10 Jun 2026 Judith Marsland · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to review, act on, and escalate abnormal blood results View source Failure to make safe discharge decisions based on clinical findings View source Lack of a structured cross-team handover from ED to speciality departments 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
Judith Marsland · 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. Marsland died in hospital on 14 November 2025 after a urinary infection progressed to sepsis, septic shock and multiorgan failure. The principal concerns were that abnormal blood results were not reviewed or escalated, she was discharged without antibiotics, and key action-plan measures for structured handover and named clinical responsibility had not been implemented.
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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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review, act on, and escalate abnormal blood results
Wider context from the report “3) I heard evidence from ████████, the lead investigator from the Trust PSII that Mrs. Marsland’s deterioration and death followed an error in not escalating the abnormal blood results that were available for clinical review during her admission to Tameside Hospital on 7ᵗʰ November 2025. The PSII concluded that all blood results should have been reviewed and acted upon by the clinical teams that saw Mrs. Marsland and that she should not have been discharged home.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make safe discharge decisions based on clinical findings
Wider context from the report “3) I heard evidence from ████████, the lead investigator from the Trust PSII that Mrs. Marsland’s deterioration and death followed an error in not escalating the abnormal blood results that were available for clinical review during her admission to Tameside Hospital on 7ᵗʰ November 2025. The PSII concluded that all blood results should have been reviewed and acted upon by the clinical teams that saw Mrs. Marsland and that she should not have been discharged home .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a structured cross-team handover from ED to speciality departments
Wider context from the report “4) ████████ evidence was that key aspects of the PSII action plan that are intended to mitigate the risk of future deaths are yet to be implemented by the Trust. In particular addressing the need for a structured cross-team handover from ED to speciality departments capturing clinical concerns, abnormal results, escalation plans, and creating named responsible clinicians .
” Open source report
15 May 2026 Edith May Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Poor quality of District Nursing team documentation View source Insufficient managerial oversight of complex District Nursing cases View source Failure of District Nurses to promptly escalate deteriorating patients View source District Nursing gateway triage failing to identify or proactively manage deteriorating patients View source Lack of an effective GP practice system to promptly triage 111 referrals and family-provided information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Assign Team Leaders active responsibility for record review, staff development and documentation-quality assurance.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Conduct deteriorating-patient audits and systematically monitor pathway use, clinical observations and NEWS2 compliance across teams.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026. View source
Action
Establish a District Nursing Improvement Group to lead work on triage, caseload management, documentation, escalation and monthly audited assurance reporting.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026. View source
Action
Use enhanced documentation audits, Quality Assurance Rounds, accreditation and governance processes to monitor and assure record quality.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Introduce Team Leader of the Day and Coordinator of the Day roles to provide senior support and clear escalation routes.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Use daily SITREP and out-of-hours handover processes to monitor capacity, demand and acuity and escalate urgent staffing pressures.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Strengthen documentation of clinical reasoning, escalation decisions and patient-centred care plans.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Recruit and introduce a senior District Nursing Caseload Facilitator role to strengthen caseload oversight, patient flow and care planning.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026. View source
Action
Establish and operate a District Nursing Documentation Group to improve documentation standards and drive continuous improvement.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Increase caseload reviews and triage to prioritise patients with complex, frail, end-of-life or changing clinical needs.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Disband the separate triage team and redistribute its resources into clinical roles within each District Nursing Team.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source
Action
Review and refine EMIS templates to support professional decision-making, risk assessment and clinical oversight.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2026. View source See 9 more actions
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AI-generated summary
Edith May Jones · 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
Edith May Jones had limited mobility and underlying health conditions, including heart failure, and developed a deteriorating sacral pressure ulcer. She was admitted to hospital with an infected stage 4 pressure ulcer, did not improve despite intravenous antibiotics, and died on 17 October 2025; the stated cause was heart failure exacerbated by the infected ulcer. Concerns included poor District Nursing documentation, limited managerial oversight, delayed escalation, shortcomings in the gateway referral triage process, and ineffective GP triage of referrals and family information.
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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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor quality of District Nursing team documentation
Wider context from the report “1. The quality of the District Nursing team documentation was poor . Consequently, it was difficult to understand the steps taken and the rationale for actions ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient managerial oversight of complex District Nursing cases
Wider context from the report “2. There was little evidence of oversight by District Nursing Team managers of how complex cases such as Mrs Jones were being managed ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of District Nurses to promptly escalate deteriorating patients
Wider context from the report “3. There was no prompt escalation of her case by the District Nurses when the situation deteriorated ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation District Nursing gateway triage failing to identify or proactively manage deteriorating patients
Wider context from the report “4. The District Nursing gateway referral system had a triage process that did not identify or manage proactively her deteriorating condition .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective GP practice system to promptly triage 111 referrals and family-provided information
Wider context from the report “5. The GP practice did not have an effective system to promptly triage referrals from the 111 service or information provided by a patients family .
” 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 Assign Team Leaders active responsibility for record review, staff development and documentation-quality assurance.
Verbatim wording from the response “• Team Leaders taking an active lead role in reviewing records, supporting staff development and providing assurance regarding documentation quality.” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct deteriorating-patient audits and systematically monitor pathway use, clinical observations and NEWS2 compliance across teams.
Verbatim wording from the response “The Division also carry out a Deteriorating Patient Audit. The result of that audit demonstrates that clinical monitoring standards for deteriorating patients remain consistently high, with April compliance at 93.3% and July at 92.3%. Physiological observation recording has strengthened further, improving from 93.8% in April to 98.5% in July, demonstrating enhanced reliability in core assessment processes. NEWS2 recording compliance has remained at 100% across both months, evidencing sustained adherence to national early-warning requirements. These metrics confirm robust clinical oversight, reliable recognition of deterioration, and continued improvement in the quality and consistency of patient observations.” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a District Nursing Improvement Group to lead work on triage, caseload management, documentation, escalation and monthly audited assurance reporting.
Verbatim wording from the response “The Divisional Nurse and AHP Director for Integrated Care recently set up the District Nursing Improvement Group providing strategic leadership and governance oversight for strengthening safety, quality and operational reliability across District Nursing. The groups programme of work is centred on improving the triage process to ensure consistent prioritisation and risk-based decision making, enhancing caseload management so workload is balanced, transparent and responsive and raising documentation standards to support accurate clinical records, defensible practice and effective information sharing. A further priority is embedding clearer expectations for recognising” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use enhanced documentation audits, Quality Assurance Rounds, accreditation and governance processes to monitor and assure record quality.
Verbatim wording from the response “• Use of audit findings to inform training priorities, learning activities and quality improvement programme” Source location Response from Tameside and Glossop Integrated Care
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 Team Leader of the Day and Coordinator of the Day roles to provide senior support and clear escalation routes.
Verbatim wording from the response “Since then, several developments have strengthened the service's response to deteriorating patients:” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use daily SITREP and out-of-hours handover processes to monitor capacity, demand and acuity and escalate urgent staffing pressures.
Verbatim wording from the response “• Improved daily management of capacity, demand and acuity through the SITREP process and Out of Hours (OOH) handover meetings, enabling earlier identification of patients requiring urgent intervention and escalation. Each day is RAG rated as Red, Amber or Green dependent on the allocation of visits and the level of deferred activity. All Red rated days are escalated to the Divisional Nurse and AHP Director for support and action. Red days are also incident reported as a red flag staffing for organisational oversight.” Source location Response from Tameside and Glossop Integrated Care
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 Strengthen documentation of clinical reasoning, escalation decisions and patient-centred care plans.
Verbatim wording from the response “• Increased focus on documenting clinical reasoning, escalation decisions and patient-centred care plans.” Source location Response from Tameside and Glossop Integrated Care
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 Recruit and introduce a senior District Nursing Caseload Facilitator role to strengthen caseload oversight, patient flow and care planning.
Verbatim wording from the response “The Division has also approved the introduction of a senior District Nursing Caseload Facilitator role, designed to provide strengthened oversight of caseload demand, patient flow and the consistency of care planning. This role will support teams to organise, review and prioritise caseloads more effectively, ensuring that all patients have clear plans, defined outcomes and timely progression through the service. At the time of writing, recruitment to this post is underway and interviews are taking place, reflecting the Division’s commitment to further enhancing safe practice, operational grip and accountable caseload management.” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a District Nursing Documentation Group to improve documentation standards and drive continuous improvement.
Verbatim wording from the response “Since then, the service has implemented a comprehensive documentation improvement programme which has been further strengthened following this inquest. This work has included:” Source location Response from Tameside and Glossop Integrated Care
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 Increase caseload reviews and triage to prioritise patients with complex, frail, end-of-life or changing clinical needs.
Verbatim wording from the response “• Increased use of caseload reviews and triage processes to ensure patients with complex needs, frailty, end-of-life care requirements and changing clinical conditions are appropriately prioritised.” Source location Response from Tameside and Glossop Integrated Care
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 Disband the separate triage team and redistribute its resources into clinical roles within each District Nursing Team.
Verbatim wording from the response “In 2025, the service managed referrals via a separate Triage team, however, on review it was noted that this team lacked the awareness of capacity and demand in teams and this may have contributed to the increase in deferred activity. Therefore, the decision was made to disband this team and redistribute the resource back into clinical roles to strengthen the triage and decision within each District Nursing Team. This enabled prompt and timely decision making by the providing team and removed any delay or unnecessary additional triage burdens.” Source location Response from Tameside and Glossop Integrated Care
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 refine EMIS templates to support professional decision-making, risk assessment and clinical oversight.
Verbatim wording from the response “• Review and refinement of EMIS templates to ensure documentation supports professional decision-making, risk assessment and clinical oversight.” Source location Response from Tameside and Glossop Integrated Care
Open published response
22 Dec 2025 Winifred Mary Wardle · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Absence of a clear multidisciplinary protocol for CT scan requests View source Failure to ensure ward-level doctors can obtain urgent CT scan decisions when needed for diagnosis View source Failure to maintain comprehensive records of decision-making on CT scan requests View source Failure to ensure clear and understood escalation routes for rejected CT scan requests View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Winifred Mary Wardle · 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
Winifred Mary Wardle was admitted to hospital with vomiting and an undiagnosed intestinal problem; an incarcerated hernia was identified by CT scan after delays in obtaining the scan. She underwent surgery, aspirated stomach contents immediately beforehand, developed pneumonia, and died after active treatment was withdrawn. The substantive concerns related to the lack of a clear multidisciplinary protocol for CT scan requests, radiology decision-making and escalation processes, and incomplete records of those decisions.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear multidisciplinary protocol for CT scan requests
Wider context from the report “(1) There appears to be an absence within the Tameside General Hospital of a clear protocol for a multi-disciplinary approach to CT scan requests ;
(2) The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis;
(3) The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at ward-level, even by consultants; and
(4) The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure ward-level doctors can obtain urgent CT scan decisions when needed for diagnosis
Wider context from the report “(1) There appears to be an absence within the Tameside General Hospital of a clear protocol for a multi-disciplinary approach to CT scan requests;
(2) The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis ;
(3) The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at ward-level, even by consultants; and
(4) The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain comprehensive records of decision-making on CT scan requests
Wider context from the report “(1) There appears to be an absence within the Tameside General Hospital of a clear protocol for a multi-disciplinary approach to CT scan requests;
(2) The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis;
(3) The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at ward-level, even by consultants; and
(4) The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clear and understood escalation routes for rejected CT scan requests
Wider context from the report “(1) There appears to be an absence within the Tameside General Hospital of a clear protocol for a multi-disciplinary approach to CT scan requests;
(2) The on-call radiologist appears to be the ultimate decision-maker in relation to CT scan requests, even where ward-level doctors require urgent clarity from CT scans to achieve a diagnosis;
(3) The lines of escalation where a request for a CT scan is not accepted by the radiology department are not clearly known or understood at ward-level, even by consultants ; and
(4) The records of the decision-making process concerning CT scan requests are not comprehensive so as to provide a clear account.
” Open source report
7 Oct 2025 Amanda Wood · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure to undertake a sepsis screen before Emergency Department discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Amanda Wood · 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
Amanda Wood died on 3 January 2025 at Tameside General Hospital as a consequence of sepsis related to a long-term gastrostomy and Crohn’s disease. The principal concern was that there was no evidence of a sepsis screen being undertaken before her discharge from the Emergency Department on 28 December 2024, after which she was readmitted within 24 hours.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a sepsis screen before Emergency Department discharge
Wider context from the report “Notwithstanding the ongoing work reported by the Trust in respect of the early identification and treatment of sepsis, I am concerned that there is no evidence of any sepsis screen being undertaken prior to Miss Wood’s discharge from the Emergency Department on 28th December 2024.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing triage, NEWS assessment and consultant review are considered sufficient; sepsis screening need not be repeated before Emergency Department discharge.
Verbatim wording from the response “Firstly, it is important to note that when patients present to the Emergency Department they are triaged in line with the Manchester Triage System, which is a clinical risk management tool used by clinicians worldwide to enable them to safely manage patient flow when clinical need far exceeds capacity. The triage system categorises patients in order of priority and all patients attending the ED should be triaged, or initially assessed, within 15 minutes. As part of this triage, observations are taken using the National Early Warning Score (NEWS) which is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. Mrs.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
18 Jun 2025 Valerie Hampson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to undertake serious incident investigations for learning View source Failure to provide recommended fracture clinic follow-up after orthopaedic review View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Valerie Hampson · 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
Valerie Hampson died at Willow Wood Hospice on 29 December 2024 as a consequence of Non-Hodgkin’s Lymphoma. The report raises concerns about the progression of a left knee wound while she was under District Nurse care, the absence of a serious incident investigation, and apparent failure to provide recommended fracture-clinic follow-up.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake serious incident investigations for learning
Wider context from the report “I am concerned that the Trust has not undertaken any serious incident investigation with a view to identifying if any learning could usefully be identified in the light of the progression of Mrs Hampson’s left leg wound whilst under the care of the District Nurses.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide recommended fracture clinic follow-up after orthopaedic review
Wider context from the report “It is a further matter of concern that the court heard evidence that an Orthopaedic review undertaken in the Emergency Department on Mrs Hampson’s initial attendance resulted in a recommendation that Mrs Hampson should be followed up in fracture clinic . For reasons which did not become clear during the inquest, the evidence of the consultant orthopaedic surgeon was that no such follow up appears to have taken place .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No fracture clinic appointment was made because the Emergency Department X-ray identified no fracture.
Verbatim wording from the response “On a further review of the Mrs Hampson’s records, there is no appointment that has been arranged for the out-patient fracture clinic. The discharge documentation states no mention of fracture clinic appointments. The follow up was that once discharged, care would continue under the District Nursing Service. Following Mrs Hampson’s attendance on 30th October 2024 she was admitted and referred to Wythenshawe and she was managed as an in-patient in Tameside Hospital until she could be transferred to Wythenshawe on 1st November 2024. I am sorry that this information was not made clear to you during the inquest. I can confirm that there was no follow up appointment made in the fracture clinic for Mrs Hampson as no fracture was identified.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A formal investigation was not considered necessary because the circumstances did not meet the Trust’s investigation criteria.
Verbatim wording from the response “Since the inquest we have revisit the care and treatment provided to Mrs Hampson. At the point the wound was noted to be deteriorating, Mrs Hampson was referred promptly back to the Emergency Department. The circumstances surrounding how the wound occurred and how it came to deteriorate did not fit the criteria for investigation in that:” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
11 Jun 2025 Lila Airelle Marsland · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to undertake examination or direct assessment before authorising transfer to the Paediatric Emergency Department View source Fragmented and disjointed storage and sharing of clinical information between professionals View source Failure to embed the Child Sepsis Screening Tool in assessment and treatment of children and young people View source Failure to fully implement the latest NICE guideline on bacterial meningitis and meningococcal disease View source Failure to record paediatric examinations in the medical record View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lila Airelle Marsland · 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
Lila Marsland became unwell with headache, fever, lethargy and neck pain and was discharged from hospital with a diagnosis of viral tonsillitis. She was found to have died at home around six and a half hours after discharge; the inquest recorded that she died as a consequence of undiagnosed and untreated pneumococcal meningitis. Concerns included the embedding of the Child Sepsis Screening Tool, implementation of relevant NICE guidance, the adequacy and recording of clinical assessments, and fragmented storage and sharing of clinical information.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake examination or direct assessment before authorising transfer to the Paediatric Emergency Department
Wider context from the report “3. It is a matter of concern that the Locum Consultant in Emergency Medicine who completed a form indicating Lila was ‘Safe to Transfer’ to the Paediatric Emergency Department did so without undertaking any examination or direct assessment of her . The doctor had previously filed a statement at court indicating he had undertaken a ‘preliminary visual assessment’ of Lila, but accepted in oral evidence that this was not, in fact, the case;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented and disjointed storage and sharing of clinical information between professionals
Wider context from the report “The court heard evidence that, over the course of almost 10 hours in hospital, Lila’s history and details of examinations and assessments undertaken were recorded on a mixture of various analogue and digital systems in operation in different parts of the Trust, leading to a risk of vital clinical information being lost in the system .
I am concerned that this, and other hospitals elsewhere in the country, continue to operate with information being stored and shared between professionals in a fragmented and disjointed way .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed the Child Sepsis Screening Tool in assessment and treatment of children and young people
Wider context from the report “1. Having carefully considered the oral evidence given in court by a range of different clinicians with varying roles and remits, I am concerned that, notwithstanding the work the Trust has undertaken in response to Lila’s death, the Child Sepsis Screening Tool is not yet fully embedded in the minds of those who assess and treat Children and Young People at the Trust ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully implement the latest NICE guideline on bacterial meningitis and meningococcal disease
Wider context from the report “2. I am concerned that the Trust is yet to fully implement the latest iteration of the National Institute of Health and Care Excellence’s Guideline Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management (NG240 Published 19 March 2024) ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record paediatric examinations in the medical record
Wider context from the report “4. I am concerned that no medical record appears to exist of the examination of Lila which was undertaken by the Locum Registrar in Paediatrics which resulted in Lila being discharged from hospital. The absence of this key piece of evidence serves to limit the ability of the Trust to derive all possible learning from Lila’s death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver monthly sepsis simulations and recurring multidisciplinary simulation training for adult and paediatric emergency departments.
Verbatim wording from the response “Sepsis simulations (SIM) are delivered monthly, the latest being in July 2025. Focus weeks have been held in April 2024 and September 2024 for both adults and paediatric ED, in addition to a sepsis focus week in March 2025. Throughout the week commencing 14th July 2025 there was an additional sepsis focus week aimed at all walk-in patients and there will be a further sepsis focus week commencing 15th September 2025 as it is World Sepsis Day on 13th September 2025.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily PEWS and sepsis audits, share results in safety huddles, review themes weekly and provide targeted training.
Verbatim wording from the response “The Trust have implemented regular audits for PEWS and sepsis. Since February 2025 this has converted to daily audits. The results of these audits are shared on safety huddles and immediate actions taken. The Paediatric ED Matron reviews the audits weekly, sends action emails if themes appear and if there is any individual learning identified there will be further training provided by the Paediatric ED Matron and the Practice Based Educators (PBE).” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an electronic triage system with mandated sepsis screening questions that cannot be bypassed.
Verbatim wording from the response “There has been a redesign to the electronic triage form so that you cannot bypass the sepsis screening questions. The ED Matron has worked closely with system developers to create an e-Card Triage System with mandated sepsis screening which forms part of the sepsis bundle. The Manchester Triage System (MTS) is in place. All triage practitioners are registered on the MTS system and annual triage audits of all triage practitioners are in place (this is on-going). Triage training is a rolling programme throughout the year, ensuring any triage practitioners who require further support or training have the opportunity to access the programme supported and delivered by the triage train the trainers and practice-based educators.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace the Safe to Transfer process with immediate emergency-department senior review and sepsis-bundle treatment, using paediatric transfer only when clinically required.
Verbatim wording from the response “The Trust has changed its ‘Safe to Transfer’ process in ED. The Children and Young Person ED has moved into the same footprint as the main ED department as of July 2024. This means that if a child is screened positive for sepsis at triaged, the triage nurse would go to a senior clinician in ED and be commenced immediately on the sepsis bundle. That patient would be streamed to a cubicle for immediate review by a doctor. All the care is given in the emergency department and only if required to transfer to paediatrics for admission would an SBAR be required. If too unwell, Paediatrics would come to ED. The form for the doctor signed in December 2023 is no longer required. The transfer form used for Lila is no longer in use.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate a seven-minute briefing on subtle meningitis signs to staff and present it at Clinical Paediatric Governance meetings.
Verbatim wording from the response “that Trusts’ meningitis guideline has been updated in line with NICE. The Trust has prepared and shared a seven-minute briefing reaffirming the subtle signs of meningitis which was distributed to all staff (consultants, trainees etc.) by email on 5th February 2025 and has also been shared at Clinical Paediatric Governance meeting on 13th February 2025.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain annual triage audits and rolling training for practitioners using the Manchester Triage System.
Verbatim wording from the response “There has been a redesign to the electronic triage form so that you cannot bypass the sepsis screening questions. The ED Matron has worked closely with system developers to create an e-Card Triage System with mandated sepsis screening which forms part of the sepsis bundle. The Manchester Triage System (MTS) is in place. All triage practitioners are registered on the MTS system and annual triage audits of all triage practitioners are in place (this is on-going). Triage training is a rolling programme throughout the year, ensuring any triage practitioners who require further support or training have the opportunity to access the programme supported and delivered by the triage train the trainers and practice-based educators.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with NICE meningitis recommendations and develop action plans, guidelines and policies addressing identified improvement areas.
Verbatim wording from the response “• The service completed an audit in November 2024 to assess staff compliance with NICE’s recommendations for ‘meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management (NG240)’. The audit identified good staff compliance in standards around initial assessment, taking blood cultures and blood sugars, undertaking correct investigations and computed tomography (CT) scans and antibiotic choice and duration.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement NICE NG240 meningitis guidance and update the Trust meningitis guideline accordingly.
Verbatim wording from the response “The National Institute of Health and Care Excellence’s Guideline Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management has been implemented and” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing sepsis training, audits and improvement work demonstrate that the screening tool is embedded among staff assessing and treating children and young people.
Verbatim wording from the response “I consider the above evidence demonstrates that the Trust is providing training for sepsis, identifying learning and implementing these changes effectively and validates that the Trust is ensuring that sepsis is embedded in the minds of those who assess and treat children and young people.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The latest NICE meningitis guideline has been implemented, and the Trust’s meningitis guideline has been updated accordingly.
Verbatim wording from the response “The National Institute of Health and Care Excellence’s Guideline Meningitis (bacterial) and meningococcal disease: recognition, diagnosis and management has been implemented and” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
19 Sep 2024 Suzanne Rose Eccles · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a system enabling Emergency Department clinicians to easily access Virtual Ward records 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
Suzanne Rose Eccles · 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
Suzanne Rose Eccles died on 3 March 2024 at Tameside General Hospital after developing pneumonia and empyema following recent surgery for lung cancer; her death was also contributed to by ischaemic heart disease. The report identified concern that Emergency Department clinicians could not easily access records made by colleagues on the Virtual Ward.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system enabling Emergency Department clinicians to easily access Virtual Ward records
Wider context from the report “Whilst the court heard evidence as to significant work which has been undertaken following the Trust’s detailed investigation into the circumstances leading to Mrs Eccles’s death, it is a matter of concern that no system currently operates whereby clinicians working in the Emergency Department can easily access records made by colleagues working on the Virtual Ward .
” 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 Operate an alert process on Lorenzo prompting Emergency Department staff to review virtual-ward patient status until GMCR access launches.
Verbatim wording from the response “Once the GMCR record is operational, ED will have their own direct access to the GMCR through the icon. Until this is launched on 16th April 2025, there is an alert process on Lorenzo that will prompt staff to review the position on Virtual Ward which has been in place since the inquest in September 2024.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain Docobo contract approval and enact the change notice to enable the GMCR virtual-ward record for Emergency Department access.
Verbatim wording from the response “The Trusts’ Neighbourhood Clinical Lead has engaged in multiple discussions with the GMCR Team and the Chief Digital Office for Greater Manchester Integrated Care Partnerships (GMICB) who have confirmed that the Trust can have access to the system. The Change Control Notice (CCN) was sent to be switched on circa 16th October 2024 and we were informed it would take 3-4 weeks but this was subject to delay from the provider. It was hoped that this would have been completed sooner but was subsequently delayed due to a financial barrier. This has now been resolved.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete clinical safety work enabling Emergency Department staff to view virtual-ward patient observations through the GMCR.
Verbatim wording from the response “Subject to the above all being signed off, the Docobo icon on the GMCR is intended to go live on 16th April 2025. Clinical safety has been carried out by the Trusts’ Chief Clinical Information Officer so that all ED staff can see the virtual ward patient observation, then the Trust will commence the training of all ED and Digital Health staff on the GMCR which we anticipate will take 3-6 weeks to implement, from 16th April 2025.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Change the EMIS alert process to prompt clinicians to review GMCR records and care plans once the GMCR is operational.
Verbatim wording from the response “Until the GMCR goes live, all patients admitted to the virtual ward have an alert added to community EMIS informing that the patient is on the virtual ward. EMIS is a clinical software system used in primary care, acute care and community pharmacy. Following the period of care, this alert is removed. Once the GMCR is operational, the alert process will remain on EMIS but will be changed to prompt clinicians to review the GMCR record/care plans. This will be led by Digital Health.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the electronic Virtual Ward Patient Management Board with live patient updates accessible across the acute organisation.
Verbatim wording from the response “In addition to the above, an electronic Virtual Ward Patient Management Board has been created and is available across the acute organisation, with live and current patient updates across all departments. Bed managers are able to see and access this Ward Board. It is just out of development and is being moved to the Emergency Departments Clinical Portal System, so that it will make it easier to see the list of patients currently under the care of the Virtual Ward. The board provides information about the level of risk that a patient is at whilst on Virtual Ward and the number of contacts that they have had each day and what condition they are being monitored/supported at home for. This board enables ED Teams to have full access to patients twenty-four hours each day, seven days a week.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all Emergency Department and Digital Health staff to use the GMCR.
Verbatim wording from the response “Subject to the above all being signed off, the Docobo icon on the GMCR is intended to go live on 16th April 2025. Clinical safety has been carried out by the Trusts’ Chief Clinical Information Officer so that all ED staff can see the virtual ward patient observation, then the Trust will commence the training of all ED and Digital Health staff on the GMCR which we anticipate will take 3-6 weeks to implement, from 16th April 2025.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move the Virtual Ward Patient Management Board to the Emergency Departments Clinical Portal System.
Verbatim wording from the response “In addition to the above, an electronic Virtual Ward Patient Management Board has been created and is available across the acute organisation, with live and current patient updates across all departments. Bed managers are able to see and access this Ward Board. It is just out of development and is being moved to the Emergency Departments Clinical Portal System, so that it will make it easier to see the list of patients currently under the care of the Virtual Ward. The board provides information about the level of risk that a patient is at whilst on Virtual Ward and the number of contacts that they have had each day and what condition they are being monitored/supported at home for. This board enables ED Teams to have full access to patients twenty-four hours each day, seven days a week.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
17 Jul 2023 Jane Elizabeth Wadsworth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure administration and escalation of missed antibiotic doses View source Failure to discuss cases with the specialist Liver team View source Lack of clear clinical ownership of specialist consultation actions View source Lack of effective consultant input into inpatient care View source Failure of Critical Care Outreach assessment to address complex non-NEWS2 indicators of ICU need View source Failure to conduct effective doctor-to-doctor discussion of potential ICU involvement View source Unavailability and insufficient capacity of the Critical Care Outreach team View source See 4 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
Jane Elizabeth Wadsworth · 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
Jane Elizabeth Wadsworth became seriously unwell after elective hip surgery, developing a deep vein thrombosis, cellulitis, sepsis, acute kidney injury and liver failure, and died on 31 December 2022 despite intensive care treatment. Concerns included missed antibiotic doses, limited consultant input, unclear escalation and doctor-to-doctor discussion about intensive care, unavailable Critical Care Outreach support, and no evidence that specialist liver advice was obtained.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure administration and escalation of missed antibiotic doses
Wider context from the report “1. Mrs Wadsworth missed three doses of antibiotics prescribed to treat her infection according to the evidence given to the inquest. This did not appear to have been escalated and there was no clear explanation regarding this occurring other than that her cannula may not have been in place and there was a delay in a doctor being available to reinsert one;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss cases with the specialist Liver team
Wider context from the report “6. Following her first admission to ICU there was a note that Mrs Wadsworth’s case should be discussed with a specialist Liver team. There was no evidence available to the inquest that such a discussion had taken place . It was not entirely clear on the evidence precisely which clinician was to take ownership of the action.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear clinical ownership of specialist consultation actions
Wider context from the report “6. Following her first admission to ICU there was a note that Mrs Wadsworth’s case should be discussed with a specialist Liver team. There was no evidence available to the inquest that such a discussion had taken place. It was not entirely clear on the evidence precisely which clinician was to take ownership of the action .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective consultant input into inpatient care
Wider context from the report “2. The evidence before the inquest was that on her admission over Christmas/New Year there was no effective consultant input into her care ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Critical Care Outreach assessment to address complex non-NEWS2 indicators of ICU need
Wider context from the report “4. The alternative support available to ward based staff and possible route into ICU according to the evidence given at inquest was via the Critical Care Outreach team. That team is staffed primarily by nurses and its key focus is on presentation linked to NEWS2 scores according to the evidence given to the inquest. Mrs Wadsworth’s case was a complex one involving issues relating to her liver function and kidney function rather than just her NEWS2 scores and it was unclear if the Critical Care Outreach Team were best placed to assess her need for ICU support ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct effective doctor-to-doctor discussion of potential ICU involvement
Wider context from the report “3. The junior doctor involved in her care felt that ICU involvement/input would be beneficial. The evidence was that there did not seem to be any doctor to doctor discussion of this . The inquest heard evidence that this was one way a patient could be transferred to ICU. It was unclear why there had not been such a discussion and whether in periods such as Christmas/ New Year where there were fewer consultants available the system worked effectively . This was not a situation where there had been a ward based ceiling of care put in place and ultimately Mrs Wadsworth was treated by ICU but was extremely unwell at that point and did not respond to that intervention at that point;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability and insufficient capacity of the Critical Care Outreach team
Wider context from the report “5. The inquest heard that on the date of one referral that team was not in any event available to the ward and the nurse who should have undertaken the role had been redeployed elsewhere in the trust and there was no capacity to fill that role ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a staff poster explaining how to prevent medication omissions and obtain unavailable medicines.
Verbatim wording from the response “The Trust recognise that there is an overall percentage of medication doses which are omitted for a ‘non-valid clinical reason’. This means that unsigned doses would be recorded under this category (along with any medication doses omitted due to lack of availability). In the last completed audit the percentage of medication doses omitted for a ‘non-valid clinical reason’ averaged 4% of all prescribed doses. This audit is part of the Trust’s standard audit cycle and the results are fed back to the multidisciplinary Medicines Safety Group. One of the actions from the last audit was to issue a new poster which highlights to all staff how to avoid omissions in medication- this includes information of how to access medication if unavailable within the clinical area.” Source location Response from Tameside and Glossop Integrated Care
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 Critical Care Unit daily review chart to document clearly who referred patients to the Liver Unit and when.
Verbatim wording from the response “The Trust acknowledge that the clinical documentation recorded within the Critical Unit was not clear with regards to who and when Mrs Wadsworth was referred to the Liver Unit. In response to this the Critical Care Unit have amended their daily review chart to provide additional clarity on this point and that this is documented in a more comprehensive way.” Source location Response from Tameside and Glossop Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide each ward with an allocated pharmacist and pharmacy technician to review treatment sheets daily and support timely medication ordering.
Verbatim wording from the response “To provide further support for inpatient areas each ward has a Ward based Pharmacy Team. Each ward area has an allocated ward pharmacist and pharmacy technician who evaluate individual treatment sheets on a daily basis. They form a key element of the multidisciplinary team caring for our patients. Pharmacy presence on the wards supports the accurate prescribing and administration of medication. They also ensure timely ordering of medications which do not form part of the routine medication stocked within the ward area.” Source location Response from Tameside and Glossop Integrated Care
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 omitted medication doses through pharmacy, ward quality-assurance and accreditation processes, reporting results and sharing learning for improvement.
Verbatim wording from the response “The Trust continue to focus on improvement in relation to missed doses of medication. There is an established program of medication audits which are reported to the Trust’s Medication Safety Group. The Medication Group meet bi-monthly and has a multidisciplinary membership. At present the Pharmacy Department perform an annual snapshot retrospective audit which focuses on omitted/unsigned doses. The audit covers inpatient areas and looks at any medication doses which are not administered as prescribed and the documented reasons for this. The most recent audit was presented to Trust Medicines Safety Group on 28/04/23.” Source location Response from Tameside and Glossop Integrated Care
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 Redesign the medication kardex to highlight time-critical medicines and streamline ward medication-ordering and emergency supply arrangements.
Verbatim wording from the response “The Trust medication kardex has been redesigned to place greater emphasis on time critical medications. Pharmacy systems for ordering medications to the ward have been streamlined and the Trust also has an emergency medication cupboard and an on-call pharmacy for obtaining medications out of hours. I attach a copy of the template of the updated medicines kardex and the PowerPoint slides to support the new medicine chart for your consideration and information.” Source location Response from Tameside and Glossop Integrated Care
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 a critical-care referral policy defining consultant-to-consultant and urgent medical-registrar referral pathways.
Verbatim wording from the response “The Admission and Discharge Policy for Critical Care clearly sets out referral pathways for those patients who may require a higher level of care leading critical care due to their current clinical condition. The referral pathway is in line with national guidance (National Confidential Enquiry into Perioperative Deaths- NCEPOD, The National Institute for Health and Care Excellence- NICE, National Patient Safety Agency-NPSA, and Royal College Physicians) that the optimal referral pathway is consultant to consultant. However the policy describes that in more critical instances where any delay may be detrimental to the patient then a referral may come from training grade doctors. It is expected that this be a medical registrar (i.e. medical middle grade either on-call or responsible for the patient).” Source location Response from Tameside and Glossop Integrated Care
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 a 24-hour, seven-day MERIT service staffed by senior anaesthetic clinicians to provide emergency critical-care support.
Verbatim wording from the response “The Trust has an established Critical Care Outreach Team which is comprised of a number of highly skilled and experienced critical care nursing colleagues. The service is available on a 24 hour, seven day a week basis. In addition to this the Trust also implemented a MERIT (Medical Emergency and Rapid Intubation Team) team as part of its response to the Covid-19 pandemic. Although the Trust, like other nations have stood down many of the supportive measures implemented in response to the pandemic, the organisation has continued with the MERIT Team. The MERIT Team is staffed by senior anaesthetic colleagues, including Consultant level from 08:30 to 18:00, and from 18:00 to 08:30 this is staffed by a middle grade anaesthetist.” Source location Response from Tameside and Glossop Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide medication-omission induction and refresher training, with medication-management assessment for nurses new to the Trust.
Verbatim wording from the response “The issue of omitted doses is covered in the nursing induction training that the Pharmacist delivers. Every nurse receives this training at the point of joining the Trust. This training can also be accessed as a refresher course. Every nurse new to the Trust also receives a medication management assessment undertaken by the Ward Manager which evidences safer practice in keeping with Trust policy. This is recorded in the individual’s personnel file and a copy sent to the learning and development department.” Source location Response from Tameside and Glossop Integrated Care
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 consultant on-call rota had no staffing deficit during the admission, contrary to concerns about ineffective consultant input over Christmas and New Year.
Verbatim wording from the response “The Trust operates a Consultant on-call rota which includes all weekends and bank holidays throughout the year. The on-call Consultant’s remit is one of assisting their Urgent Care consultant colleagues in the review of new patients who have been admitted to the Acute Medical Unit and also to perform the review and care planning of any acutely unwell medical patients located in the medical wards across the Hospital if required.” Source location Response from Tameside and Glossop Integrated Care
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 outreach absence procedures, staffing oversight and MERIT support provided alternative safeguards when an outreach practitioner was redeployed.
Verbatim wording from the response “the appropriate medical plan to be put in place. At the time of Mrs Wadsworth’s admission the Outreach Practitioner had been allocated to an inpatient area to mitigate risk following a short notice staff absence. However despite this the ward team could have also considered contacting the MERIT team for advice and guidance for Mrs Wadsworth.” Source location Response from Tameside and Glossop Integrated Care
Open published response
16 May 2023 Roger Southwick · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to complete Falls Risk Assessments accurately View source Failure of investigation reports to identify and address falls-risk assessment deficiencies View source Failure to reassess falls risk following information about compromised mobility and unsteadiness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Amend the falls-prevention policy to assess changes from a patient’s baseline mobility and support holistic patient and relative or carer assessment.
Stated plannedThe respondent said that this action was planned when they made their response on 17 May 2023. View source
Action
Recirculate the falls proforma within the Acute Medical Unit and implement monthly ward-link-nurse audits of assessment accuracy.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Create a Safer Care Assurance Panel to review moderate-harm falls incidents, root-cause analyses, missed opportunities and learning to prevent future harm.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Operate a twice-weekly Incident Review Group to review falls and other incidents, support timely reviews, and share immediate learning.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Operate the Safer Care Group to develop, implement and monitor falls-prevention work, including training, audit, performance gaps and improvement plans.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source
Action
Operate the Serious Incident Review Group with executive oversight to determine investigations, review serious harm incidents and support organisational learning.
Stated completedThe respondent said that this action was complete when they made their response on 17 May 2023. View source See 3 more actions
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AI-generated summary
Roger Southwick · 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
Roger Southwick was admitted to hospital on 5 November 2022 with breathlessness, a chest infection and low sodium levels following heart failure. He fell on 7 November after an inaccurate falls risk assessment and concerns about his mobility were not acted on; he sustained a significant subdural haemorrhage and died on 9 November 2022. The substantive concerns were failures to accurately assess and reassess his falls risk, and the failure of the investigation report to identify these issues.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete Falls Risk Assessments accurately
Wider context from the report “(1) There was a failure to complete the Falls Risk Assessment accurately ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigation reports to identify and address falls-risk assessment deficiencies
Wider context from the report “(3) The Investigation Report prepared by the Trust failed to identify and therefore did not address issues 1 and 2 above .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess falls risk following information about compromised mobility and unsteadiness
Wider context from the report “(2) There was a failure to reassess the risk of falls when staff were informed by members of the deceased’s family of his significantly compromised mobility and unsteadiness on his feet ;
” 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 Amend the falls-prevention policy to assess changes from a patient’s baseline mobility and support holistic patient and relative or carer assessment.
Verbatim wording from the response “The Trust have reviewed the Falls prevention policy and have identified further improvement to the policy which will now include the assessment of the patient to include changes from their ‘baseline’ mobility, this will facilitate a holistic patient and relative/carer approach to assessing mobility and any acute changes.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recirculate the falls proforma within the Acute Medical Unit and implement monthly ward-link-nurse audits of assessment accuracy.
Verbatim wording from the response “The requirement of when and how complete a falls risk assessment is clearly described in the Trust’s Slips, and Falls Policy, which is accessible to all staff in the Trust (attached for your information). There has been a focused piece of work undertaken on the Acute Medical Unit in relation to falls risk assessment and the accuracy of this. During the inquest of Mr Southwick, the falls proforma was not completed in line with Trust policy following a fall. This proforma has been recirculated within the Acute Medical Unit team with emphasis on the importance of the accuracy of this document. As such a monthly audit has been implemented and is completed by the ward link nurse for falls.
This focused piece of work has been discussed at a number of forums including:” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Safer Care Assurance Panel to review moderate-harm falls incidents, root-cause analyses, missed opportunities and learning to prevent future harm.
Verbatim wording from the response “• Safer Care Assurance Panel has been created to review falls and pressures ulcer incidents, which caused moderate harm. Chaired by a Deputy Director of Nursing or Head of Nursing, this forum reviews Root Causes Analyses (RCAs) to identify areas of good practice and any missed opportunities or lapses in care to ensure learning can be gained and future harms prevented.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a twice-weekly Incident Review Group to review falls and other incidents, support timely reviews, and share immediate learning.
Verbatim wording from the response “To provide additional oversight and learning of falls incidents the Trust now also operate a scrutiny process which comprises of the following:” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Safer Care Group to develop, implement and monitor falls-prevention work, including training, audit, performance gaps and improvement plans.
Verbatim wording from the response “• Safer Care Group –The Safer Care Group was created to lead the development, implementation and monitoring of work within the Safer Care portfolio which includes falls. The Group is chaired by one of the trusts Deputy Chief Nurses and the patient safety clinical lead. This group reports into Service Quality and Governance (SQAG) via the Patient Safety Programme Board. The group monitors performance, training and audit in relation to harm prevention across the Integrated Care Foundation Trust. It measures compliance against key targets taking responsibility for identification of gaps and develops improvement plans to address and action these. Oversight of divisional work is monitored via this group, with key update reports including a summary of training compliance, audit results, action plan updates, learning from incidents and any quality improvement work being delivered.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Serious Incident Review Group with executive oversight to determine investigations, review serious harm incidents and support organisational learning.
Verbatim wording from the response “• Serious Incident Review Group (SIRG). The Serious Incident Review Group is held on a weekly basis and supports robust governance systems relating to the declaration, investigation, completion and learning from serious incident investigations declared in line with the Serious Incident Framework (2015). SIRG has replaced the current Executive Scrutiny Panel and reports into the Service, Quality Assurance and Governance Group (SQAG). SIRG has Executive oversight and receives and reviews all incidents where a patient(s) is suspected to have come to significant harm, or where a never event is suspected; determine the agreed level/type of investigation to be completed and where relevant, to agree external reporting to commissioning and regulatory bodies.” Source location Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Open published response
25 Nov 2022 Mrs Joan Robinson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to consistently support, hold and attend the Nutrition and Hydration Committee View source Failure to mandate Malnutrition Universal Screening Tool training for nurses and healthcare assistants View source Failure to achieve completion of Malnutrition Universal Screening Tool training 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
Mrs Joan Robinson · 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 Joan Robinson was admitted to hospital after sustaining multiple cervical spinal fractures in a fall at home. During her admission she developed confusion, difficulty swallowing, poor oral intake, atrial fibrillation, congestive cardiac failure and acute kidney injury, and palliative care was instituted. Concerns related to incomplete and non-mandatory training in the Malnutrition Universal Screening Tool and insufficient support, holding or attendance for the Trust’s Nutrition and Hydration Committee.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently support, hold and attend the Nutrition and Hydration Committee
Wider context from the report “3. It is a further matter of concern given the importance of adequate nutrition and hydration as a part of basic patient care, that the Trust’s own internal investigation into the care and treatment provided to Mrs Robinson has found that the ‘Nutrition and Hydration Committee [is] not consistently supported, held or attended’ .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to mandate Malnutrition Universal Screening Tool training for nurses and healthcare assistants
Wider context from the report “2. Connected with the above, it is a matter of concern that whilst the Trust describes this training as ‘essential’ it is not deemed mandatory for completion by certain staff groups such as nurses and healthcare assistants ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to achieve completion of Malnutrition Universal Screening Tool training
Wider context from the report “1. The court heard evidence that, despite training on the Malnutrition Universal Screening Tool being regarded by the Trust as ‘essential’, the completion rate of training within the organisation is currently just 58.74% ;
” Open source report
6 Aug 2022 Ernest Bacon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Failure to review relevant clinical notes during assessment View source Failure to flag sepsis concerns in patient notes View source Failure to escalate non-compliance with the sepsis policy View source Failure to provide face-to-face clinical review View source Insufficient availability of doctors for ward clinical reviews View source Delays in further clinical review after continued sepsis triggers View source Failure to recognise the seriousness of a patient's condition View source Failure to place sepsis-triggering patients on the sepsis pathway View source Failure to flag deteriorating patients during handover View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Deliver sepsis awareness, training and dissemination activities through briefings, scenario sessions, toolbox talks and sharing learning with clinical teams.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022. View source
Action
Agree additional nursing posts to support sepsis identification, training and compliance across the organisation.
Stated completedThe respondent said that this action was complete when they made their response on 30 September 2022. View source
Action
Conduct monthly internal spot-check audits of sepsis pathway compliance and report non-compliance through incident forms.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022. View source
Action
Progress a business case to increase junior-doctor provision and reduce reliance on locum and agency doctors.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022. View source
Action
Implement a Trust-wide sepsis improvement programme covering recognition, Sepsis Care Bundle use, antibiotics, blood cultures and deteriorating-patient assessment.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022. View source
Action
Run a Trust-wide incident-reporting programme addressing incident and near-miss identification, reporting, learning and action.
Stated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022. View source See 3 more actions
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AI-generated summary
Ernest Bacon · 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
Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review relevant clinical notes during assessment
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen . The seriousness of his condition was not recognised and he was not flagged up on handover;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to flag sepsis concerns in patient notes
Wider context from the report “4. The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy. The reason for non-escalation was unclear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate non-compliance with the sepsis policy
Wider context from the report “4. The nursing team recognised that he was triggering for Sepsis but the notes were not flagged and the failure to follow the Sepsis policy was not escalated in accordance with Trust Policy . The reason for non-escalation was unclear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide face-to-face clinical review
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone . His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of doctors for ward clinical reviews
Wider context from the report “1. The Inquest heard that when Mr Bacon became unwell on 16th January the Trust was staffed at weekend/OOD doctor numbers . This meant that there were a very limited number of doctors available within the hospital when the ward staff asked for a clinical review when Mr Bacon triggered for sepsis on the NEWS2 system. The Inquest heard that the staffing numbers of doctors and reliance on junior doctors at weekend to cover the wards is part of the national staffing model;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in further clinical review after continued sepsis triggers
Wider context from the report “3. The Trust Policy required he be treated for Sepsis. However he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the seriousness of a patient's condition
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to place sepsis-triggering patients on the sepsis pathway
Wider context from the report “3. The Trust Policy required he be treated for Sepsis. However he was not placed on the Sepsis pathway and a further review did not take place until a further doctor was asked to examine him at about 22.30 despite his NEWS2 score continuing to trigger for Sepsis;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to flag deteriorating patients during handover
Wider context from the report “2. As a consequence of the availability of doctors he was not reviewed face to face but via telephone. His notes were not seen. The seriousness of his condition was not recognised and he was not flagged up on handover ;
” 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 Deliver sepsis awareness, training and dissemination activities through briefings, scenario sessions, toolbox talks and sharing learning with clinical teams.
Verbatim wording from the response “The Trust has had a Trust wide a focus on World Sepsis Day which was held on the 13th September 2022. The Trust’s Safer Care team have held a focus on sepsis week which took place over the week of 12th -18th September 2022. The objective of the week was to raise the profile of sepsis throughout the organisation and to reiterate recognition and management of suspected sepsis. During the week results of the sepsis audit and a detailed action plan on the sepsis improvement work was shared at the Trust’s Grand Round and the Managing Deteriorating Patient Group. In addition to this, 7-minute briefings on recent sepsis incidents have been developed and are being shared across the Trust. The Safer Care team have also created sepsis related scenarios to engage teams in identifying red flags for sepsis and encourage adherence to the use of sepsis care bundles.” Source location Response from Tameside and Glossop Integrated Care
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 Agree additional nursing posts to support sepsis identification, training and compliance across the organisation.
Verbatim wording from the response “The sepsis improvement work has also been reported to the Trust’s Quality and Governance Committee, which is chaired by a Non-Executive Director. As a direct action following this meeting additional nursing posts were agreed which will specifically support clinical teams in sepsis identification, training and compliance across the organisation.” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly internal spot-check audits of sepsis pathway compliance and report non-compliance through incident forms.
Verbatim wording from the response “To provide internal assurance spot check audits have been implemented to specifically look at compliance with the sepsis pathway. The audits have commenced and include a review of 10 patients each month. Where compliance with the pathway has not been present, an incident form will be completed contemporaneously.” Source location Response from Tameside and Glossop Integrated Care
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 Progress a business case to increase junior-doctor provision and reduce reliance on locum and agency doctors.
Verbatim wording from the response “Whilst the Trust does acknowledge that the junior doctor rota meets national guidance it does need to be strengthened further to support increased activity and acuity in the ward areas. The Trust is currently progressing a business case to increase the level of junior doctor provision which also aims to reduce reliance on locum and agency doctors.” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Trust-wide sepsis improvement programme covering recognition, Sepsis Care Bundle use, antibiotics, blood cultures and deteriorating-patient assessment.
Verbatim wording from the response “Immediately following the inquest touching the death of Mr. Bacon the Trust completed a retrospective root cause analysis investigation into the clinical care of Mr Bacon, and in particular the response to his raised National Early Warning Score (NEWS) and recognition of sepsis. This was also retrospectively reported on the Trust’s incident reporting electronic system. A number of learning points were identified as a result of the investigation and the findings have been used to support a Trust wide sepsis improvement plan.” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a Trust-wide incident-reporting programme addressing incident and near-miss identification, reporting, learning and action.
Verbatim wording from the response “In addition to this, there has been a Trust wide focus on incident reporting throughout the month of September 2022. This work has been underway across the organisation and is being led by the Assistant Director of Integrated Governance throughout, culminating in the Trust’s Patient Safety Conference on October 6th 2022. This programme of events and activities seeks to engage staff at all levels and focusses on identification of incidents or near misses, incident reporting, acting on and learning from incidents.” Source location Response from Tameside and Glossop Integrated Care
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 Overnight junior doctor cover exceeded Royal College of Physicians national guidance when the deterioration occurred.
Verbatim wording from the response “On Sunday night 16th / 17th January 2022, the night when Mr. Bacon’s condition sadly deteriorated, the level of junior doctor cover for the medical wards overnight exceeded that set out in national guidance by the Royal College of Physicians (2018). The actual number of doctors on call at that time were three Tier 1 doctors and one Tier 2 doctor covering non-covid medical beds. At the time that Mr. Bacon died the Trust were experiencing a significant increase in clinical activity as they were responding to the Omicron Covid wave.” Source location Response from Tameside and Glossop Integrated Care
Open published response
4 Aug 2022 James Robert Curry · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to provide orthopaedic bed placement for patients requiring hip fracture surgery View source Failure to provide NICE-compliant orthogeriatric care on admission View source Failure to provide hip fracture surgery within NICE-compliant timescales View source Failure to provide timely bed access for elderly patients with hip fracture View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Robert Curry · 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
James Robert Curry died at Tameside General Hospital on 18 November 2021 from bronchopneumonia after an accidental fall caused a fractured neck of femur. The report identified prolonged waiting in the emergency department, shortages of beds and theatre capacity, lack of orthogeriatric care, and surgery taking place outside the recommended timescale as substantive concerns.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide orthopaedic bed placement for patients requiring hip fracture surgery
Wider context from the report “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case;
2. Mr Curry needed an orthopaedic bed to enable him to have the operation . The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance;
3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide NICE-compliant orthogeriatric care on admission
Wider context from the report “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case;
2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance ;
3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide hip fracture surgery within NICE-compliant timescales
Wider context from the report “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case;
2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance;
3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely bed access for elderly patients with hip fracture
Wider context from the report “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case ;
2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance;
3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance.
” 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 Report surgery delays exceeding 36 hours, complete root cause analyses, and review findings weekly for learning and approved actions.
Verbatim wording from the response “Where the Trust are not able to meet the 36 hour timeframe for surgery for patient with a fracture neck of femur a clinical incident report is submitted. Following the incident a root cause analysis is completed by the Trauma Coordinators to identify reasons for the delay and opportunities for learning. The root cause analysis investigations are then reviewed weekly in the “NOF Review Meeting” for comment, action and approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron for Trauma and Orthopaedics and the Directorate Manager.” Source location Response from Tameside and Glossop Integrated Care
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 compliance with NICE hip-fracture guidance and submit daily data to the National Hip Fracture Database and related audit programme.
Verbatim wording from the response “For assurance of performance with the National Institute for Health and Care Excellence (NICE) Clinical guidance the Surgery, Women’s and Children’s Division are monitoring compliance on an ongoing basis. The Trust submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma co-ordinators daily. The Trust have implemented a Divisional fractured neck of femur improvement programme which is reported and monitored daily via the Divisional senior leadership team.” Source location Response from Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a divisional fractured-neck-of-femur improvement programme with daily senior-leadership reporting and monitoring.
Verbatim wording from the response “For assurance of performance with the National Institute for Health and Care Excellence (NICE) Clinical guidance the Surgery, Women’s and Children’s Division are monitoring compliance on an ongoing basis. The Trust submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma co-ordinators daily. The Trust have implemented a Divisional fractured neck of femur improvement programme which is reported and monitored daily via the Divisional senior leadership team.” Source location Response from Tameside and Glossop Integrated Care
Open published response
17 Jul 2022 Kathleen Stewart · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to identify incident learning from what went wrong View source Failure to assess the fitness of the Emergency Department system for acting on abnormal clinical imaging reports View source Failure to act on abnormal clinical imaging reports and provide indicated follow-up View source Failure to assess whether problems acting on abnormal clinical imaging reports are broader than an isolated incident View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kathleen Stewart · 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
Kathleen Stewart fell at her care home and was taken to hospital after reporting groin pain. Her pelvic X-ray was later reported as showing a minimally displaced fracture, but the report was not acted upon; she was discharged without the indicated follow-up and subsequently deteriorated and died. The concerns included the failure to act on the abnormal imaging report and the lack of a specific investigation into the incident and related systems.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify incident learning from what went wrong
Wider context from the report “1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus;
It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy;
2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:-
a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident ;
b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or
c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the fitness of the Emergency Department system for acting on abnormal clinical imaging reports
Wider context from the report “1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus;
It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy;
2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:-
a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident;
b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or
c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on abnormal clinical imaging reports and provide indicated follow-up
Wider context from the report “1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus;
It is a matter of concern that this X-Ray report was not acted upon , and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy ;
2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:-
a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident;
b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem); or
c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess whether problems acting on abnormal clinical imaging reports are broader than an isolated incident
Wider context from the report “1. The court heard evidence that, whilst the Middle Grade doctor who treated Mrs Stewart in the Emergency Department did not identify any bony injury, a Radiographer who formally reported on the pelvic X-Ray the following day identified a minimally displaced fracture of the right superior pubic ramus;
It is a matter of concern that this X-Ray report was not acted upon, and as such Mrs Stewart did not receive the indicated follow up of analgesia and referral for physiotherapy;
2. It is a further matter of concern that the Trust does not appear to have undertaken any specific investigation as to why this was the case. As such, the Trust has not taken the opportunity to:-
a) Identify what went wrong in Mrs Stewart’s case and ascertain what learning can be derived from the incident;
b) Ascertain whether this was an isolated incident or whether there was (or is) a broader problem in relation to acting on abnormal reports of clinical imaging (and if so, the nature and extent of any such problem) ; or
c) Consider the fitness or purpose of the system in place within the Emergency Department for acting on abnormal reports of clinical imaging.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a monthly organisation-wide incident-reporting focus covering incident identification, reporting, response and learning.
Verbatim wording from the response “In addition to this, a planned monthly focus on incident reporting is currently underway across the organisation and being led by the Assistant Director of Integrated Governance throughout September, culminating in the Trust’s Patient Safety Conference on October 6th 2022. This programme of events and activities seeks to engage staff at all levels and focuses on identification of incidents or near misses, incident reporting, acting on and learning from incidents.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Repeat the radiology governance audit on a six-month rolling programme, including compliance with the new SOP.
Verbatim wording from the response “It is our intention to repeat this audit on a six month rolling programme and this will include standards to measure compliance with the new SOP as detailed in the section one of this response. This specific audit has also been added to the Trust Audit plan which is overseen at the Service Quality and Assurance Group and the Quality and Governance Committee.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 radiology findings using a large random sample to assess Emergency Department fracture identification and follow-up actions.
Verbatim wording from the response “The investigation was informed by an audit of radiology findings, using a large random sample from June 2022. In respect of Emergency Department clinicians identifying fractures, the audit found that the Trust scored favourably when compared to the National average (3.1%, compared to 3.7% Nationally). The audit also identified that the small number of fractures not identified by Emergency Department clinicians were all acted upon appropriately when the report was received from a Radiologist or Reporting Radiographer.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Incident Reporting and Incident and Complaint Investigation Policy against the NHS England Patient Safety Framework.
Verbatim wording from the response “It is considered that this could have been handled differently, with improved triangulation. Detailed action to improve this have been outlined to you in my letter of 11th August 2022 and you are aware that the Trust’s Incident Reporting, and Incident and Complaint Investigation Policy is currently being reviewed alongside the NHS England Patient Safety Framework to ensure that this aligns. The policy will outline the process for identifying, reporting, managing, investigating and learning from patient safety incidents. The purpose of this review of policy is to support a systematic, compassionate and effective response to patient safety incidents; with a clear focus on learning and continuous improvement. This work will ensure accountability, compassion, openness and ownership of improvement and will provide a basis for local training and development.” Source location Response from NHS Tameside and Glossop Integrated Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a retrospective multidisciplinary learning review of the incident and identify learning from the case.
Verbatim wording from the response “As a result of your concerns outlined above, the Trust has undertaken a retrospective concise investigation into Mrs Stewart’s case in the form of an Multi Disciplinary Team (MDT) learning review involving Urgent Care and Radiology.” Source location Response from NHS Tameside and Glossop Integrated Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and test an electronic RAG-priority radiology reporting and alerting system for Emergency Department findings.
Verbatim wording from the response “Whilst the Trust has current safety net procedures in place, we are working to introduce a system whereby a Radiologist or Reporting Radiographer will be able to immediately assign a level of priority to each report in the Radiology reporting system, CRIS. This will be completed using a using a Red-Amber-Green (RAG) rating.” Source location Response from NHS Tameside and Glossop Integrated Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require Consultant review on the day for specified X-rays received by the Emergency Department before 22:00.
Verbatim wording from the response “The audit will be used to inform future teaching sessions for junior doctors; providing additional education in respect of pubic rami, lumbar spine and thoracic spine X-Rays. These X-Rays will also be reviewed by a Consultant on the day of performance where received by the Emergency Department prior to 22:00 hours. This is intended to reduce the occasions on which injuries are not identified by doctors within the Emergency Department.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a multidisciplinary learning event and share learning from the case to support prevention of harm and improve future patient experience.
Verbatim wording from the response “I hope that this provides you with assurance that this matter has been taken seriously with a commitment to improve and learn from these events. In addition to this, in September 2022, Mrs Stewart’s case will form part of a multidisciplinary learning event being held by the Trust. We will seek to share the learning from Mrs Stewart’s case in order to prevent harm to, and improve the experience of, future patients. Inevitably, this will include a focus on incident reporting, which supports our aims outlined earlier in this letter.” Source location Response from NHS Tameside and Glossop Integrated Care
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 reporting and escalation SOP covering responsibilities, documentation, monitoring, oversight and escalation of unread or unacknowledged findings.
Verbatim wording from the response “A Standard Operating Procedure (SOP) has been developed to support the roll out of this new electronic capability, which provides an explanation of the reporting and escalation process and outlines the clinical responsibilities of both Radiology and Emergency Department colleagues. The SOP includes monitoring and oversight arrangements to ensure compliance with the process. The SOP also provides clear guidance on the need to record action taken in relation to any abnormal results identified after the patient has left the Department, this will be recorded in the patient’s electronic notes. The automated alerting system will also have the capability to escalate any un-read or un-acknowledged radiology findings to operational and clinical leads for action.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 Prioritise and monitor daily Emergency Department Consultant review of radiology reports, with administrative processing of required actions.
Verbatim wording from the response “In the interim, to mitigate risk Emergency Department Consultant reviews of all radiology reports received within the Department is being prioritised and is being monitored on a daily basis by the Urgent Care Clinical Director and Associate Divisional Director, overseen by the Medicine and Urgent Care Divisional Quality and Safety Board. For those radiology reports where an action is required the Emergency Department Consultants work with the Urgent Care” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The incident was closed after discussion with the Emergency Department Clinical Director, with no further action identified at that time.
Verbatim wording from the response “The MDT learning panel noted that a review of Mrs Stewart’s care by the Learning from Deaths Team was undertaken in December 2021. The Learning from Deaths Team identified concerns that the family and care home had not been informed of the fractured pubic rami and an incident form was completed, in accordance with Trust guidelines. At that time, work was ongoing to improve results governance within the organisation; with collaboration between Urgent Care, Radiology and the Clinical Information Team. There was a risk on the Urgent Care Risk Register in relation to results governance, with mitigation and further action recorded. Following a discussion with the Emergency Department’s Clinical Director, the incident was closed, with no further action identified. It is apparent that operational pressures as a result of our Covid-19 response impacted upon our oversight of this.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 An audit found that the small number of fractures missed by Emergency Department clinicians were acted upon appropriately when radiology reports were received.
Verbatim wording from the response “The investigation was informed by an audit of radiology findings, using a large random sample from June 2022. In respect of Emergency Department clinicians identifying fractures, the audit found that the Trust scored favourably when compared to the National average (3.1%, compared to 3.7% Nationally). The audit also identified that the small number of fractures not identified by Emergency Department clinicians were all acted upon appropriately when the report was received from a Radiologist or Reporting Radiographer.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
22 Jun 2022 Derek Holmes · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Delays and unfit processes for obtaining advice from a specialist hospital View source Failure to conduct prompt, rigorous and effective investigations of clinical incidents View source Failure to revisit patient safety incident harm grading View source Inadequate processes to ensure patient call-bells are working at all times View source Failure of formal investigation learning to address the breadth of identified patient safety issues View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Derek Holmes · 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
Derek Holmes, who had advanced metastatic prostate cancer and congestive cardiac failure, was admitted to hospital with several acute problems and fell while attempting to get out of bed. He sustained a left hip fracture requiring surgery and died after developing vomiting and signs of a chest infection. Concerns included errors in the Trust’s Root Cause Analysis, inadequate formal examination of issues including patient call-bells and delays in obtaining specialist advice, and the grading of the fall’s harm.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and unfit processes for obtaining advice from a specialist hospital
Wider context from the report “1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths;
2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:
• the adequacy of existing processes designed to ensure patient call-bells are working at all times; and
• why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose .
3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct prompt, rigorous and effective investigations of clinical incidents
Wider context from the report “1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors . Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths ;
2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:
• the adequacy of existing processes designed to ensure patient call-bells are working at all times; and
• why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose.
3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to revisit patient safety incident harm grading
Wider context from the report “1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths;
2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:
• the adequacy of existing processes designed to ensure patient call-bells are working at all times; and
• why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose.
3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate processes to ensure patient call-bells are working at all times
Wider context from the report “1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths;
2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:
• the adequacy of existing processes designed to ensure patient call-bells are working at all times ; and
• why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose.
3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of formal investigation learning to address the breadth of identified patient safety issues
Wider context from the report “1. Notwithstanding the fact that the document had passed through the Trust’s quality assurance process, it is a matter of concern that the Root Cause Analysis investigation into the circumstances of Mr Holmes’s fall contained a number of basic and obvious errors. Prompt, rigorous and effective investigations of clinical incidents are essential to deriving learning and improving patient safety, thereby reducing the risk of future deaths;
2. The formal learning derived from the Trust’s investigation (in the form of an Action Plan to the Root Cause Analysis) does not appear to take into account the breadth of issues raised by the case and which were apparent to the Trust from complaints correspondence and statements obtained from staff in advance of the inquest. As such, the Trust does not appear to have taken the opportunity to formally examine and critically analyse key issues such as:
• the adequacy of existing processes designed to ensure patient call-bells are working at all times; and
• why a delay has occurred in obtaining advice from a specialist hospital in the present case and whether the processes by which such advice is obtained are fit for purpose.
3. Connected with the above, the Trust does not appear to have revisited the grading of “moderate” harm originally assigned to Mr Holmes’s fall on the Acute Medical Unit notwithstanding his death being reported to the Coroner on the basis there was reason to suspect it contributed to his death. The court heard evidence to the effect that this grading informs the nature and extent of investigation which arises from a patient safety incident (thus impacting upon the learning which can be derived from such an incident).
” 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 Implement Trust-wide witness statement training and develop supporting statement templates.
Verbatim wording from the response “Beyond this, to further strengthen internal processes, the Trust are undertaking training to support the development of staff. Witness statement training is being implemented Trust wide to help support those who have been approached to prepare statements. Clinical and nursing staff understand that they may be asked to provide a written report about their involvement in a patient’s care. The training will accentuate that the statement is to focus on the facts relevant to death and is to be detailed and accurate. In order to maintain consistency, templates are being drafted to ensure structure is provided.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require senior divisional review and approval evidence in root cause analysis documents before assurance-panel consideration.
Verbatim wording from the response “The documentation of oversight and Divisional approval of investigations has been amended and strengthened following the learning from Mr Holmes’ inquest. The root cause analysis template has been updated to include evidence of review and approval by senior members of the Divisional operational, nursing and clinical leadership teams. It is proposed that any root cause analysis document will not be accepted for review at an assurance panel if this information is not completed. A process has also been introduced to undertake a quality assessment of investigations undertaken as part of our falls pathway. In this process, a member of the Safer Care Team will review the completed root cause analysis for accuracy against the clinical and nursing records prior to assurance panel.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
Verbatim wording from the response “Prior to the inquest of Mr Holmes, I had instructed a review of the Trust’s Incident Reporting and Incident and Complaints Investigation Policy. This was in the context of Patient Safety 2, as information and resources become available to inform the Trust approach. The learning from this inquest has further informed the quality assurance process. The review and update to the Policy has been undertaken by the Head of Investigations, Learning and Audit and Head of Nursing for Professional Standards and Assurance, overseen by the Assistant Director of Integrated Governance.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver comprehensive root cause analysis investigation training for relevant clinical and corporate staff.
Verbatim wording from the response “The Trust recognise the importance of comprehensive investigation training to underpin the methodology and rigor that must be applied to this process. As such, the Trust are providing root cause analysis investigation training days which commence in September 2022, and” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement revised call-bell, oxygen and suction checking through a safety checklist, standard operating procedure and auditable oversight.
Verbatim wording from the response “In relation to the issue raised relating to patient call bells, a safety checklist has been revised with an accompanying standard operating procedure intended to support the regular testing and checks of emergency equipment within all inpatient areas. This includes a daily check by operational staff of the call bell, oxygen and suction located at each bedside. This is overseen by a weekly assessment, recorded within the safety checklist. This is then auditable as part of assessments completed by members of the Safer Care Team for each area and reviewed as part of the Ward accreditation process. As this is a new process, this has been socialised with the divisional leadership teams to ensure their views and comments are considered in the implementation of this.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
Verbatim wording from the response “The Trust has also introduced a bimonthly oversight meeting for triangulation of scheduled and new inquests with existing or newly instructed investigatory processes, with Head of Investigations, Audit and Learning, Head of Assurance, Compliance and Governance, Head of Nursing for Professional Standards and Assurance and Legal Services Manager, chaired by the Assistant Director of Integrated Governance. This process has sought to ensure the improved triangulation of current investigations and support early identification of any changes in status to the patient (such as their death) or delays in conclusion. Patient tracking list methodology will be used to inform this process and ensure that there is oversight of all learning activity associated with investigations and inquests.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
Verbatim wording from the response “The development of a clinical review process is ongoing at the time of preparing this response to ensure that all incident investigations, inquest statements and reviews undertaken as part of our learning from deaths process are assessed and considered cohesively before an inquest. This aims to ensure consistency across all streams of investigation and learning and will help provide an additional clinical check to ensure that any potential discrepancies are responded to, enhancing our approach to learning.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Quality-assess falls-pathway investigations against clinical and nursing records before assurance-panel review.
Verbatim wording from the response “The documentation of oversight and Divisional approval of investigations has been amended and strengthened following the learning from Mr Holmes’ inquest. The root cause analysis template has been updated to include evidence of review and approval by senior members of the Divisional operational, nursing and clinical leadership teams. It is proposed that any root cause analysis document will not be accepted for review at an assurance panel if this information is not completed. A process has also been introduced to undertake a quality assessment of investigations undertaken as part of our falls pathway. In this process, a member of the Safer Care Team will review the completed root cause analysis for accuracy against the clinical and nursing records prior to assurance panel.” Source location Response from NHS Tameside and Glossop Integrated Care
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 the Ulysses Safeguard improvement project to standardise use and increase reporting functionality.
Verbatim wording from the response “The Trust are currently undertaking a comprehensive improvement project focused upon the Ulysses Safeguard system, which is the electronic risk management system used by the Trust. It is a system which allows for web-based reporting of incidents and safeguarding concerns, alongside system based operational management of complaints, incidents, claims, inquests, safeguarding and risk. It is also a platform which has the facility to recognise and acknowledge good professional practice known as ‘Excellence reporting’. The improvement project aims to increase utility of this system, with standardisation of use and increased reporting functionality.” Source location Response from NHS Tameside and Glossop Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require appropriate Matron review and approval of investigations through the revised Safer Care Assurance Process.
Verbatim wording from the response “In regard to the errors identified within the root cause analysis, steps have been taken following the inquest of Mr Holmes to strengthen the process in which these documents are checked for quality and factual accuracy, with increased divisional ownership and oversight. The Safer Care Assurance Process has been revised to explicitly include the expectation for all investigations of this form to be reviewed and approved as an accurate account of the incident and learning by an appropriate Matron. Although it is not possible to completely remove the human factors which can affect this process, it is anticipated that this should reduce the opportunity for errors such as those identified in the root cause analysis document presented in relation to Mr. Holmes.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 organisational learning on investigation methodology and responding to people who raise concerns.
Verbatim wording from the response “The policy builds of the principles of good compliant handling that have been recommended by the Parliamentary Health Service Ombudsman. This includes the Trust’s approach to managing the complaints, responding to complainants and keeping people informed about the concerns that they raise. As part of this approach, learning will be disseminated across the organisation regarding the required methodology and how we respond and support people when they raise concerns. Ongoing monitoring of the policy will take place through local audits of informal concerns and formal investigations. This will support the completion of other investigations such as root cause analysis and use the same principles so that these can be communicated across the organisation, alongside learning from investigations.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 a live register of staff who have completed root cause analysis investigation training.
Verbatim wording from the response “The training has been targeted initially to key members of clinical and corporate teams who are likely to undertake root cause analysis or complaints investigations as part of their role. Once undertaken the Integrated Governance Team will hold a live register of staff who have completed root cause analysis investigation training. This is to ensure that on the commissioning of any new investigation, at least one member of the team has completed this training.” Source location Response from NHS Tameside and Glossop Integrated Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the updated investigator toolkit to each root cause analysis investigation team.
Verbatim wording from the response “Overseen by the Head of Investigations, Learning and Audit a resource tool kit for investigators has been reviewed an updated to include guidance on triangulation, factual accuracy and a data mapping tool which should be included as part of the investigation process. The tool kit will be provided to each investigation team at the commencement of a root cause analysis investigation.” Source location Response from NHS Tameside and Glossop Integrated Care
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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 a full-time clinical staff member to support the strengthened inquest triage and review process.
Verbatim wording from the response “As part of the new process, a clinical review of the case and a review of any previous investigations is also performed at the outset where we are able, in order to identify any linked actions. This process would allow for the revisiting of levels of harm for individual incidents to ensure that this is appropriate, with advice from the specialist teams. There is also the addition of a full time clinical member of staff to support this process moving forward, and a more rigorous review system to capture potential delays. The Trust has started to implement this process ensuring communication is maintained with HM Coroner throughout.” Source location Response from NHS Tameside and Glossop Integrated Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require review of root cause analysis requests by senior nursing and governance leaders when a patient dies during investigation.
Verbatim wording from the response “In addition to this, the Safer Care Assurance Process also includes a caveat that the request for root cause analysis is reviewed by the Head of Nursing and Assistant Director of Integrated Governance should the patient die during the investigation process. This is intended to provide an opportunity to stop and reassess whether continuation of the enquiries is the most appropriate cause of action, or whether an additional or more comprehensive form of investigation is required.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct ongoing local audits to monitor adherence to the complaints and investigation policy.
Verbatim wording from the response “The policy builds of the principles of good compliant handling that have been recommended by the Parliamentary Health Service Ombudsman. This includes the Trust’s approach to managing the complaints, responding to complainants and keeping people informed about the concerns that they raise. As part of this approach, learning will be disseminated across the organisation regarding the required methodology and how we respond and support people when they raise concerns. Ongoing monitoring of the policy will take place through local audits of informal concerns and formal investigations. This will support the completion of other investigations such as root cause analysis and use the same principles so that these can be communicated across the organisation, alongside learning from investigations.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
Verbatim wording from the response “To provide an additional safety net in this process, the Trust has also taken steps to amend and improve the triage system for newly listed inquests. In the context of the recent letter HM Senior Coroner received from Mr Richard Jolly of Weightmans LLP, in relation to the provision of our inhouse legal team, processes have been reinvigorated to ensure triage, review and instruction sent out to clinicians within seven days of the initial inquest request.” Source location Response from NHS Tameside and Glossop Integrated Care
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 Disseminate a briefing on triangulation and factual accuracy in investigations across the Trust.
Verbatim wording from the response “The Trust has used the case of Mr Holmes and subsequent learning to develop a seven minute briefing which has been shared widely across the Trust, to reemphasise the importance of triangulation and accuracy of data used within any investigations including root cause analysis and complaints.” Source location Response from NHS Tameside and Glossop Integrated Care
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 Large-scale comprehensive investigation training was challenging because COVID redeployed governance staff and staff attendance was not mandatory.
Verbatim wording from the response “Whilst basic training has been provided for Trust members of staff in incident management over the last two years and support has been offered, and comprehensive, individual and bespoke support has been provided to individuals completing investigations, the delivery of largescale comprehensive investigation training has been challenging in the context of Covid and the Covid response. The reasons for this are twofold; both in terms of the redeployment of key members of the corporate governance team to support clinical areas, and in terms of the ability of staff to attend, when the training is not mandatory.” Source location Response from NHS Tameside and Glossop Integrated Care
Open published response
16 Sep 2021 Irene Ann Esaw · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to complete adequate assessments of patients’ needs View source Failure to clarify multi-agency responsibility for capacity and needs assessments View source Failure to adequately assess patients’ mental capacity for care decisions View source Failure to recognise clinical indicators of neglect as safeguarding concerns View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Irene Ann Esaw · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Irene Ann Esaw, who had dementia and was dependent on her grandson for all nutritional, mobility, hygiene and personal care, was discharged from hospital without a formal care package or community referrals. She was later found deceased at home in an emaciated state, with severe untreated pressure sores, tissue damage and widespread sepsis. The principal concerns were failures to assess mental capacity, recognise clinical signs of neglect, and ensure effective multi-agency assessment and working.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete adequate assessments of patients’ needs
Wider context from the report “3. Multi-agency Working –
My findings reveal that in the treatment of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments. The effect of this was that there was never an adequate assessment of her needs completed . ████████, the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking. I am concerned that this continues to need to be addressed.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify multi-agency responsibility for capacity and needs assessments
Wider context from the report “3. Multi-agency Working –
My findings reveal that in the treatment of Mrs. Esaw, there were assumptions made by the clinical team and the IUCT that the other agency was responsible for capacity and needs assessments . The effect of this was that there was never an adequate assessment of her needs completed. ████████, the Principal Social Worker for Adult Social Care told me in her evidence that even though IUCT are on the wards at Tameside, there is still further work to be done to understand the roles that the IUCT and the clinical team are undertaking . I am concerned that this continues to need to be addressed.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess patients’ mental capacity for care decisions
Wider context from the report “1. Identifying and Assessing Mental Capacity –
My findings in relation to Mrs. Esaw’s death were that there was a fundamental failure by the clinical and nursing staff to adequately consider and assess Mrs. Esaw’s capacity to make decisions about her own care needs whilst she was a patient at Tameside General Hospital between 12ᵗʰ and 28ᵗʰ September 2018. This failure in my view, undermined her discharge planning and was one of the key reasons why the discharge was unsafe. I understand that work is ongoing in this area, but I am concerned having heard the evidence of ████████, the Deputy Director of Nursing and Professional Standards that it is still a “work in progress” identified by this and other incidents reported to the Trust. I am concerned that there are still issues that the Trust aren’t completely compliant with and that this needs to be addressed.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise clinical indicators of neglect as safeguarding concerns
Wider context from the report “2. Recognising the Clinical Signs of Neglect –
My findings indicate that in 2018 there was no adequate consideration by the clinical or nursing staff that Mrs. Esaw’s clinical presentation in of itself indicated neglect and therefore a safeguarding concern . The Trust’s Safeguarding Lead ████████ told me that following on from the Domestic Homicide Review, the Trust recognises that more work needs to be done around the recognition of what is neglect and those medical indicators of neglect . She recognised that there needs to be a strengthening of recognition in staff of safety concerns . I understand that this is part of the Safeguarding Lead’s portfolio, but I am concerned that this still needs to be addressed.
” Open source report
24 May 2021 Roger Edward Humphrey Ballard · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to document clinical decisions and rationale, including decisions contrary to neurosurgical advice View source Failure to clearly report and record scan findings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Roger Edward Humphrey Ballard · 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
Roger Edward Humphrey Ballard was admitted to hospital with a head injury, and a CT scan showed a contusion and subarachnoid haemorrhage. His anticoagulation medication was not stopped despite neurosurgical advice, and he was later readmitted with a catastrophic bleed. Concerns included unclear reporting and recording of the scan findings and inadequate documentation of clinical decisions, including the decision not to follow specialist advice.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document clinical decisions and rationale, including decisions contrary to neurosurgical advice
Wider context from the report “2. The documentation regarding clinical decisions taken including the decision to not follow the advice of the neurosurgeons was not documented in the notes. It was unclear if there was an expectation that where clinicians took a decision contrary to such advice how and in what detail the rationale should be recorded within the notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly report and record scan findings
Wider context from the report “1. The inquest heard evidence that the way in which the scan was reported and then recorded was not clear and contributed to the treating clinician not appreciating the scan findings.
” 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 Complete the Trust-wide rollout of the Results Governance Tracker requiring timely PACS acknowledgement of imaging results.
Verbatim wording from the response “In addition, I wish to give you wider assurances around how imaging is reported and reviewed by clinicians at the Trust. The Trust has been developing a Results Governance Tracker, which has already been implemented in one major area of the Trust. It is anticipated that this roll-out will continue, although it did undoubtably experience some delays due to the pandemic. Once this Tracker is Trust-wide, it will ensure that all Pathology and Radiology results will have to be acknowledged as read on the PACS system within a specified timeframe. This will assist our clinicians in complying with the existing expectations on their practice and ensure safer care for patients.” Source location 2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct the documentation standards audit.
Verbatim wording from the response “The clinician involved in this matter has reflected on this point and learning has also been included in the 7 Minute Briefing, shared across the Trust. Further, a documentation standards audit has also been commenced and dependent on the” Source location 2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct the commissioned serious incident investigation and present its findings to the Executive Scrutiny Panel.
Verbatim wording from the response “To ensure that all learning has been identified in relation to this issue, an investigation has also been commissioned as part of our serious incident framework and the findings of this will be presented to our Executive Scrutiny Panel which I and the Executive Director of Nursing and Integrated Governance attend.” Source location 2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an action plan addressing issues identified by the documentation standards audit.
Verbatim wording from the response “The clinician involved in this matter has reflected on this point and learning has also been included in the 7 Minute Briefing, shared across the Trust. Further, a documentation standards audit has also been commenced and dependent on the” Source location 2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
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 GMC documentation standards and junior doctor induction sufficiently require recording clinical decisions, specialist advice, deviations and reasons in medical records.
Verbatim wording from the response “It is an expected standard that any decisions made relating to a patient’s care and management plan are to be documented within the medical records. This includes discussions with tertiary centre colleagues, the advice they provide, and any decisions made to deviate from this advice and the reasons why. As I am sure you are aware, this requirement is within the GMC standards and guidance relating to documentation, and is absolutely expected from all medical staff. In addition, as part of junior doctor induction, clinicians are sign-posted to resources to assist them in managing their professional responsibilities and obligations regarding documentation in medical records.” Source location 2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
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 radiology policy sufficiently requires clinicians to review CT scan reports directly on PACS rather than rely on transcribed medical records.
Verbatim wording from the response “When an investigation is undertaken such as a CT scan, it is expected that the treating clinicians should be logging onto the PACS system and reviewing the scan report instead of relying on what has been transcribed in the medical records. This is to avoid any misinterpretation or the omission of any detail, which may be vital when making a clinical decision about a patient’s management plan and on-going treatment. This expectation is clearly documented in the Trust’s Radiology Requesting and Reporting Policy, which all clinicians are required to be familiar with as part of their post at the Trust.” Source location 2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Open published response
11 Aug 2020 Sylvia Scully · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of routine clinical governance processes to initiate formal Serious Untoward Incident investigations or similar investigations View source Failure to use a Rapid Assessment and Treatment Model for walk-in Emergency Department patients View source Limited remote access to relevant systems for urgent out-of-hours imaging reporting View source Insufficient equipment for urgent out-of-hours imaging reporting from home View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sylvia Scully · 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
Sylvia Scully became unwell with sudden abdominal pain and vomiting and attended Tameside General Hospital on 9 February 2020. A radiologist initially reported another patient’s scan in error, and the correct diagnosis of hollow viscus perforation was made after her condition had deteriorated so severely that she could not withstand emergency surgery; she died in hospital on 10 February 2020. Concerns included variations in radiologists’ access to systems and equipment for out-of-hours reporting, the absence of a formal investigation into her care, and the lack of a Rapid Assessment and Treatment Model for walk-in emergency patients.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of routine clinical governance processes to initiate formal Serious Untoward Incident investigations or similar investigations
Wider context from the report “1. Notwithstanding the circumstances of Mrs Scully’s death, the Trust’s routine clinical governance processes have not resulted in a formal Serious Untoward Incident investigation or similar taking place in respect of the care and treatment provided to her. This is a matter of concern given the great importance to patient safety of robust and effective investigations being undertaken in a timely fashion;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a Rapid Assessment and Treatment Model for walk-in Emergency Department patients
Wider context from the report “2. A Rapid Assessment and Treatment Model was not in use at the Trust’s Emergency Department at the time of Mrs Scully’s attendance in respect of ‘walk-in’ patients . Such a paradigm would have seen Mrs Scully assessed early on by a senior doctor who had the experience and authority to promptly initiate all relevant investigations (including ordering CT Scans) and commence treatment, in advance of review by the surgical team.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited remote access to relevant systems for urgent out-of-hours imaging reporting
Wider context from the report “1. The court heard evidence that the Consultant Radiologist on-call for the Trust and reporting on urgent out-of-hours imaging from home, had more limited remote access to relevant systems than radiologists working for remote reporting companies and had been provided with less equipment than such an individual. Given the importance of effective out-of-hours reporting of imaging to emergency care, it is considered authoritative guidelines as to requisite access and recommended equipment could assist in reducing such variations.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient equipment for urgent out-of-hours imaging reporting from home
Wider context from the report “1. The court heard evidence that the Consultant Radiologist on-call for the Trust and reporting on urgent out-of-hours imaging from home, had more limited remote access to relevant systems than radiologists working for remote reporting companies and had been provided with less equipment than such an individual . Given the importance of effective out-of-hours reporting of imaging to emergency care, it is considered authoritative guidelines as to requisite access and recommended equipment could assist in reducing such variations.
” 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 Have senior clinicians undertake Case Review and Lessons Learned reviews for relevant patient-safety concerns.
Verbatim wording from the response “It is appreciated that this level of scrutiny is not always apparent and evident for the purpose of the Inquest therefore, the Trust’s Integrated Governance Team have considered how they can evidence different responses to patient safety incidents, including Multi-Disciplinary Team reviews, complaints investigations and expert opinions, which occur outside of a formal SUI process. A new ‘Case Review and Lessons Learned’ document has been produced which will be provided as part of the coronial disclosure process. Senior Clinicians with the expertise in the area of concern will undertake such case reviews. The findings and lessons learned document will be presented in a ‘Case Review and Lessons Learned’ report which the Trust intend on disclosing as part of the coronial process for the benefit of the family and Court if a serious incident investigation is not required.” Source location 2020-0156-Response-from-NHS-Tameside-and-Glossop-Integrated-Care_Redacted.pdf
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 Allocate a Lead Consultant to ensure priority 1 and 2 Emergency Department patients receive timely senior assessment and prompt investigations.
Verbatim wording from the response “models and their applications and have continuously reviewed them along with staffing requirements in light of the COVID-19 pandemic. The Trust have adopted new ways of working to ensure patients who are categorised as a 1 or 2 are seen in a timely manner. Between Monday to Friday, 08.00 hours to 22.00 hours and on weekends between 10.00 hours to 18.00 hours, there is a “Lead Consultant” allocated to ensure these urgent patients are seen within 30 minutes following Triage. This is to ensure these patients are seen by the appropriate team and appropriate investigations are requested quickly. When a Triage Nurse has undertaken her initial assessment, it is then their responsibility to immediately highlight them to the Team Leader.” Source location 2020-0156-Response-from-NHS-Tameside-and-Glossop-Integrated-Care_Redacted.pdf
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 incident investigation processes and review were considered sufficient, so a formal serious untoward incident investigation was not undertaken.
Verbatim wording from the response “In order to address your concerns, I would first like to take the opportunity to explain the Trust’s incident investigation process, which was effective at the time of Mrs Scully’s attendance. I hope by explaining this and various other types of investigations the Trust undertake, it will provide you with reassurance that whilst a Serious Untoward Incident was not undertaken in Mrs Scully’s case, her treatment and care was reviewed by the Trust.” Source location 2020-0156-Response-from-NHS-Tameside-and-Glossop-Integrated-Care_Redacted.pdf
Open published response
23 Apr 2020 Gordon Fenton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Lack of a formalised joint process for reviewing treatment plans and determining optimum medical and psychiatric care View source Lack of effective coordination of shared psychiatric and acute medical care View source Failure to reliably and consistently share medical records and information between Trusts View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gordon Fenton · 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
Gordon Fenton, a 70-year-old man detained under the Mental Health Act, developed a urinary tract infection and related complications during periods of care between psychiatric and medical services, and died in hospital on 29 June 2019 after a seizure and cardiac arrest. The principal concerns were inadequate information sharing and the lack of a formal joint decision-making process between the two NHS Trusts, with the inquest finding that this prolonged and contributed to ineffective management of his infection.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formalised joint process for reviewing treatment plans and determining optimum medical and psychiatric care
Wider context from the report “3. There does not appear to be a formalised decision-making process in place involving both Trusts to review the treatment plan to determine the optimum medical and psychiatric care to suit the particular patient’s needs .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective coordination of shared psychiatric and acute medical care
Wider context from the report “1. The inquest heard that there was a particular tension in relation to shared care between Pennine Care NHS Foundation Trust and Tameside and Glossop Integrated Care NHS Trust for patients who are subject to psychiatric care, who have acute medical problems .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably and consistently share medical records and information between Trusts
Wider context from the report “2. There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts .
” 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 Establish working parameters for Digital Health Team support to older mental health inpatients on Summers and Hague wards.
Verbatim wording from the response “The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT’s older peoples’ mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr Fenton was a patient. The offering of Digital Health services will be conducted as a pilot in the first instance for 8 weeks, which will then be reviewed to establish a more formal offer and outcomes. It is hoped that if this procedure is successful that similar processes will be developed for all of our patients requiring shared input.” Source location 2020-0102-Response-from-Tameside-and-Glossop-Integrated-Care_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct an eight-week Digital Health services pilot and review it to determine a more formal service offer and outcomes.
Verbatim wording from the response “The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT’s older peoples’ mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr Fenton was a patient. The offering of Digital Health services will be conducted as a pilot in the first instance for 8 weeks, which will then be reviewed to establish a more formal offer and outcomes. It is hoped that if this procedure is successful that similar processes will be developed for all of our patients requiring shared input.” Source location 2020-0102-Response-from-Tameside-and-Glossop-Integrated-Care_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate joint mental health inpatient transfer and return-transfer pathways covering physical deterioration, chronic conditions and required clinical information.
Verbatim wording from the response “A number of joint pathways have also been created with regards to Mental Health Inpatient Transfers of Care and Return Inpatient Transfers of Care. In terms of transfers of care, the process will be split into three categories;” Source location 2020-0102-Response-from-Tameside-and-Glossop-Integrated-Care_Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide documented self-directed training on the approved joint standard operating procedure to all relevant staff.
Verbatim wording from the response “Once the new SOP is approved by both Trusts, self-directed training will be carried out by all staff to which the SOP is relevant and this training documented in their training record. I understand that in the meantime PCFT are using our Digital Health Team for advice and guidance with regards to mental health patients requiring medical input.” Source location 2020-0102-Response-from-Tameside-and-Glossop-Integrated-Care_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and trial a joint standard operating procedure for older mental health inpatients requiring medical input.
Verbatim wording from the response “As part of our investigation into your concerns, extensive discussions have taken place between the Associate Director and Mental Health Quality Lead at PCFT, Head of Assurance & Governance for TGICFT and Lead Nurse for Mental Health & Learning Disabilities at TGICFT in relation to ongoing improvements in shared service, specifically in relation to creating a formal standard operating procedure and enhancing services we offer.” Source location 2020-0102-Response-from-Tameside-and-Glossop-Integrated-Care_Redacted
Open published response
16 Dec 2019 Shirley Anne Nightingale · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of a system requiring suitably experienced clinician agreement for departures from recognised best practice timescales View source Lack of a clear system to follow up required OGD before the next-day AMU ward round View source Failure to record the rationale for departing from recognised best practice timescales View source Lack of a clear clinician escalation and prioritisation system for OGD lists and patient need when OGD capacity is unavailable View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shirley Anne Nightingale · 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
Shirley Anne Nightingale died at Tameside General Hospital on 20 May 2019 after a catastrophic gastrointestinal bleed. The report identified concerns about the lack of clear systems for prioritising urgent endoscopies, following up requests, and recording or authorising departures from recommended timescales.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system requiring suitably experienced clinician agreement for departures from recognised best practice timescales
Wider context from the report “3. When a decision was made to depart from the recognised best practice timescales the rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system to follow up required OGD before the next-day AMU ward round
Wider context from the report “2. The inquest heard that it had been identified in Accident and Emergency that the OGD was required. The notes were marked accordingly but there was no clear system to ensure that this was followed up prior to the ward round on AMU the next day ;
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the rationale for departing from recognised best practice timescales
Wider context from the report “3. When a decision was made to depart from the recognised best practice timescales the rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear clinician escalation and prioritisation system for OGD lists and patient need when OGD capacity is unavailable
Wider context from the report “1. The inquest heard that there was no clear system for escalation /prioritisation by treating clinicians in relation to management of the OGD lists and patient need where the OGD team said there was no capacity ;
” Open source report
17 May 2019 Mellin Beard · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Significant reliance on agency nurses for ward staffing View source Failure to provide timely referrals for discharged patients requiring community nursing services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mellin Beard · 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
Mellin Beard, who had complex health problems including spinal cord compression and reduced mobility, developed pressure sores that later deteriorated despite care. He died on 16 October 2018 from left ventricular failure due to ischaemic and hypertensive heart disease, with infected pressure sores among the contributing health problems. Concerns included delays in referrals for community nursing after hospital discharge and significant reliance on agency nurses.
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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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Significant reliance on agency nurses for ward staffing
Wider context from the report “2. The Ward Manager of Ward 31 confirmed in her evidence that, at the time of the care provided to Mr Beard, there was only one permanent substantive registered nurse working on the ward, with the vast majority of shifts being fulfilled by agency workers ;
Whilst the Ward Manager gave evidence of significant improvements to recruitment and retention of nursing staff on the ward, and of additional actions her and her team have introduced to promote consistency amongst agency staff, it is a matter of concern that there is still significant reliance on agency nurses (with the financial and continuity of care implications which can arise from that) within the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely referrals for discharged patients requiring community nursing services
Wider context from the report “1. A member of the Trust’s community nursing team gave evidence to the effect that it was ‘common’ not to receive timely referrals in respect of patients who were discharged from hospital and required community nursing services . Whilst it was apparent from the evidence before the court as a whole that this concern does not relate solely to patients who have been receiving in-patient care at Tameside General Hospital, and that some improvements have been made with the introduction of an e-discharge system, it is a matter of particular concern that this problem continues to subsist at the Trust in particular due to the integrated care model as between acute and community services the organisation purports to espouse;
” 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 Trial alternative staffing roles, including Registered Nurse Associates.
Verbatim wording from the response “• Trialling of alternative roles such as the Registered Nurse Associate;” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Recruit and retain newly qualified nurses through coordinated recruitment and preceptorship support.
Verbatim wording from the response “I am also able to assure you that we do a lot of work to recruit newly qualified nursing staff. Our recruitment team works in connection with our Preceptorship Team, who are responsible for the training and education of our trainee nurses, to ensure the transition from trainee to qualified is a smooth process and involves securing a permanent post with the Trust. Since September 2018 we have retained 39 newly qualified nurses, which is an improvement from our position in September 2017, when we retained 32 newly qualified nurses. We expect these figures to continue to rise given the work being done by our teams.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Track missed-referral incidents and escalate identified trends or themes through divisional meetings for timely action.
Verbatim wording from the response “In addition to reviewing individual incidents, which are raised when a missed referral is identified, these incidents are tracked by relevant services and any trends or themes are looked for to ensure these are quickly identified and addressed. Any trends or themes that are identified are highlighted to the relevant divisions in their regular divisional meetings so that appropriate steps can be taken to address them in a timely manner.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Advertise nursing vacancies through NHSJobs, recruitment websites, Trust systems and social media.
Verbatim wording from the response “The Trust is an active partner in the Greater Manchester-wide Nursing Leadership Workforce and Recruitment work. We run ‘Recruitment Open Days’, which have increased in frequency and are now occurring each quarter. To prepare for these days and to ensure high attendance numbers, the Trust advertises these events on Social Media and websites such as NHSJobs, LinkedIn, Indeed, and the Trust's recruitment website, TRAC, which is a system that is used by close to 90% of all Trusts. During these Open Days prospective employees meet with teams they are interested in joining and have a tour of the site to see what the working environment is like. We make every effort to engage them and support them from the start on what is hopefully a long career with the Trust. I am happy to” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Tighten referral processes while migrating from fax machines to electronic communication systems.
Verbatim wording from the response “Given we are still working towards moving onto the electronic system, we have taken steps to tighten our processes in the meantime and are currently working through our strategy for the removal of all fax machines and the migration to electronic communication systems.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Attend regional college job fairs and university open days to promote Trust employment opportunities.
Verbatim wording from the response “We are also attending college job fairs and university open days in the Greater Manchester area to discuss employment opportunities with the Trust.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Implement a Recruitment and Retention Action Plan with executive and workforce oversight.
Verbatim wording from the response “In addition, since 2016 the Trust has been working to improve our registered nurse retention rate. At that time, the Trust was contacted by NHS Improvement who offered targeted support to improve our retention rate for registered nurses, as the Trust was in the lower quartile of performance. Since then, the Trust has managed this issue via a Recruitment and Retention Action Plan, with outcomes being reviewed by the Executive Management Team and the Workforce Committee. Although our involvement in this support programme has now finished, we continue to measure performance and associated outcomes.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Improve vacancy filling and roster forecasting using recruitment and electronic rostering systems.
Verbatim wording from the response “• Reducing time for fill for vacancies, aided by TRAC recruitment database;” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Move all Trust referrals to District Nurses onto an electronic portal.
Verbatim wording from the response “As part of our investigation into your concern, discussions have been held with the Head of Nursing, Community Adults, the Service Director and Lead Nurses of the Trust's Intermediate Tier Services, and the Team Lead for SPOC in relation to ongoing improvements in the District Nursing referral process. I am happy to inform you that we will be moving onto an electronic portal for all referrals to District Nurses made within the Trust. Once this has been running for a while, we will investigate the potential for non-Trust agencies to also use this portal for referrals, as we receive a high number of referrals from care homes.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Run quarterly recruitment open days for registered nursing posts.
Verbatim wording from the response “The Trust is an active partner in the Greater Manchester-wide Nursing Leadership Workforce and Recruitment work. We run ‘Recruitment Open Days’, which have increased in frequency and are now occurring each quarter. To prepare for these days and to ensure high attendance numbers, the Trust advertises these events on Social Media and websites such as NHSJobs, LinkedIn, Indeed, and the Trust's recruitment website, TRAC, which is a system that is used by close to 90% of all Trusts. During these Open Days prospective employees meet with teams they are interested in joining and have a tour of the site to see what the working environment is like. We make every effort to engage them and support them from the start on what is hopefully a long career with the Trust. I am happy to” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring retention performance and take proactive steps to support future improvement.
Verbatim wording from the response “Although we have seen success in the past 12 months, we will continue to closely monitor retention performance and take pro-active steps to ensure future success in this area. I hope to have assured you of the ongoing efforts made by the Trust to recruit and retain registered nursing staff.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Reinforce clinical incident reporting for missed referrals to support investigation, learning and training.
Verbatim wording from the response “Further, whenever a missed referral is identified by any member of staff, they have a responsibility to raise a clinical incident report so that the matter can be investigated. District Nurses have continuously reinforced the importance of a robust incident-reporting culture so as to ensure further incidents can be prevented and appropriate learning and training can take place to keep patients safe.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Use onboarding and staff-recognition schemes to support nursing staff retention.
Verbatim wording from the response “• Starting on-boarding sessions, to engage with staff who have joined the Trust;” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Strengthen exit interviews, career-development conversations and internal transfers to improve nursing retention.
Verbatim wording from the response “• Strengthening the Exit Interview process, with earlier notification/intervention;” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Design and deliver a preceptorship programme for newly qualified nurses.
Verbatim wording from the response “• Designing and delivering a Preceptorship programme for newly qualified Nurses;” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Missed referrals are not considered common, based on team experience, incident review and evidence from the referral service.
Verbatim wording from the response “As mentioned above, we have made enquiries to assist you in understanding more fully if missed referrals are ‘common’. A meeting took place at the beginning of June with the Trust's entire group of District Nursing Team Leads and their Matron at which a discussion was had regarding the regularity of missed referrals. The consensus was very much that this was not a ‘common’ or regular occurrence from their professional experience. A review of all incidents detailing a missed referral from March 2018 to March 2019 was completed. This review found that a total of eight missed referrals were identified in this twelve month period. A rate 0.67 missed referrals per month is not considered to be ‘common’ by the Trust. Enquiries were also made with the Trust's Single Point of Contact [SPOC], which is a Trust service that receives and triages all referrals to District Nurses trust-wide.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-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 Bank and agency nurses remain necessary for safe operations, with consistent deployment, local induction and communicated performance expectations considered sufficient safeguards.
Verbatim wording from the response “As you may know, Bank staff are employees of the Trust who take on shifts in other areas of the Trust, when the need arises. These employees are familiar with Trust policies and procedures and can therefore facilitate a consistent treatment environment for patients, even if they are not always on their usual ward. Further, efforts are made to ensure that when Agency staff are used, the same individuals are used consistently in the same areas. Again, this is to ensure continuity of care and to ensure that these individuals are familiar with the way the Trust operates.” Source location 2019-0157-Response-by-Tameside-and-Glossop-Integrated-Care-NHS-Trust
Open published response
26 Jan 2018 Mrs. Riaz Begum · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Unavailability of ERCP procedure lists during consultant annual leave View source Insufficient radiology staffing capacity for CT-guided drainage procedures View source Failure to adequately escalate urgent drainage needs to Radiology management View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mrs. Riaz Begum · 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. Riaz Begum developed a bile leak and sepsis following a laparoscopic cholecystectomy, and later developed acute pancreatitis after an ERCP to repair the leak. She died on 16 July 2017 despite treatment for sepsis and multi-organ failure. Concerns included delays in CT-guided drainage and ERCP, insufficient radiology capacity, inadequate escalation, and the potential impact of consultant leave on ERCP availability.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ERCP procedure lists during consultant annual leave
Wider context from the report “(3) I am further concerned by the evidence of ████████ that after took annual leave on the 3rd July, there were no further lists for ERCP procedures until his return on the 11th July . Whilst there may have been other surgical consultants available to review Mrs. Begum whilst he was on leave, his evidence was that once a bile leak was confirmed the ERCP should have taken place and this on his account would not have been possible for 6 days after the leak was diagnosed . I found that this delay played a part in the development of acute pancreatitis in Mrs. Begum and I am concerned that any other delays caused by annual leave being taken may cause further delays for ERCP’s for a patient which creates a risk of future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiology staffing capacity for CT-guided drainage procedures
Wider context from the report “(1) I am concerned that on the 3rd July 2017, a CT Scan indicated the need for fluid drainage to take place under CT guidance. Despite this procedure being deemed necessary, it was not done until the 5th July 2017. The evidence I have heard causes me concern that there were insufficient radiologists/ radiological nurses available to carry out the procedure .
(2) I am also concerned that after the 3rd July the need for the drainage to take place was not adequately escalated to Radiology management when ████████ indicated he could not undertake the procedure within the timescale requested. When the matter was escalated on the 5th July, ████████ had to be essentially told to do the procedure and offered an additional professional fee. I consider that the lack of availability of suitable capacity for undertaking a drainage procedure in the case of someone being treated for sepsis and possible bile leak puts at risk.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately escalate urgent drainage needs to Radiology management
Wider context from the report “(1) I am concerned that on the 3rd July 2017, a CT Scan indicated the need for fluid drainage to take place under CT guidance. Despite this procedure being deemed necessary, it was not done until the 5th July 2017. The evidence I have heard causes me concern that there were insufficient radiologists/ radiological nurses available to carry out the procedure.
(2) I am also concerned that after the 3rd July the need for the drainage to take place was not adequately escalated to Radiology management when ████████ indicated he could not undertake the procedure within the timescale requested . When the matter was escalated on the 5th July, ████████ had to be essentially told to do the procedure and offered an additional professional fee. I consider that the lack of availability of suitable capacity for undertaking a drainage procedure in the case of someone being treated for sepsis and possible bile leak puts at risk.
” Open source report
17 Jul 2017 Matthew Robert Edwards · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to ensure follow-up appointments are booked before discharge View source Unavailability of timely CT angiogram slots View source Delays in dispatching discharge summaries 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
Matthew Robert Edwards · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Robert Edwards was found dead at home on 25 September 2016 after attending hospital twice with chest pain and being referred for further tests. The report identified concerns about delayed dispatch of his discharge summary, failure to arrange follow-up investigations and appointments, and a delay in obtaining a CT angiogram due to a shortage of slots.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure follow-up appointments are booked before discharge
Wider context from the report “2. The follow up appointment was not made for Mr Edwards on his discharge. When the discharge summary was dispatched subsequently this was not picked up and there was no system in place to ensure that follow up appointments had been booked prior to discharge.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of timely CT angiogram slots
Wider context from the report “3. There was a delay of at least 1 week for a CT angiogram. This was due to a shortage of slots. As a result the diagnosis of a possible embolism was not ruled out at an early stage.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in dispatching discharge summaries
Wider context from the report “1.Matthew Edwards was discharged from Tameside Hospital in February 2016. The discharge summary was not dispatched until July 2016. The evidence was that this was not a one off difficulty and that a significant backlog had developed with discharge summaries routinely being dispatched many months after discharge. As a result, Matthew Edwards GP was not notified about his period as an in patient. When he attended a subsequent GP appointment, she was unclear about the discharge plan for Mr Edwards and the rationale for it.
” 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 Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
Verbatim wording from the response “I am advised that a new process is to be put in place for the discharge of patients from the Emergency Department. The Trust is implementing its plan to introduce new bespoke software to enable the production of an electronic casualty card, to replace the current handwritten casualty cards produced by the team in the Emergency Department. This will mean that the key data from the electronic casualty card will be used to create a discharge summary which will be electronically sent to the patient’s GP practice in near real time. It is anticipated that this will ensure that a discharge summary is completed for every patient seen within the Emergency Department without increasing the burden on the clinical teams.” Source location Matthew-Edwards-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen discharge-summary governance through designated clinical and operational leadership, reiterated consultant accountability, compliance monitoring and ward-level safety-net alerts.
Verbatim wording from the response “The Divisional Director of Operations for Adult Medicine has been tasked with leading on this issue, with support from Brendan Ryan, Medical Director. The responsibility to ensure that every patient has a discharge summary rests with the Consultant responsible for that episode of care, and this has been reiterated to all consultants. Compliance is being monitored by the Trust's Service Quality & Operational Governance Group (SQOGG), and the Clinical Directors and Directorate Managers are providing leadership on this issue to ensure that improvements are made and maintained.” Source location Matthew-Edwards-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy additional resources to clear the discharge-summary backlog and restore timely completion.
Verbatim wording from the response “In order to bring the position back to a baseline from which the Trust could confidently move forwards with new processes, extra resources were brought in to clear a backlog that had regrettably developed with discharge summaries. I wish to assure you that the Trust fully recognises the importance of discharge summaries as a handover of care between different organisations and services involved in the care of a patient. I was disappointed to learn that a backlog had developed due to other organisational pressures and asked my Executive team to take immediate steps to identify the source of the problem and remedy it as swiftly as possible.” Source location Matthew-Edwards-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The CT angiogram delay did not reflect an acute clinical risk or an appointment shortage; urgent cases could be expedited.
Verbatim wording from the response “It would appear that this issue may have arisen in part out of misunderstanding and which I hope I can clarify, and having confirmed the position with the Ambulatory Care and Radiology Teams.” Source location Matthew-Edwards-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
Verbatim wording from the response “This issue arose in the context of a particular and historical set of circumstances, in which a discharge summary was not completed for some five months following discharge. The junior member of medical staff completing the discharge summary made an assumption that the follow up actions would have taken place some months previously, and which has since been acknowledged as an incorrect assumption. This was an individual human error, which has been the subject of reflection and development on the part of the junior member of medical staff concerned.” Source location Matthew-Edwards-Response
Open published response
28 Jun 2016 David Michael little · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to train staff to recognise blocked-bowel symptoms and their seriousness View source Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns View source Failure to assess differential diagnoses from the most serious potential condition View source Failure to verify inpatient identity before transfer to radiology View source Lack of a clear diagnostic pathway and monitoring plan on admission View source Failure to communicate adequately with families View source Poor communication between radiology staff and clinicians and nurses View source See 4 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
David Michael little · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to train staff to recognise blocked-bowel symptoms and their seriousness
Wider context from the report “2. The hospital had no clear diagnostic pathway or monitoring plan on admission, the staff appeared not to be trained to recognise the symptoms of a blocked bowel nor the potential seriousness thereof nor to be aware of the dire consequences of failure to diagnose and treat 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns
Wider context from the report “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward . In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess differential diagnoses from the most serious potential condition
Wider context from the report “3. Where there is a differential diagnosis of two or more potential conditions, the staff simply treated the least serious and assumed that was the correct diagnosis rather than taking the most serious and working backwards from that standpoint .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to verify inpatient identity before transfer to radiology
Wider context from the report “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient , and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear diagnostic pathway and monitoring plan on admission
Wider context from the report “2. The hospital had no clear diagnostic pathway or monitoring plan on admission , the staff appeared not to be trained to recognise the symptoms of a blocked bowel nor the potential seriousness thereof nor to be aware of the dire consequences of failure to diagnose and treat 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate adequately with families
Wider context from the report “4. The communication between and among staff generally was poor but especially between the radiology department and the clinicians and nurses. There was little or no good communication with the family which led to additional distress for them at a time of great sorrow.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication between radiology staff and clinicians and nurses
Wider context from the report “4. The communication between and among staff generally was poor but especially between the radiology department and the clinicians and nurses . There was little or no good communication with the family which led to additional distress for them at a time of great sorrow.
” 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 Establish and ratify a small bowel obstruction surgical pathway covering diagnostic priorities and monitoring for this patient group.
Verbatim wording from the response “The Trust has devised a small bowel obstruction surgical pathway (Document 3 attached) which now describes the pathway and monitoring plan for this patient group. Learning undertaken following Mr Little’s death has been incorporated into this pathway. It has been agreed by the surgical, nursing and clinical teams and will be ratified as described in the document, through the governance forums in General Surgery, Radiology, Urgent Care & Critical Care before being signed off at Trust level by the end of September.” Source location 2016-0237-Response-by-Tameside-Hospital-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 Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
Verbatim wording from the response “Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.” Source location 2016-0237-Response-by-Tameside-Hospital-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 Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Verbatim wording from the response “In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.” Source location 2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
Verbatim wording from the response “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.” Source location 2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Open published response
4 Mar 2016 Ranjan Raman · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Failure of nurses to read medical entries View source Failure of medical staff to read nursing notes View source Inadequate detail in incident reports View source Failure to retain shift hand-over sheets View source Insufficient assessment of falls risk View source Failure to complete or retain neurological observation charts View source See 3 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
Ranjan Raman · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The report states that the deceased was admitted to hospital with low sodium levels and high blood pressure, fell three times, and sustained a head injury followed by a fatal bleed. Concerns included insufficient falls-risk assessment, missing or incomplete neurological observation charts, poor communication between medical and nursing staff, destruction of shift hand-over sheets, and inadequate incident-report details.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nurses to read medical entries
Wider context from the report “3. There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes, and the nurses were similarly not looking at the medical entries .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to read nursing notes
Wider context from the report “3. There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes , and the nurses were similarly not looking at the medical entries.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate detail in incident reports
Wider context from the report “5. Although an “Incident Report” was carried out in this case, the details available to the Coroners court were sketchy and inadequate .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain shift hand-over sheets
Wider context from the report “4. The hand-over sheets for each shift were being shredded by the nurses as soon as the shift was completed . Whilst it is appreciated that these cannot be placed on the record of an individual patient for reasons of confidentiality, there is no reason why they could not be filed on the wards and retained for say 14 days which would allow further reference to be made to them, should this be deemed necessary or helpful.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient assessment of falls risk
Wider context from the report “1. The evidence showed that there was no, or no sufficient, assessment of her Falls Risk .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or retain neurological observation charts
Wider context from the report “2. The Neurological observation charts were either never completed or had been lost from the notes .
” 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 Reissue the neurological-observations flowchart and direct ward leaders to apply its recording requirements after relevant unwitnessed falls.
Verbatim wording from the response “This indicates that the requirement for staff to undertake neurological observations as cited on the flowchart needs to be reinforced and practices monitored to ensure robust implementation of the policy standards.” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review falls documentation and align resulting improvements with patient-safety and National Falls Audit actions.
Verbatim wording from the response “The records indicate that there was a falls assessment undertaken for Mrs Mistry. This was updated and reviewed several times during her admission. The Trust acknowledges the Coroner’s observations that the assessment was not sufficiently completed and the Falls assessment tool should have been updated and reviewed after Mrs Mistry was found to have been on the floor following unwitnessed events on the 14/09/15 and the 17/09/15. The Trust has initiated one to one training and support for the members of staff involved and is currently undertaking a review of the documentation as a result of the Coroner’s comments. This piece of work will also align to actions and improvement plans we have in” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with community partners, service users and agencies to improve falls-risk identification and pathway continuity.
Verbatim wording from the response “The Trust is also focusing on falls prevention and falls assessment in the wider context. Working with our community partners, service users and agencies to look at improving the quality and lifestyle of Tameside residents and identifying and assessing those patients who may be of particular risk in relation to falls, and agreeing how we ensure pathway continuity. This involves ensuring that information held by the GP and community services and other healthcare and social services provide an integrated view of the patient’s overall picture.” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess wider falls-prevention measures, including osteoporosis diagnosis, injury-risk identification, reablement and exercise or mobility therapy.
Verbatim wording from the response “We will also be looking at the wider picture in respect of earlier diagnosis of osteoporosis and identification of patients at higher risk of a bony injury from a fall, intervention and reablement and the benefit of exercise and mobility therapy meaning that people and their carers are less dependent on intensive services and less likely to need admission to hospital and to have to mobilise and be cared for in unfamiliar environments.” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide one-to-one falls training and support to involved staff.
Verbatim wording from the response “The records indicate that there was a falls assessment undertaken for Mrs Mistry. This was updated and reviewed several times during her admission. The Trust acknowledges the Coroner’s observations that the assessment was not sufficiently completed and the Falls assessment tool should have been updated and reviewed after Mrs Mistry was found to have been on the floor following unwitnessed events on the 14/09/15 and the 17/09/15. The Trust has initiated one to one training and support for the members of staff involved and is currently undertaking a review of the documentation as a result of the Coroner’s comments. This piece of work will also align to actions and improvement plans we have in” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider introducing electronic archiving of ward and departmental handover sheets.
Verbatim wording from the response “The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no evidence that neurological observation charts were lost from the records; that inference would be conjecture.
Verbatim wording from the response “The Trust has a Falls Policy in place which clearly includes a flowchart which relates to the requirement to assess the patient following a fall or suspected fall. The Falls Policy and flowchart indicates that neurological observations would only be appropriate where a head injury was indicated or suspected. The Trust acknowledges that in the unwitnessed event involving Mrs Mistry on the 17/02/2016 a head injury could not be ruled out. In this event the flowchart indicates the taking of neurological observations (Unwitnessed fall and was verbalising that she had banged her head). However staff did not commence the charts. There is no evidence to suggest that these charts had been lost from the records. Any inference to this would be conjecture.” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Paper handover sheets are not archived because confidentiality and maintaining reliance on the current sheet create practical constraints, although electronic archiving may be introduced.
Verbatim wording from the response “The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incident investigations are proportionate to patient harm; an unwitnessed fall causing no harm requires only a concise local investigation.
Verbatim wording from the response “The Trust has a standard in place which details the expectations regarding processes for reporting of and management of incidents within the Trust. The type, process for and level of incident investigation is proportionate to the impact and level of harm sustained by the patient. For an event where the patient is found on the floor following an unwitnessed event which was ascertained at the time to have resulted in no harm (as occurred in Mrs Mistry’s case) the investigation is undertaken is concise and local and the important aspect of the interventions are to review the falls risk assessment and to try to reduce the risk of a fall occurring again to either that individual patient or to other patients within the hospital environment.” Source location R-Mistry-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The decision to use particular patient records is a clinical decision for individual clinical staff.
Verbatim wording from the response “The decision to use the records of a patient is a clinical decision for individual clinical staff on a continuous basis. The Trust is not unique in that nursing and medical staff record their observations or interactions separately in the patient’s medical records. This is a matter of practicality from the user’s viewpoint and allows the medical and nursing staff to access and update their records at the same time without hindering each other but also allows the staff to contemporaneous records and to access the most recent records which fall within their main area/discipline of practice without having to find entries amongst other disciplines entries.” Source location R-Mistry-Response
Open published response
24 Feb 2016 Wilfrid Pearson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Failure to maintain an up-to-date Status Epilepticus protocol View source Failure to promulgate the Status Epilepticus protocol to all relevant medical staff View source Failure to establish lawful authority for detaining an agitated patient View source Failure by ITU doctors to prioritise brain protection View source Failure to understand the need for and method of escalating care to HDU or ITU View source Failure of ITU registrar attendance at the ward when required View source Inadequate clarity, accuracy and completeness of medical and nursing notes View source Insufficient junior medical staffing capacity View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wilfrid Pearson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Wilfrid Pearson was admitted to Tameside Hospital on 22 April 2015 with epilepsy, developed status epilepticus, and died at a local hospice about a month later. Concerns included possible failures in updating and communicating the status epilepticus protocol, unclear and incomplete records, inadequate escalation of care, staffing pressures, and the legal basis for detaining him after he left the ward.
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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an up-to-date Status Epilepticus protocol
Wider context from the report “1. The protocol for the observation, diagnosis and treatment of Status Epilepticus was written by the Consultant Neurologist who gave evidence to me. There was some doubt as to whether the document had been properly updated and whether and how it was promulgated to all relevant medical staff including locum doctors.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promulgate the Status Epilepticus protocol to all relevant medical staff
Wider context from the report “1. The protocol for the observation, diagnosis and treatment of Status Epilepticus was written by the Consultant Neurologist who gave evidence to me. There was some doubt as to whether the document had been properly updated and whether and how it was promulgated to all relevant medical staff including locum doctors .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish lawful authority for detaining an agitated patient
Wider context from the report “5. The deceased “absconded” from the ward and was described as agitated and confrontational. He was “brought back to the ward by Security”. I was told that no D.O.L.S. order was made or even contemplated , and he was not subject to compulsory detention under the Mental Health Act , therefore one has to ask where they derived the legal authority to detain the patient?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by ITU doctors to prioritise brain protection
Wider context from the report “3. There was no understanding of the need for, and method of, escalation of the care to the HDU or ITU and indeed according to the expert witness instructed by the Trust the impression is that the ITU doctors did not consider that brain protection was a high priority in Mr Pearson’s case”.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the need for and method of escalating care to HDU or ITU
Wider context from the report “3. There was no understanding of the need for, and method of, escalation of the care to the HDU or ITU and indeed according to the expert witness instructed by the Trust the impression is that the ITU doctors did not consider that brain protection was a high priority in Mr Pearson’s case”.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of ITU registrar attendance at the ward when required
Wider context from the report “4. There appears to have been a huge stress on the junior medical staff and I was told that “the ITU Registrar refused to attend the ward , but it is not normal for the ITU registrar to refuse to attend ” and one of the junior doctors said “we were short staffed and overstretched”. This seems to have added to the omissions of care which were apparent.
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate clarity, accuracy and completeness of medical and nursing notes
Wider context from the report “2. The medical and nursing notes for Mr Pearson left much to be desired in terms of their clarity, accuracy and completeness .
” 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 Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient junior medical staffing capacity
Wider context from the report “4. There appears to have been a huge stress on the junior medical staff and I was told that “the ITU Registrar refused to attend the ward, but it is not normal for the ITU registrar to refuse to attend” and one of the junior doctors said “we were short staffed and overstretched ”. This seems to have added to the omissions of care which were apparent.
” 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 Promote Deprivation of Liberty Safeguards principles through executive bulletins and Trust-wide posters.
Verbatim wording from the response “In addition Weightmans LLP have provided four sessions of Mental Capacity Training in September and October of 2015 for medical staff and Consultants. The Trust has another session scheduled for May 2016. To further promote the principles of DOLS and ensure staff are aware of these the trust has promotes this through the Trusts communication including my Chief Executive Bulletins ‘Catch up with Karen’ and posters have been distributed and displayed across the Trust.
The Quality and Governance Team monitor DOLS and the timescales and a report is produced weekly which provides an update to the Director of Quality and Governance on the status of DOLS.
Since the admission of Mr Pearson the Trust has undergone two CQC visits during which we have been challenged and scrutinised against the Trusts processes in place for Safeguarding Adults and Mental Capacity.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor Deprivation of Liberty Safeguards compliance and timescales through weekly reports to the Director of Quality and Governance.
Verbatim wording from the response “In addition Weightmans LLP have provided four sessions of Mental Capacity Training in September and October of 2015 for medical staff and Consultants. The Trust has another session scheduled for May 2016. To further promote the principles of DOLS and ensure staff are aware of these the trust has promotes this through the Trusts communication including my Chief Executive Bulletins ‘Catch up with Karen’ and posters have been distributed and displayed across the Trust.
The Quality and Governance Team monitor DOLS and the timescales and a report is produced weekly which provides an update to the Director of Quality and Governance on the status of DOLS.
Since the admission of Mr Pearson the Trust has undergone two CQC visits during which we have been challenged and scrutinised against the Trusts processes in place for Safeguarding Adults and Mental Capacity.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employ a Lead Nurse to advise staff and monitor compliance with Deprivation of Liberty Safeguards processes.
Verbatim wording from the response “Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered.
The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include the Status Epilepticus Policy in the mandatory Junior Doctor Grand Round.
Verbatim wording from the response “The Trust’s Education Department have confirmed that Status Epilepticus Policy will now be included as part of the Junior Doctor Grand Round (this is the training programme that all Junior Doctors must complete).
The Trust’s intranet has a search facility for documents which directs staff seeking guidance to documents including the Status Epilepticus Standards. The search also directs staff to the NICE Guidance Quality Standards for Epilepsies.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review medical staffing rotas to maximise senior cover and monitor staffing levels.
Verbatim wording from the response “Since the time of Mr Pearson’s admission the rotas for medical staffing have been reviewed to maximise appropriate levels of senior cover and to monitor the levels of medical staffing.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the Status Epilepticus Policy through junior doctor training, medical team discussions and the Trust intranet.
Verbatim wording from the response “As well as making improvements to the Trust’s local policy, steps have been taken to ensure all clinicians at the Trust have awareness of the policy. It has been included as part of the training of Junior Doctors, and has been discussed with the Trust’s medical teams. The policy is also easily available for clinicians on the Trust’s intranet.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise nursing documentation and reinforce Ward Manager and Matron monitoring of documentation quality.
Verbatim wording from the response “I am disappointed that HM Coroner found the medical and nursing records left much to be desired and I am sorry that you found this to be the case. HM Coroner will be aware that individual nursing and medical clinicians are responsible for their own professional standards. The Trust has a standard for medical record keeping and expects records to be timed and reflect an actual chronology.
The Clinicians carrying out the assessment should document the time the assessment was carried out as well as the time of the medical entry. This is our Trust standard and the Trust encourage and promote this.
The Trust has, since Mr Pearson’s admission, revised some of the nursing documentation and reinforced the role of Ward Managers and Matrons in monitoring the quality of documentation completed by staff.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with local-authority Deprivation of Liberty Safeguards leads and Mental Capacity Advocates on safeguarding processes.
Verbatim wording from the response “Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered.
The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver continuing Mental Capacity and Deprivation of Liberty Safeguards training for Trust staff, including the scheduled May 2016 session.
Verbatim wording from the response “Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered.
The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue recruiting medical staff and collaborate with Health Education North West and junior doctors to improve training experience and long-term attraction.
Verbatim wording from the response “These take into account the mix in relation to substantive staff and locum staff. The Trust maintains an ongoing recruitment programme and has been working with Health Education North West and junior doctors to improve the experience of junior doctors in training and to attract medical staff long term.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Change and review the Critical Care Unit processes and care pathway.
Verbatim wording from the response “The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical picture at a point in time. The Trust has a standard for the admission and discharge for Critical Care which provides guidance for clinical staff on the process for admission/escalation and this was revised in May 2014 to include further detail in relation to the National Early Warning Score and escalation and reviewed again in May 2015. This is available to all staff on the Trust’s intranet.
The Critical Care Unit and the processes and pathway for Critical Care have been subject to extensive change since April 2014 and have been subject to independent third party review and inspection. They have been reviewed by the CQC as an independent third party in April 2015.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and publish Critical Care admission, discharge and escalation standards, including National Early Warning Score guidance.
Verbatim wording from the response “The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical picture at a point in time. The Trust has a standard for the admission and discharge for Critical Care which provides guidance for clinical staff on the process for admission/escalation and this was revised in May 2014 to include further detail in relation to the National Early Warning Score and escalation and reviewed again in May 2015. This is available to all staff on the Trust’s intranet.
The Critical Care Unit and the processes and pathway for Critical Care have been subject to extensive change since April 2014 and have been subject to independent third party review and inspection. They have been reviewed by the CQC as an independent third party in April 2015.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Trust’s Status Epilepticus Policy using current clinical guidance.
Verbatim wording from the response “I am informed that since Mr Pearson’s admission in April 2014 nearly two years ago, Dr Douglass has revised the Trust’s Status Epilepticus Policy on two occasions, firstly in direct response to the admission of Mr Pearson and additionally at the time of review in 2015. The policy has been revised to assist clinicians in being able to more easily review and understand the appropriate steps to take when a patient presents with Status Epilepticus. The revisions were made by direct reference to recent guidance on Status Epilepticus published in the Lancet Medical Journal. Please find enclosed a copy of our current policy.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit key aspects of medical clinical documentation through the Trust’s Clinical Audit programme.
Verbatim wording from the response “The Trust’s Clinical Audit programme, the Trust’s Clinical Lead for Clinical Audit has been working with doctors in training and audits have been undertaken which include key aspects of medical clinical documentation.” Source location W-Pearson-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical condition.
Verbatim wording from the response “The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical picture at a point in time. The Trust has a standard for the admission and discharge for Critical Care which provides guidance for clinical staff on the process for admission/escalation and this was revised in May 2014 to include further detail in relation to the National Early Warning Score and escalation and reviewed again in May 2015. This is available to all staff on the Trust’s intranet.
The Critical Care Unit and the processes and pathway for Critical Care have been subject to extensive change since April 2014 and have been subject to independent third party review and inspection. They have been reviewed by the CQC as an independent third party in April 2015.” Source location W-Pearson-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations