patients with minor conditions.
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 Emergency Department staffing to manage patient volume
Wider context from the report “1. I heard evidence from the medical staff and others that the staffing levels within the Emergency Department were such that the doctors simply could not cope with the volume of work , thus leading to inordinate delays in treating the patients . I was specifically informed that there were, as is frequently the case, numerous patients at the Emergency Department with what can only be described as minor or trivial complaints.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations