Concerns raised 2 Failure of the pre-day-surgery assessment system to require questions about patients' haematological family history View source Failure of the pre-day-surgery assessment system to record negative answers about patients' own haematological history 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
Mr Marriott · 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 Marriott underwent haemorrhoidal artery ligation with mucopexy surgery as a day patient and died at home on 15 April 2024; a post-mortem found pulmonary embolism, which the evidence indicated resulted from the surgery. The pre-assessment system did not directly require questions about a patient's haematological family history or record negative answers about the patient's own haematological history.
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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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the pre-day-surgery assessment system to require questions about patients' haematological family history
Wider context from the report “The evidence was that the system which is used for assessment of patients prior to day surgery does not (a) directly require a question to be asked about their haematological family history or (b) record negative answers to the questions related to the patient's own haematological history
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the pre-day-surgery assessment system to record negative answers about patients' own haematological history
Wider context from the report “The evidence was that the system which is used for assessment of patients prior to day surgery does not (a) directly require a question to be asked about their haematological family history or (b) record negative answers to the questions related to the patient's own haematological history
” 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 Add the family-history question to the patient questionnaire through a future questionnaire-service update.
Verbatim wording from the response “The Trust has not added this question to the patient questionnaire, but this will be completed with a future update of the questionnaire service itself making the whole process easier for patients. This action will be completed by January 2026.” Source location Response from Surrey and Sussex Healthcare 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 Undertake an after-action review to identify how the gap arose and establish learning and remedial actions.
Verbatim wording from the response “In addition to these urgent clinical and administrative changes, the Trust has also undertaken an After-Action Review to ascertain how this gap was not identified earlier, and to seek recommendations and actions to ensure any learning from the death of a patient is established promptly and action taken.” Source location Response from Surrey and Sussex Healthcare 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 Add family-history prompts, including venous thromboembolism, to the pre-operative assessment form.
Verbatim wording from the response “The patient questionnaire did not have a place for the patient to enter this important family history.
The pre-operative assessment form did not have prompts for the question to be reviewed or asked.
The Trust has now added an extra question on the pre-operative assessment ‘power’ form on the Family History Page. The Trust has also included other potential family history that may need further investigation (for example: cardiac, musculoskeletal).” Source location Response from Surrey and Sussex Healthcare NHS Trust
Open published response
24 Feb 2025 Pamela Anne Marking · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 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
Pamela Anne Marking · 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 Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.
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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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Wider context from the report “1. The term ‘Physician Associate’ is misleading to the public
Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner . This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform patients and families that Physician Associates are not medically qualified
Wider context from the report “3. The right of patients and family to seek a second opinion
The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the Physician Associate role
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic
Evidence was heard that cricoid pressure was ineffective it was not routinely applied for a RSI intubation . After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “2. Lack of public understanding of the role of Physician Associate
Witnesses from the Trust gave evidence that a Physician Associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief. This blurring of roles without public knowledge and understanding of the role of a Physician Associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing Physician Associates to potentially undertake roles outside of their competency thereby compromising patient safety .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed , this gives rise to a concern they are working outside of their capabilities .
” 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 Install Emergency Department signage identifying clinical team members by their scrub colours.
Verbatim wording from the response “Within the Emergency Department, since the Inquest, we have installed clear signage throughout, identifying the different members of the clinical team by the different colours of scrubs that they wear.” Source location Response from Surrey and Sussex NHS
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 Issue and implement an Emergency Department Physician Associate scope of practice requiring senior doctor oversight, appropriate patient selection, escalation, and medical review before discharge or admission.
Verbatim wording from the response “In response to the issues raised in this Inquest, and in response to the new guidance from the Royal College of Emergency Medicine, enclosed with this letter, we have issued a new scope of practice document for PAs in our ED and implemented it immediately, as of 3rd March 2025. This specifically states that it is planned for a patient to be discharged from ED after seeing a PA, that patient must first be reviewed in person by a senior ED doctor, Tier 4 or 5. All our PAs and ED Consultants have been instructed to follow this change and are supportive of it and the document has been circulated.” Source location Response from Surrey and Sussex NHS
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 Move Physician Associates to Tier 1 of the Emergency Department rota in line with updated national guidance.
Verbatim wording from the response “The Trust has always followed national guidance regarding the scope of practice for Physician Associates. We recognise that PAs are not medically qualified, and we do not allow PAs to undertake roles outside of their competency, but they nonetheless have a valid role within the clinical team. Until February 2025 the Royal College of Emergency Medicine guidance was that in the Emergency Department Physician Associates should work on Tier 2 of the ED rota. That did not mean that PAs were the same as Tier 2 resident doctors, but that they could work alongside them. As of 28th February 2025, the Royal College of Emergency Medicine issued new guidance, stating that PAs should now be on Tier 1 of the ED rota. We immediately made that change and implemented the new guidance in full. We have issued a new scope of practice document for PAs in the ED which we have enclosed with this letter.” Source location Response from Surrey and Sussex NHS
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 Amend the local Physician Associate governance policy to reflect changes in national guidance and regulation.
Verbatim wording from the response “The PA involved in Mrs Marking’s care has undertaken an extensive reflective practice review with a number of the ED Consultants and will include this in their annual appraisal. We have had a local governance policy in place for all PAs that work at the Trust since 2015. Within this we worked to all available national guidance at the time and have amended the” Source location Response from Surrey and Sussex NHS
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 Communicate and reinforce the use of cricoid pressure for rapid sequence induction in bowel obstruction through meetings, induction training, and simulation training.
Verbatim wording from the response “The use of cricoid pressure during RSI is not universal in all situations as it can make intubation more difficult and is listed as an optional measure by the Difficult Airway Society. However, the Trust accepts that in the setting of bowel obstruction, with the increased risk of aspiration, cricoid pressure should have been used. This has been communicated across the whole anaesthetic team at a departmental meeting and in the Mortality & Morbidity meeting. All anaesthetic trainees at their departmental induction are instructed to use cricoid pressure and this is reiterated in regular simulation training.” Source location Response from Surrey and Sussex NHS
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 a modified total intravenous anaesthesia technique with predetermined propofol and muscle-relaxant boluses when performing rapid sequence induction with TIVA.
Verbatim wording from the response “At the Trust, if a clinician is using TIVA for RSI, they always use a modified TIVA technique which involves a predetermined dose of propofol as induction agent as a bolus and a predetermined dose of muscle relaxant as a bolus dose. This allows for rapid anaesthesia, as per the enclosed guideline.” Source location Response from Surrey and Sussex NHS
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 Identify Physician Associates through distinctive clothing, lanyards, and explicit introductions that clarify they are not doctors.
Verbatim wording from the response “The term ‘Physician Associate’ is a national term, sanctioned by national bodies, and describes a particular group of healthcare professionals who have completed a recognised training programme. However, the Trust recognises that there is a lack of awareness amongst the public and indeed amongst some healthcare staff that Physician Associates are not medically qualified practitioners. Since we first employed Physician Associates (PAs) at the Trust we have tried to make this distinction as clear as possible. At the Trust, PAs always wear uniquely coloured” Source location Response from Surrey and Sussex NHS
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 national guidance, local governance policy and competency frameworks are considered sufficient to keep Physician Associates within their scope of practice.
Verbatim wording from the response “The Trust has always followed national guidance regarding the scope of practice for Physician Associates. We recognise that PAs are not medically qualified, and we do not allow PAs to undertake roles outside of their competency, but they nonetheless have a valid role within the clinical team. Until February 2025 the Royal College of Emergency Medicine guidance was that in the Emergency Department Physician Associates should work on Tier 2 of the ED rota. That did not mean that PAs were the same as Tier 2 resident doctors, but that they could work alongside them. As of 28th February 2025, the Royal College of Emergency Medicine issued new guidance, stating that PAs should now be on Tier 1 of the ED rota. We immediately made that change and implemented the new guidance in full. We have issued a new scope of practice document for PAs in the ED which we have enclosed with this letter.” Source location Response from Surrey and Sussex NHS
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 “Physician Associate” is a nationally sanctioned term describing healthcare professionals with recognised training, rather than an inherently misleading title.
Verbatim wording from the response “The term ‘Physician Associate’ is misleading to the public: Mrs Marking’s son was under the mistaken belief that the Physician Associate was a doctor by this title in circumstances where no steps were taken by the Emergency Department or the Physician Associate to explain or clearly differentiate their role from that of medically qualified practitioners.” Source location Response from Surrey and Sussex NHS
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 that it has explained everything within its remit regarding patients’ and families’ ability to seek a second medical opinion.
Verbatim wording from the response “The right of patients and family to seek a second opinion: The lack of public knowledge that a Physician Associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a Physician Associate rather than a medically qualified doctor.” Source location Response from Surrey and Sussex NHS
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 National guidance supports modified total intravenous anaesthesia during rapid sequence induction, which is accepted practice across the United Kingdom.
Verbatim wording from the response “Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery: Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice.” Source location Response from Surrey and Sussex NHS
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 Cricoid pressure is not universally required during rapid sequence induction because it can make intubation more difficult and is an optional measure.
Verbatim wording from the response “Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic: Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.” Source location Response from Surrey and Sussex NHS
Open published response
19 Feb 2025 Margaret Kathleen Rodgers · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Insufficient ward nursing staffing levels to meet the demand of acutely ill patients with high dependency needs View source Failure to complete pressure ulcer risk assessments within 6 hours of hospital admission in the Emergency Department 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
Margaret Kathleen Rodgers · 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 Kathleen Rodgers fell at home on 3 December 2023, sustained rib and spinal fractures, and was admitted to hospital. During her admission she developed hospital-acquired pneumonia, a sacral pressure ulcer requiring two surgical procedures, and a urinary tract infection; she died from congestive cardiac failure on 12 January 2024. The coroner was concerned that unresolved recommendations about pressure-ulcer risk assessments and ward staffing were placing patients at risk of early 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient ward nursing staffing levels to meet the demand of acutely ill patients with high dependency needs
Wider context from the report “b. The court also heard that in December 2023 to January 2024, the period of Mrs Rodgers admission, the hospital was experiencing a high level of operational pressures and that on occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high dependency needs . The Trust is undertaking a review of the staffing template for the ward, but that work is not complete and not yet incorporated into the budget .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete pressure ulcer risk assessments within 6 hours of hospital admission in the Emergency Department
Wider context from the report “a. NICE and the National Wound Care Strategy guidance is that patients admitted to hospital have a pressure ulcer risk assessment within 6 hours of admission. This means that the first assessment will often need to be undertaken in the Emergency Department (ED). The court heard that the work to ensure that the ED completes such assessments is ongoing and not yet embedded and that there are practical difficulties, for example when ED patients were located on corridors .
” 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 Use Cerner reminders and the ClinOps Ward View board to identify and oversee outstanding patient assessments and tasks.
Verbatim wording from the response “2) Cerner prompts and ClinOps” Source location Response from Surrey Sussex 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 Maintain an additional nursing assistant on the Nuffield Ward night rota to support patient safety.
Verbatim wording from the response “2) Staffing levels on Nuffield ward are 5 qualified nurses and 3 non-qualified staff during the day, and 3 qualified and 3 non-qualified at night. We have already increased the night rota to have an extra nursing assistant than the template allows and this was recognised through the need for acuity, and we allow this as a cost pressure to maintain patient safety. The matrons assess the acuity on wards on a daily basis and will use clinical decision making to ensure that wards are safe, if there are any concerns they will escalate to senior management and additional staff will be requested for that shift if necessary. We are also able to move staff to work on different wards if acuity requires it.” Source location Response from Surrey Sussex 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 Assess ward acuity daily and escalate concerns to secure additional staff or redeploy staff between wards when necessary.
Verbatim wording from the response “2) Staffing levels on Nuffield ward are 5 qualified nurses and 3 non-qualified staff during the day, and 3 qualified and 3 non-qualified at night. We have already increased the night rota to have an extra nursing assistant than the template allows and this was recognised through the need for acuity, and we allow this as a cost pressure to maintain patient safety. The matrons assess the acuity on wards on a daily basis and will use clinical decision making to ensure that wards are safe, if there are any concerns they will escalate to senior management and additional staff will be requested for that shift if necessary. We are also able to move staff to work on different wards if acuity requires it.” Source location Response from Surrey Sussex 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 Hold twice-daily safer-staffing huddles to review staffing gaps, mitigation, redeployment and temporary staffing needs, escalating unresolved issues to the Chief Nurse.
Verbatim wording from the response “The Trust holds twice daily safer staffing huddles, attended by the Head of Nursing or a matron representative. During these meetings, each division reports staffing levels, mitigation actions taken, and any remaining gaps. The staffing situation is reviewed using the Safe Care Live system to identify potential cross-divisional moves or the need for temporary staffing. If these options are insufficient, corporate nursing teams are deployed to provide clinical support. The meeting also reviews staffing for the next day and on Fridays the weekend staffing is also considered. If staffing issues cannot be resolved, they are escalated to the Chief Nurse for further action.” Source location Response from Surrey Sussex 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 Incorporate additional shifts into the Nuffield Ward roster template and use temporary staffing to address staffing requirements.
Verbatim wording from the response “staffing increases have not yet been reflected in the ward budgets, Nuffield Ward has addressed this by incorporating additional shifts into the roster template and utilising temporary staffing.” Source location Response from Surrey Sussex 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 Carry out the biannual Safer Nursing Care Tool review of ward establishments and assess necessary staffing increases.
Verbatim wording from the response “The second concern was as follows: 'The court also heard that in December 2023 to January 2024, the period of Mrs Rodgers admission, the hospital was experiencing a high level of operational pressures and that on occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high dependency needs. The Trust is undertaking a review of the staffing template for the ward, but that work is not complete and not yet incorporated into the budget.'” Source location Response from Surrey Sussex 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 Train all Emergency Department staff, including agency staff, to use the Purpose T pressure-ulcer risk assessment tool.
Verbatim wording from the response “1) Purpose T (Pressure Ulcer Risk Primary or Secondary Evaluation Tool) training” Source location Response from Surrey Sussex 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 Conduct two-hourly Nurse Quality Rounds and provide supernumerary Practice Development Nurse support to identify and complete outstanding assessments.
Verbatim wording from the response “4) Nurse Quality Rounds
These are designated rounds at 2 hourly intervals involving the band 7 nurse in charge, Matron and PDN (all three are not required for the round). They do an eyeball assessment on every patient, including those receiving corridor care, with the aim of supporting staff to ensure tasks and assessments are completed. The purpose of the round is to provide an additional level of safety netting as they may pick up something that a less experienced nurse might miss. Junior staff can also ask questions and seek guidance on any assessment their patient needs which they are unclear about.” Source location Response from Surrey Sussex 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 Build an informatics report to monitor and audit Emergency Department compliance with required assessments.
Verbatim wording from the response “5) Planned audits to monitor progress relating to compliance in the ED” Source location Response from Surrey Sussex 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 Compliance with Emergency Department pressure-ulcer assessments cannot currently be audited because the systems provide only live data.
Verbatim wording from the response “5) Planned audits to monitor progress relating to compliance in the ED” Source location Response from Surrey Sussex NHS Trust
Open published response
20 Mar 2024 Anne Johnston Rowland · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Outstanding infrastructure repairs affecting timely hip-fracture surgery View source Failure to use the NICE timeframe for hip-fracture surgery 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
Anne Johnston Rowland · 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
Anne Johnston Rowland suffered a neck of femur fracture on 27 February 2023 and underwent fixation surgery on 3 March 2023 after waiting for surgery at East Surrey Hospital. Her immobility while waiting contributed to aspiration pneumonia, and she died at the hospital on 31 March 2023. The coroner was concerned that limited theatre capacity, infrastructure risks, and the Trust’s 48-hour surgery metric could delay hip fracture surgery beyond the NICE timeframe and place patients at risk of early death.
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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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Outstanding infrastructure repairs affecting timely hip-fracture surgery
Wider context from the report “Continuing infrastructure risks at East Surrey Hospital have potential to compromise the Trust’s ability to perform operations on patients with fractured hips on the day of admission or the day thereafter , which is the timeframe set out in the NICE Guidelines on the Management of Hip Fractures.
East Surrey Hospital use a metric of 48 hours within which to conduct such surgery and not the NICE timeframe for hip surgery.
Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The coroner is concerned that in using a different metric to that in the NICE guidelines and the outstanding infrastructure repairs the Trust is placing such patients at risk of early 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the NICE timeframe for hip-fracture surgery
Wider context from the report “Continuing infrastructure risks at East Surrey Hospital have potential to compromise the Trust’s ability to perform operations on patients with fractured hips on the day of admission or the day thereafter, which is the timeframe set out in the NICE Guidelines on the Management of Hip Fractures.
East Surrey Hospital use a metric of 48 hours within which to conduct such surgery and not the NICE timeframe for hip surgery .
Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The coroner is concerned that in using a different metric to that in the NICE guidelines and the outstanding infrastructure repairs the Trust is placing such patients at risk of early death.
” 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 Approve multimillion-pound investment in new theatre-complex air-handling and chiller systems.
Verbatim wording from the response “6. The Trust's Executive Committee have approved the case for a” Source location Response from Surrey and Sussex Healthcare
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 Monitor fractured-neck-of-femur pathway performance weekly and monthly against NICE 36-hour and 48-hour surgery measures, with governance review through Trust committees and the Board.
Verbatim wording from the response “1. The Trust continually monitors the pathway for patients with fractured neck of femur using several key metrics, based on NICE guidance and the Best Practice Tariff. As regards the time to surgery, the Trust monitors weekly and monthly the proportion of patients who had surgery within the timeframe identified in NICE guidance (36 hours) which is also the target for the payment of the Best Practice Tariff. We also monitor the proportion of patients who have surgery within 48 hours. We do not do this because we are disregarding the 36-hour target, we do this so that we have visibility of any delays beyond 36 hours and when any delays are a matter of a few hours or significantly longer than that.” Source location Response from Surrey and Sussex Healthcare
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 the second phase of theatre-complex infrastructure work by installing new chillers and air-handling units for the remaining half.
Verbatim wording from the response “multimillion-pound investment in 2023-24 for new air handling and chillers for the theatre complex which will correct the long-term problems experienced in the orthopaedic theatres and will prevent the cancellation of lists due to infrastructure failings. The first phase of this work was completed in April 2024, with new chillers and air handling units installed for half of the theatre complex. The second phase requires more substantial capital work but will be completed by the end of 2024, with new chillers and air handling units installed for the other half of the theatre complex.” Source location Response from Surrey and Sussex Healthcare
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 new chillers and air-handling units for half of the theatre complex as the first phase of infrastructure improvements.
Verbatim wording from the response “multimillion-pound investment in 2023-24 for new air handling and chillers for the theatre complex which will correct the long-term problems experienced in the orthopaedic theatres and will prevent the cancellation of lists due to infrastructure failings. The first phase of this work was completed in April 2024, with new chillers and air handling units installed for half of the theatre complex. The second phase requires more substantial capital work but will be completed by the end of 2024, with new chillers and air handling units installed for the other half of the theatre complex.” Source location Response from Surrey and Sussex Healthcare
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 fractured-neck-of-femur demand management to daily site-team meetings, including review and prioritisation of patients awaiting surgery and theatre capacity within 36 hours.
Verbatim wording from the response “2. The daily operation of the hospital is overseen by the site team, in the hospital operations centre. Since March 2023 we have added a focus on managing the daily trauma demand within our site team meetings - held daily at 08:30, 12:30, 15:30 and 17:00. The surgical team discuss in that meeting the numbers of fractured neck of femur patients awaiting surgery, the capacity within theatres to operate within 36 hours and the capacity is prioritised.” Source location Response from Surrey and Sussex Healthcare
Open published response
6 Dec 2023 John LEE · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to provide mouth care to dementia patients on each occasion that they eat View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
John LEE · 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 Lee, an 83-year-old man with dementia, died in hospital on 3 September 2022 after choking on food. The inquest recorded that he was not closely monitored or provided with effective mouth care while eating, despite recommendations to check his mouth after meals. The Court was concerned that dementia patients at the Trust may not receive mouth care after each occasion they eat, presenting a risk of future 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mouth care to dementia patients on each occasion that they eat
Wider context from the report “The Court is concerned that there is a risk that dementia patients at the Trust are not receiving mouth care on each occasion that they eat and this presents a risk of future deaths.
” 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 dementia patients’ admission care, dietary, swallow and mouth-care arrangements to identify safety improvements.
Verbatim wording from the response “I asked ████████, Consultant Admiral Nurse for Dementia to review the care dementia patients receive specifically in relation to mouth care when eating and to include their dietary and swallow assessments from the time of their admission. The review included expertise from ████████, Mouthcare Lead; Clinical Lead for Speech and Language Therapy (SALT); and ████████, Chief Nurse Informatics Officer.” Source location Response from Surrey and Sussex Healthcare 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 Introduce nurse-rounding documentation to record assistance offered, accepted or declined for food, fluids and mouth care.
Verbatim wording from the response “4.
Recommendation / Issue to be addressed: Mouth care matters. Staff complete mouthcare sections correctly on Cerner. Mouth care recommendation for patients who have been identified as a swallowing risk due to dysphagia.
Action category: Directive.
Action (SMART): Mouth care. Nurse rounding section (Assist with food/fluid/mouthcare). Record if assistance offered and accepted, declined etc.
Action owner (job title): ████████
Deadline for action: Dec 2024 (dependent on Cerner being updated).
Expected improvement / success measures: Improved recording of mouthcare assessment and provides evidence that mouthcare needs have been met.
Audit results / evidence: Complete audit of use of Mouth care recording on Cerner of patients with dysphagia (from Cerner list of patients with Dysphagia).” Source location Response from Surrey and Sussex Healthcare 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 Cerner mouth-care documentation and recommend changes, including an initial baseline assessment.
Verbatim wording from the response “3.
Recommendation / Issue to be addressed: Mouth care matters on Cerner. Review mouthcare documentation on Cerner with the electronic patient record team.
Action category: Corrective.
Action (SMART): Mouth care. Review and recommend changes to electronic recording of mouth care matters on Cerner. This will include Initial assessment to establish base line.
Action owner (job title): ████████
Deadline for action: June 2024.
Expected improvement / success measures: Improved recording of mouth care matters on Cerner.
Audit results / evidence: Correct Cerner documentation in place and staff aware of where to record mouth care.” Source location Response from Surrey and Sussex Healthcare NHS Trust
Open published response
13 Nov 2023 Bavaniamma Theiventhiran · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to provide hip surgery within the recommended timeframe for patients with fractured neck of femur 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
Bavaniamma Theiventhiran · 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
Bavaniamma Theiventhiran, aged 80, fractured her left neck of femur in a fall at home on 26 February 2023 and was admitted to East Surrey Hospital. Although there was no clinical reason to delay surgery, it took place on 2 March 2023, and she died at the hospital on 6 March 2023 after developing acute kidney injury. The Coroner was concerned that East Surrey Hospital was not meeting recommended surgery timeframes for over half of patients with fractured neck of femur, placing such patients at risk of early 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide hip surgery within the recommended timeframe for patients with fractured neck of femur
Wider context from the report “The NICE Guideline on the Management of Hip Fractures recommends that hip surgery take place on the day of the injury or the day thereafter in order, amongst other things, to reduce complications. The most recent monthly figures indicate that East Surrey Hospital is not meeting this timeframe for over half of patients who present to the hospital with a fractured neck of femur . The Coroner is concerned that in failing to comply with the NICE Guideline in this way , the Trust is placing such patients at risk of early death.
” Open source report
29 Sep 2023 Douglas Nickols · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Delays in performing operations for hip fracture patients within the day of admission or the following day 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
Douglas Nickols · 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
Douglas Nickols suffered an unwitnessed fall at his care home on 28 February 2023, sustaining a fractured left neck of femur. He was admitted to East Surrey Hospital, but surgery did not take place until 5 March 2023; he later developed bronchopneumonia and died at the hospital on 11 March 2023. The principal concern was that limited trauma capacity meant hip-fracture surgery could be delayed beyond the NICE-recommended timeframe, potentially placing patients at risk of early 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in performing operations for hip fracture patients within the day of admission or the following day
Wider context from the report “On some occasions at East Surrey Hospital it is not possible to perform operations on patients with fractured hips on the day of admission or the day thereafter , which is the timeframe set out in the NICE Guidelines on the Management of Hip Fractures . Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The Coroner is concerned that in failing to comply with the NICE guidelines in this way , the Trust is placing such patients at risk of early death.
” Open source report
5 Sep 2022 Stephen WELLS · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Lack of progress in reviewing or renegotiating the inter-Trust Service Level Agreement View source Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems View source Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT View source Lack of clarity for GPs about where to raise concerns regarding hospital or tertiary-care treatment View source Insufficient guidance or refresher training for hospital doctors on use of the relevant Datix system View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Stephen WELLS · 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
Stephen Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.
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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of progress in reviewing or renegotiating the inter-Trust Service Level Agreement
Wider context from the report “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about:
i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021.
ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems
Wider context from the report “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about:
i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021.
ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT
Wider context from the report “c) I heard evidence that Mr Wells was told his key contact in SASH was a named Clinical Nurse Specialist. When his care transferred to RSFT, witnesses expected his key contact to be changed to a CNS based within the St Luke’s Cancer Centre in Guildford. During the inquest I asked to whom the CNS was at RSFT and following enquiries learnt that the St Luke’s staff believed the key contact was the SASH CNS. I remain concerned that there is insufficient clarity for both patients and staff when there is an IPT from SASH to RSFT and vice versa .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity for GPs about where to raise concerns regarding hospital or tertiary-care treatment
Wider context from the report “a) I heard evidence that Mr Wells GP wrote two urgent letters to the RSFT consultant oncologist and HPB surgeon dated 22 September 2021 raising concerns that the patient had heard nothing further after the liver surgery in September 2020. These letters were sent to the East Surrey hospital by the GP. I heard evidence that both consultants hold clinics in two East Surrey hospitals as well as within their own Trust area. Principally the letters were about lack of treatment for a cancer patient and I heard evidence during the inquest that the RSFT witness assisting the court on governance & risk issues did not know the doctors had received the letters and presumably were not logged on the Datix system thereby raising concerns regarding:
i. whether additional guidance may be appropriate for GPs to know where to raise concerns about patient treatment in hospital or tertiary care ; and
ii. whether further guidance or refresher training is needed for hospital doctors regarding use of the relevant Datix 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance or refresher training for hospital doctors on use of the relevant Datix system
Wider context from the report “a) I heard evidence that Mr Wells GP wrote two urgent letters to the RSFT consultant oncologist and HPB surgeon dated 22 September 2021 raising concerns that the patient had heard nothing further after the liver surgery in September 2020. These letters were sent to the East Surrey hospital by the GP. I heard evidence that both consultants hold clinics in two East Surrey hospitals as well as within their own Trust area. Principally the letters were about lack of treatment for a cancer patient and I heard evidence during the inquest that the RSFT witness assisting the court on governance & risk issues did not know the doctors had received the letters and presumably were not logged on the Datix system thereby raising concerns regarding:
i. whether additional guidance may be appropriate for GPs to know where to raise concerns about patient treatment in hospital or tertiary care; and
ii. whether further guidance or refresher training is needed for hospital doctors regarding use of the relevant Datix system .
” Open source report
19 Apr 2022 Sebastian NOTTAGE · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2 Lack of guidance on the timeframe and steps for completing the Seven-day short stay booklet View source Lack of guidance on verifying Emergency Department information directly with the patient when completing the Seven-day short stay booklet View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sebastian NOTTAGE · 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
Sebastian Nottage, aged 26, was admitted to hospital for acute pancreatitis and left the ward without telling staff shortly before 8am on 30 June 2020. He subsequently sustained fatal injuries after being hit by a London-bound train. The substantive concerns were a lack of clear guidance on completing the admission/discharge booklet, including the completion timeframe, what to do if it was incomplete, and whether information should be checked directly with the 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on the timeframe and steps for completing the Seven-day short stay booklet
Wider context from the report “- There is no clear guidance in place in relation to the timeframe for the full completion of the ‘Seven-day short stay booklet for admission/discharge’ and the steps to take if the booklet has not been fully completed on the day of admission to the unit. The Coroner considers that further guidance and/or training on this matter may be required.
- There is no clear guidance in place in relation to the manner in which the ‘Seven-day short stay booklet for admission/discharge’ ought to be completed, and particularly whether it is permissible to rely on information recorded in the Emergency Department without checking it directly with the patient. The Coroner considers that further guidance and/or training on this matter may be 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on verifying Emergency Department information directly with the patient when completing the Seven-day short stay booklet
Wider context from the report “- There is no clear guidance in place in relation to the timeframe for the full completion of the ‘Seven-day short stay booklet for admission/discharge’ and the steps to take if the booklet has not been fully completed on the day of admission to the unit. The Coroner considers that further guidance and/or training on this matter may be required.
- There is no clear guidance in place in relation to the manner in which the ‘Seven-day short stay booklet for admission/discharge’ ought to be completed, and particularly whether it is permissible to rely on information recorded in the Emergency Department without checking it directly with the patient. The Coroner considers that further guidance and/or training on this matter may be required.
” 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 Create and deliver a simulation video demonstrating a perfect admission, including patient engagement and completion of the seven-day booklet.
Verbatim wording from the response “As part of the Trust’s teaching programme for all nursing staff, it is planned (completion in August) that there will be a simulation video to demonstrate the “Perfect Admission” which will incorporate engagement with patients, how to extract information to ensure there is completion of documentation and will include the 7-day Short Stay Booklet Admission/Discharge and Daily Evaluation.” Source location Response from Surrey and Sussex Healthcare 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 current nursing staff not to rely solely on medical records through ward handovers, safety huddles, and management meetings.
Verbatim wording from the response “Nursing staff will be reminded not to reply solely on the medical records during the above teaching sessions. These reminders will be via the daily Ward Handovers, daily Safety Huddles, and monthly Ward Manager and Matron Meetings.” Source location Response from Surrey and Sussex Healthcare 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 and reprint the seven-day booklet with instructions to complete pages 1–14 within 24 hours, check daily, and explain any gaps.
Verbatim wording from the response “The booklet is being reviewed and will be reprinted to incorporate enhanced instructions regarding completion of the booklet. Specifically, the wording at the top of each page will be:
“Page 1-14 complete within 24 hours and check daily to ensure completion.”” Source location Response from Surrey and Sussex Healthcare 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 Roll out digital documentation incorporating the seven-day booklet content into an electronic record with clinician access and timed completion tasks.
Verbatim wording from the response “In September 2022, the Trust will roll out Digital Documentation (an electronic patient record system). The information from the 7-day booklet will be “built in” to the digital programme, and there will be one record in which all information is accessible to all clinicians. The digital documentation will largely replicate the content of the current paper booklet to ensure that the same information is captured, and it has been reviewed as part of the digital programme to ensure it reflects current best practice. It is envisaged that the electronic patient record will enable all the clinicians to access the patient’s entire record; and it will help clinicians to ensure there is a safer, leaner and “real time” documentation of the care they provide to patients.” Source location Response from Surrey and Sussex Healthcare 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 Continue monthly documentation audits to monitor booklet completion and identify ward or individual training requirements.
Verbatim wording from the response “The Trust has revised the teaching session for “Ward documentation” which is part of the Ward Ready Course. I attach a copy of the revised lesson plan detailing the content provided to all new nursing staff. This training is delivered via the Trust’s Practice Development Team to all new members of the nursing workforce during their induction programme. The current nursing workforce will be reminded of the expectations and importance of completing documentation via the daily Ward Handovers, daily Safety Huddles, and monthly Ward Manager and Matron Meetings. In addition, the Matron’s Monthly Documentation Audit will continue to address compliance with completion of documentation, and any training requirements for wards and individuals.” Source location Response from Surrey and Sussex Healthcare 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 Existing booklet guidance instructs nursing staff to take the patient history rather than rely solely on information in medical records.
Verbatim wording from the response “In respect of the manner in which the booklet ought to be completed, page 8 currently outlines the expectation that the nursing staff should not solely rely on information that is already with the patient’s medical records. Specifically, it states:
“Take the patient history, do not rely on information from the medical notes.”” Source location Response from Surrey and Sussex Healthcare 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 A definitive booklet-completion timeframe cannot be provided because admission pathways, admission times, patient capacity and presentation vary.
Verbatim wording from the response “The current 7-day Short Stay Booklet Admission/Discharge and Daily Evaluation outlines the expectation that the nursing staff will complete the information within the booklet during the early stages of the patient’s admission. It is not possible to provide a definitive time frame within which this is completed, as this will be dependent upon the patient’s admission pathway (whether they are emergency or elective) the time of day they are admitted and their capacity and presentation at the time.” Source location Response from Surrey and Sussex Healthcare NHS Trust
Open published response
5 Nov 2020 Linda Doherty · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 7 Failure to consult clinicians who had been treating the patient before placing her on end of life care View source Inaccurate scoring of Malnutrition Universal Scoring Tool charts View source Failure to properly complete required food charts View source Failure to consult the Intensive Care team when assessing suitability for intensive care before placing a patient on end of life care View source Failure to identify patients who require food charts View source Failure to action recommendations stemming from multidisciplinary team meetings View source Delay in recognising significant patient weight loss 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
Linda Doherty · 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
Linda Doherty died in hospital on 7 August 2017 after developing Crohn’s Disease, intestinal failure, malnutrition, sepsis and acute kidney injury. The report identified failures to follow up CT scan findings, recognise and adequately address her nutritional deterioration, and concerns about inaccurate or incomplete nutrition monitoring and the process for placing her on end-of-life care.
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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult clinicians who had been treating the patient before placing her on end of life care
Wider context from the report “5. Mrs Doherty was placed on end of life care on 5 August 2017 by a Senior House Officer (SHO) following consultation with his Consultant, both of whom had had only limited prior involvement with her. The decision to place her on end of life care was made without any consultation with the Intensive Care team, to ascertain whether she would be suitable for intensive care, and without any consultation with the clinicians who had been treating her over the course of the preceding three months . Consideration should be given as to whether appropriate end of life policies and procedures are in place and whether staff are sufficiently aware of them.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate scoring of Malnutrition Universal Scoring Tool charts
Wider context from the report “2. The Malnutrition Universal Scoring Tool (MUST) charts for Linda Doherty were inaccurately scored during the period from 3 to 23 July 2017 . Consideration should be given as to whether staff are sufficiently trained in how to score MUST charts.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly complete required food charts
Wider context from the report “3. The food charts for Linda Doherty were not completed from 23 June to 12 July 2017 and again from 18 to 23 July 2017 , despite Mrs Doherty being at risk of malnutrition. Consideration should be given as to whether appropriate procedures are in place to (i) identify those patients who require food charts and (ii) to ensure that they are properly completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult the Intensive Care team when assessing suitability for intensive care before placing a patient on end of life care
Wider context from the report “5. Mrs Doherty was placed on end of life care on 5 August 2017 by a Senior House Officer (SHO) following consultation with his Consultant, both of whom had had only limited prior involvement with her. The decision to place her on end of life care was made without any consultation with the Intensive Care team, to ascertain whether she would be suitable for intensive care , and without any consultation with the clinicians who had been treating her over the course of the preceding three months. Consideration should be given as to whether appropriate end of life policies and procedures are in place and whether staff are sufficiently aware of them.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify patients who require food charts
Wider context from the report “3. The food charts for Linda Doherty were not completed from 23 June to 12 July 2017 and again from 18 to 23 July 2017 , despite Mrs Doherty being at risk of malnutrition. Consideration should be given as to whether appropriate procedures are in place to (i) identify those patients who require food charts and (ii) to ensure that they are properly completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to action recommendations stemming from multidisciplinary team meetings
Wider context from the report “1. There was no colorectal follow up in relation to the findings of the CT scan carried out on 2 December 2016 despite it being recommended by the Upper Gastro-Intestinal Multi-Disciplinary Team meeting at East Surrey Hospital on 20 December 2016 . Consideration should be given as to whether the appropriate procedures are in place to ensure that recommendations stemming from MDT meetings are actioned appropriately .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delay in recognising significant patient weight loss
Wider context from the report “4. The MUST charts recorded that Mrs Doherty’s weight was 65kg in early June 2017 and had reduced to 57kg by 11 July 2017, yet the multi-disciplinary team caring for her did not recognize that she had lost a significant amount of weight until 1 August 2017 . Consideration should be given as to whether any additional measures or training are required to prevent similar delays in the future.
” 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 annual MaST training on MUST scoring, nutrition screening and assessment, supported by online learning and ward-based refresher training.
Verbatim wording from the response “Dietitians had identified deficiencies in ward based nutrition screening and in early 2018 reviewed the knowledge and understanding of ward based staff. Following this review, a new training package was developed based on its findings, which has now become a clinical core topic of the Mandatory and Statutory training (MaST) at SASH which staff complete annually. Compliance is monitored via the on-line Electronic Staff Record (e-ESR) and reminders are sent to staff 3 months in advance of expiry.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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-weekly nutritional ward rounds led by a Consultant Gastroenterologist.
Verbatim wording from the response “A need for a specialist multi professional Nutrition Support team was identified for the oversight of the provision of nutrition for patients with complex artificial feeding needs. This group is a national recommendation and aims to optimise the metabolic care of the sickest patients in hospital, by performing regular nutrition ward rounds with supporting members e.g. surgeons and feeding into the proposed complex nutrition MDT meeting. The team consists of a gastroenterology consultant, nutrition nurse specialist, senior nutrition support dietitian and a pharmacist. In October 2020, the Trust appointed a Consultant Gastroenterologist with a special interest in nutrition who has reviewed the current nutrition policies, procedures and service at SASH.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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 Implement a formal complex nutrition MDT meeting with active surgeon membership.
Verbatim wording from the response “Twice weekly nutritional ward rounds are now taking place, led by this Consultant Gastroenterologist, and a monthly complex nutrition MDT meeting will be operational by April 2021. This will be a forum for surgeons and dietitians to meet monthly to review nutritional needs of specific patients, any refusal of treatment and the use of parental nutrition.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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 Audit the effect of MaST nutrition training on completion of MUST documentation and address any identified deficiencies with further training.
Verbatim wording from the response “4. Undertake an audit to assess the impact of the MaST nutrition training on the completion of the MUST documentation.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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 MUST checks in daily ward huddles and escalate nutrition concerns to the nurse in charge.
Verbatim wording from the response “All the wards now have ‘daily huddles’, where the ward team come together to discuss nursing issues and MUST is part of the daily checks. Any problems or concerns are escalated to the nurse in charge.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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 Record nutrition assessments, care plans, MUST scores, BMI, weight loss, fluid intake and food intake in the Patient Bedside Safety Booklet.
Verbatim wording from the response “At the time of the patient’s admission in 2017, the recording of food charts took place on loose sheets of paper. In August 2018 the ‘Patient Bedside Safety Booklet: Risk assessments and care plans’ was introduced and is now used for all in-patients. This booklet includes all the documentation for nursing assessments, for example falls management, skin integrity and cannula care.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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 audit of nutrition training impact was delayed by COVID-19 pressures and limitations.
Verbatim wording from the response “An audit to assess the impact of this training and use of the documentation is due but has been delayed due to the pressures of the COVID-19 pandemic.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
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 databases, tracking, cancer nurse specialist monitoring and escalation arrangements support appropriate follow-up of MDT recommendations.
Verbatim wording from the response “The current arrangements for the follow up of the recommendations made at the Upper GI MDT meeting were reviewed. The outcome for all patients discussed at the MDT meeting, whether cancer patients or not, are recorded on the Somerset database (a digital platform designed for healthcare professionals to manage cancer patient care). This is monitored by cancer services trackers who are then able to escalate to the most appropriate person any concerns i.e. tests not being requested and will chase dates as needed.” Source location 2020-0224-Response-from-East-Surrey-Hospital-Redacted.pdf
Open published response
20 May 2015 Mrs Wanda Stachurska · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Lack of staff awareness of relevant mental health policies View source Failure to provide training or guidance to staff interpreting during mental health assessments View source Use of non-healthcare professionals to interpret during mental health assessments View source Routine use of untrained staff as interpreters for mental health assessments View source Failure to undertake a serious incident review after a patient death shortly after discharge View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs Wanda Stachurska · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Wanda Stachurska was found deceased on 18 November 2014 after being discharged from hospital the previous evening following a suicide attempt involving an overdose and attempted hanging. Concerns included the quality of the mental health risk assessment, including the use of an untrained security guard as an interpreter and the failure to communicate relevant information about the earlier attempted hanging. The report also raised concerns that neither Trust conducted a serious incident review 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of relevant mental health policies
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital ;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide training or guidance to staff interpreting during mental health assessments
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of non-healthcare professionals to interpret during mental health assessments
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments ;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Routine use of untrained staff as interpreters for mental health assessments
Wider context from the report “(1) That the quality of the mental health risk assessment may be diminished if:
(a) Mental health staff are not aware of relevant SASH policies when working at East Surrey Hospital;
(b) the use of untrained staff as interpreters for mental health assessments is the norm rather than an exceptional or emergency occurrence ;
(c) staff members who are not health care professionals are asked to interpret during mental health assessments;
(d) Staff members who are asked to interpret during mental health assessments are not given any training or guidance as to how to carry out this role.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a serious incident review after a patient death shortly after discharge
Wider context from the report “(2) Neither SASH nor SABP had considered that they should undertake a serious incident review into the case despite the death of a patient only a few hours after discharge .
(a) An opportunity to learn lessons from the above events has hence been delayed and potentially been lost;
(b) To decline to conduct a serious incident review because of a pre-determined opinion that there had been not been any omissions or shortcomings by the organisation might reflect a misunderstanding by SASH of the purpose and value of such investigations.
” Open source report
21 Mar 2014 MRS KERRY JACOBS · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 3 Lack of a protocol for pharmacist-clinician discussion of queried drug dosages View source Lack of recording of deliberate decisions and grounds for prescribing medication outside usual practice or BNF guidelines View source Failure to confirm or report actual prescriptions to the patient’s consultant 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
MRS KERRY JACOBS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Kerry Jacobs died on 8 July 2013 from a pulmonary embolism arising from a deep vein thrombosis in her right calf. Concerns included the prescription of a steroid dose outside usual ENT practice and BNF guidelines without adequate documentation or confirmation with the consultant, and the lack of a protocol requiring discussion between pharmacists and clinicians when prescriptions are queried.
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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for pharmacist-clinician discussion of queried drug dosages
Wider context from the report “(2) There was no discussion between the pharmacist and either the prescribing doctor or the patient’s consultant regarding the dosage when the query was raised by the pharmacist. I was informed by the consultant physician who conducted the SUI that, where a pharmacist queries the intended prescription of a drug, it is good practice for the clinician and pharmacist to discuss the matter and consider together the risks and benefits of the prescription. He stated that it “would clearly be of value” to have a protocol requiring such a discussion to take place, where practicable. The Trust has no such protocol.
I consider that, although I did not find that Mrs Jacobs’ death would have been prevented by correction of her prescription, there is a risk that future deaths may occur in similar circumstances and action should be taken to reduce the risk that the prescription of an unintentionally high dose of a drug is not identified and corrected.
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of recording of deliberate decisions and grounds for prescribing medication outside usual practice or BNF guidelines
Wider context from the report “(1) There was nothing within Mrs Jacobs’ hospital records indicating any awareness that she had been prescribed steroid dose which was out with usual ENT practice and the BNF guidelines. Nor was the actual prescription issued confirmed with or reported to patient’s consultant. The evidence was that there is no policy or procedure within the Trust which requires a doctor who prescribes a medication outside usual practice and/or BNF guidelines to note within the patient’s clinical record that they have made the deliberate decision to do so and to record their grounds for so deciding .
” 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 Surrey and Sussex Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm or report actual prescriptions to the patient’s consultant
Wider context from the report “(1) There was nothing within Mrs Jacobs’ hospital records indicating any awareness that she had been prescribed steroid dose which was out with usual ENT practice and the BNF guidelines. Nor was the actual prescription issued confirmed with or reported to patient’s consultant. The evidence was that there is no policy or procedure within the Trust which requires a doctor who prescribes a medication outside usual practice and/or BNF guidelines to note within the patient’s clinical record that they have made the deliberate decision to do so and to record their grounds for so deciding.
” 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 directive requiring clinicians to document the rationale for prescribing outside BNF or usual-practice guidance and record pharmacist prescription-query discussions and outcomes.
Verbatim wording from the response “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.” Source location 2014-0133-Response-by-Surrey-Sussex-Healthcare-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 Add compliance with the prescribing documentation directive to the Trust’s 2014/2015 audit programme.
Verbatim wording from the response “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.” Source location 2014-0133-Response-by-Surrey-Sussex-Healthcare-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 the medication-screening procedure requiring direct discussion between prescribing clinicians and screening or dispensing pharmacists, with escalation to another prescriber when necessary.
Verbatim wording from the response “Response: It is correct there is no formal Trust policy in place, however, ████████ Chief Pharmacist, has re-iterated the medication screening procedure to the Trust’s Pharmacy Technicians and Pharmacists. I attach a copy of his email communication dated 7 May 2014 in which he specifically has instructed the Pharmacy Department that “the prescribing clinician and the screening and dispensing pharmacist must have an inter-professional direct discussion about the prescription (not via secretaries), and if the prescribing clinician is not available, then the pharmacy technician or pharmacist must speak to another prescriber clinician who is able to make a decision.”” Source location 2014-0133-Response-by-Surrey-Sussex-Healthcare-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 Disseminate the prescribing documentation directive to clinical staff through divisional MDT and departmental meetings.
Verbatim wording from the response “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.” Source location 2014-0133-Response-by-Surrey-Sussex-Healthcare-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