23 Feb 2016 Edith Kirkham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to read or understand medical and nursing notes View source Inadequate staffing levels and expertise in the ward View source Inadequate planning and unclear management standards for intermediate care View source Failure to mobilise patients when clinically indicated View source Unavailability of records for patients’ ward stays View source Delays in arranging indicated physiotherapy View source Failure to hand over patients’ individual needs from hospital to the ward View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Edith Kirkham · 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 Kirkham fell at home on 13 August 2015, broke her hip, underwent surgery and was later moved to intermediate care, where she was not mobilised despite medical advice; she died some days later in North Manchester General Hospital. Concerns included unclear management arrangements, inadequate staffing and handover, failures to read or understand clinical instructions, lack of physiotherapy, and missing records relating to her stay.
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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 read or understand medical and nursing notes
Wider context from the report “3. The staff, or some of them, who gave evidence at the inquest, had either failed to read the medical/nursing notes, or if they had so read them, they had failed to understand them . The consultant surgeon had clearly indicated that the patient was to mobilise and was able to fully weight-bear, however for the whole of the week she spent in this ward she was nursed in bed and not mobilised at all.
” 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 staffing levels and expertise in the ward
Wider context from the report “2. Perhaps as a result of the problems highlighted at (1) above, the ward appears to have been inadequately staffed, both as to numbers of staff and the level of expertise thereof .
” 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 planning and unclear management standards for intermediate care
Wider context from the report “1. The intermediate care arrangement at Darnton House, I was informed, was a joint venture between L and M Health care and Tameside Hospital, but there seems to have been inadequate planning and unclear rules as to the level and type of management required for the patients/residents . Was the required standard that of a hospital or that of a care home. No-one seemed to know and this led to general uncertainty.
” 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 mobilise patients when clinically indicated
Wider context from the report “3. The staff, or some of them, who gave evidence at the inquest, had either failed to read the medical/nursing notes, or if they had so read them, they had failed to understand them. The consultant surgeon had clearly indicated that the patient was to mobilise and was able to fully weight-bear, however for the whole of the week she spent in this ward she was nursed in bed and not mobilised at all .
” 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 records for patients’ ward stays
Wider context from the report “6. Despite the request from me as HM Senior Coroner, it appears that no records were available relating to the whole of her stay in this ward .
” 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 arranging indicated physiotherapy
Wider context from the report “5. Mrs Kirkham was moved to the intermediate care ward on a Friday preceding a bank-holiday weekend, and despite the clear indication that she was to have physiotherapy, none was arranged for four days after her arrival .
” 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 hand over patients’ individual needs from hospital to the ward
Wider context from the report “4. There was no apparent handover from the hospital to this ward , as to the individual needs of the patient , and the staff were therefore placed in an impossible position.
” Open source report
20 Jan 2016 Derek Edward Hare · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide timely hospital appointments for reported abdominal problems View source Failure to retain patients in hospital when abdominal pain requires continued urgent assessment View source Failure to maintain a single coherent set of clinical notes 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
Derek Edward Hare · 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 Edward Hare underwent a colectomy and later embolization after experiencing severe abdominal pain and rectal bleeding. A subsequent colonoscopy led to failure of the bowel anastomosis, causing loss of bowel content and sepsis; he died after later surgery. The substantive concerns included separate hospital records, repeated refusal of requests for review, and discharge on 6 May 2015 despite abdominal pain when keeping him in hospital might have benefited his care.
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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 provide timely hospital appointments for reported abdominal problems
Wider context from the report “2. The deceased incessantly asked for appointments at the hospital because he knew that his abdomen was “not right”, yet he was constantly refused/denied such an appointment . This meant that it is possible that the problem which he had was diagnosed much later than might have been the case , and the outcome might have been different.
” 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 patients in hospital when abdominal pain requires continued urgent assessment
Wider context from the report “3. On the 5th May 2015 he was admitted via emergency ambulance to TGH with abdominal pains. On the 6th May it was determined that he did not need an emergency colonoscopy and the “urgency was not there”. He was sent home. He attended on the 19th June and had to undergo a laparotomy when the problem of the broken anastomosis was discovered and he died on the twelfth August. It was agreed by one of the consultant surgeons giving evidence to me that it would have benefited his care to have kept him in hospital on the 6th May .
” 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 a single coherent set of clinical notes
Wider context from the report “1. It would appear that throughout his various admissions to the hospital, two completely separate sets of “notes” were open and being used . Thus when the doctor tried to refer to the notes in court he could not do so and had to seek a short adjournment to find the relevant entry. If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient .
” 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 Reiterate and reinforce the record-keeping policy requiring staff to use one current set of records during each admission, through clinical leads and governance meetings.
Verbatim wording from the response “In respect of your concerns regarding the case notes I recognise that staff entries into the records should be in one set of records which should be the current ones in use during the patient’s admission. This is the Trust’s standard and expectation and has been reiterated to the Consultant Clinical Leads, Lead Clinicians and Senior Nurses in the Clinical Divisions for discussion to all staff and for discussion at their Clinical Governance and team meetings. As you have highlighted where it is necessary to provide two sets of notes for reference to the previous history and continuity of care there is a risk that medical staff may enter their notes in the older set of notes. This reiteration and reinforcement of the record keeping policy will minimise this.” Source location D-hare-Response
Open published response
29 Oct 2015 Hilda Haughton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Fire doors taking increased time to close View source Failure to raise cot sides as required View source Lack of candour by hospital staff 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
Hilda Haughton · 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
Hilda Haughton was admitted to hospital with pneumonia and an acute exacerbation of COPD, and was injured when a fire door was electronically released during a power failure and struck her. The concerns included a subsequent fall from her bed when cot sides had not been raised, alleged lack of candour by hospital staff, and whether the response to the speed and power of electronically released fire doors was adequate.
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 Fire doors taking increased time to close
Wider context from the report “2. The fire-doors are held open by electro-magnets. These are designed to be released remotely to contain any fire which may break out in the hospital. I was told that this type of door fastener is common to very many hospital wards around the U.K. The length of time it takes for the doors to close affects the speed and power with which they move. This time has been increased at Tameside hospital from 3 seconds to 6 seconds. Is this an adequate response and should this issue be raised with all hospitals having these door fasteners? (Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to raise cot sides as required
Wider context from the report “1. Mrs Haughton having sustained the head injury on the 28th April, some 7 days later she was able to fall out of her bed because the cot sides had not been raised as they should have been , and there was a lack of candour by the hospital staff, and this, inter alia, deprived the family of the possibility of seeking a second opinion as to her injuries. (Tameside)
” 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 candour by hospital staff
Wider context from the report “1. Mrs Haughton having sustained the head injury on the 28th April, some 7 days later she was able to fall out of her bed because the cot sides had not been raised as they should have been, and there was a lack of candour by the hospital staff , and this, inter alia, deprived the family of the possibility of seeking a second opinion as to her injuries. (Tameside)
” 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 Meet regularly with patients and families to discuss experiences and apologise when things go wrong.
Verbatim wording from the response “I along with my leadership team have a strong leadership ethos regarding candour and believe that leading by example is key in demonstrating the Trust’s commitment in relation to candour. My Director of Quality and Governance and I both regularly meet with families and patients to discuss their experiences and to apologise when things go wrong.” Source location Hilda-Haughton-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 Commission independent expert reports and share them with patients, relatives, carers and staff for learning.
Verbatim wording from the response “In order to ensure the Trust is transparent and learns from incidents, complaints and claims we have commissioned a significant number of independent expert reports to ensure transparency and openness with our patients, relatives and carers which we share with them and with our staff for learning.” Source location Hilda-Haughton-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 Train staff in investigations, root-cause analysis, communication, reporting, openness and the Duty of Candour.
Verbatim wording from the response “During February and March 2015 the Trust ran several workshops which were delivered by external facilitators and were attended by a wide range of staff which focused on investigations, Root Cause Analysis and incorporated communication and supported the culture of reporting and openness. We trained over 75 staff in this and Being Open and Duty of Candour was central to the training.” Source location Hilda-Haughton-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 Trust policies and continue considering statutory Duty of Candour obligations when updating policies and procedures.
Verbatim wording from the response “The Trust has been very proactive in relation to ensuring Duty of Candour, Trust policies have been reviewed and consideration continues to be given regarding statutory obligation when reviewing and updating policies and procedures.” Source location Hilda-Haughton-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 Commission and publish patient-experience films to share patients’ and relatives’ perspectives with staff and support learning.
Verbatim wording from the response “The Trust has commissioned a number of patient experience films with our patients and their relatives to ensure that their perspective and their experiences are shared with staff and that we learn from these. One of the consistent messages in these is the importance of communication and how this effects the patients and families perception and how this influences their view of the Services in relation to openness and candour. These are available on the Trust intranet and public internet and focus on both the negative” Source location Hilda-Haughton-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 fall did not trigger the statutory Duty of Candour under Regulation 20.
Verbatim wording from the response “I wish to take this opportunity to make it clear that the incident on 6 May 2015 did not invoke the Statutory Duty of Candour under Regulation 20 (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. An unwitnessed fall occurred on or around 04:50 on 6 May 2015. The medical records demonstrate that following this Mrs Haughton was given a head-to-” Source location Hilda-Haughton-Response
Open published response
19 May 2015 Sheila Johnson · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Inaccuracies in internal investigation reports View source Insufficient and perfunctory investigations of patient deaths View source Failure to interview key witnesses during investigations View source Lack of a system for urgent recall of discharged patients with potentially life-threatening conditions View source Failure to assess the clinical content and appropriateness of nursing and medical documentation 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
Sheila Johnson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheila Johnson died on 15 May 2013 from catastrophic haemorrhage from a femoral graft wound, less than 24 hours after discharge from hospital with an open left groin wound. The report identified failures in responding to recognised bleeding before discharge and concerns about the inadequacy of the Trust’s investigation, including the omission of key witnesses, limited review of clinical documentation, factual inaccuracies, and the lack of an urgent recall system for patients discharged with potentially life-threatening conditions.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in internal investigation reports
Wider context from the report “(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report.
(2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths.
(3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod.
(4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed.
(5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate.
(6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made .
(7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future.
(8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions.
” 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 and perfunctory investigations of patient deaths
Wider context from the report “(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report.
(2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths.
(3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod .
(4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed.
(5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate.
(6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made.
(7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future.
(8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions.
” 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 interview key witnesses during investigations
Wider context from the report “(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report.
(2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths.
(3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod.
(4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed .
(5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate.
(6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made.
(7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future.
(8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions.
” 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 system for urgent recall of discharged patients with potentially life-threatening conditions
Wider context from the report “(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report.
(2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths.
(3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod.
(4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed.
(5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate.
(6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made.
(7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future.
(8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions .
” 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 clinical content and appropriateness of nursing and medical documentation
Wider context from the report “(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report.
(2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths.
(3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod.
(4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed.
(5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature . No consideration was given to the clinical content of those entries and as to whether or not they were appropriate .
(6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made.
(7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future.
(8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions.
” 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 an urgent recall procedure directing staff to contact patients or relatives, then primary-care, community or police services when necessary.
Verbatim wording from the response “The Trust acknowledges your concerns and accepts them in full. The fact that there was no formal system for the urgent recall of patients discharged with potentially life threatening conditions, has been addressed by the Patient Flow Manager.” Source location 2015-0238-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 Rewrite and implement the serious incident investigation policy with guidance on reporting, investigation, best practice, system failures and record-keeping standards.
Verbatim wording from the response “In relation to your particular concerns regarding the quality of the internal investigation undertaken at this time, the Trust’s processes have been revised significantly and beyond all recognition. The current policy for the management of serious incidents including their investigation has been rewritten and implemented. The policy provides clear guidance to Trust staff in relation to incident reporting and the investigation process, with the aim of improving the quality of the Trust’s investigations. We have had this monitored by the CQC and CCG and reported to external oversight groups.” Source location 2015-0238-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 Introduce an Executive-led Serious Incident Review Panel to scrutinise investigation reports and action plans and require clinical leads to report changes and learning.
Verbatim wording from the response “We have also introduced improvements to the process for internal review of serious incident reports. There is now an Executive led Serious Incident Review Panel which reviews all serious incident investigation reports and action plans and scrutinises and challenges them, providing feedback to the investigation teams when further clarity is required. The panel also require that responsible nursing and medical leads attend the meeting to feed back what changes have been made and what lessons have been learnt from investigations.” Source location 2015-0238-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 Train senior officers across all divisions in root-cause analysis and incident investigation through external facilitation.
Verbatim wording from the response “We recognise that staff undertaking incident investigations need to be appropriately trained. Since the investigation into Mrs. Johnson’s death the Trust has invested significantly in additional training provided by an external facilitator. This has delivered root cause analysis and investigation training across all divisions of the Trust, the most recent training taking place in March of this year. More than 75 senior officers have been trained in RCA. This has underpinned the revised policy to ensure investigations are more robust and recommendations are acted upon and patient care and safety is improved.” Source location 2015-0238-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 Require Directors to review each serious incident and assign an investigation level, team and relevant professional advice.
Verbatim wording from the response “All serious incidents are reviewed by Directors who assign a level of investigation and an investigation team to each serious incident, consisting either of appropriate individuals from the Trust or where relevant external independent persons. Professional advice relevant to the specialty is now obtained.” Source location 2015-0238-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 Existing serious incident processes provide significant assurance that appropriate systems and processes are in place.
Verbatim wording from the response “The auditors concluded in their report dated 10th March 2015 that the serious incident processes provided significant assurance to the Trust that systems and processes were in place.” Source location 2015-0238-Response-by-Tameside-Hospital-NHS-Trust
Open published response
4 Feb 2015 Paul Moroney · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Unavailability of records of previous oxygen levels on readmission View source Failure to monitor oxygen saturations before discharge after oxygen therapy View source Failure to record oxygen saturations during hospital care View source Failure to monitor oxygen saturations during hospital care View source See 1 more concern
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
Paul Moroney · 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
Paul Moroney attended Tameside Hospital by ambulance on 27 August 2014 with worsening breathing and concern about a blood clot, was discharged with arrangements to return the following day, and later required a second emergency ambulance. Concerns included the lack of monitoring or recording of his oxygen saturations, discontinuation of oxygen before discharge without monitoring, and the absence of previous oxygen-level records when he was readmitted.
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 records of previous oxygen levels on readmission
Wider context from the report “3. When he was re-admitted to the hospital there was no record available to the staff about his previous oxygen levels .
” 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 monitor oxygen saturations before discharge after oxygen therapy
Wider context from the report “2. Having been put on oxygen in the hospital, this was discontinued and he was sent home without his Oxygen saturations being monitored
” 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 oxygen saturations during hospital care
Wider context from the report “1. Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded
” 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 monitor oxygen saturations during hospital care
Wider context from the report “1. Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded
” 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 Oxygen saturations were monitored and recorded during the hospital attendance, contrary to the concern that they were not.
Verbatim wording from the response “1. Whilst at the hospital on the first occasion, no oxygen saturations were monitored or recorded.” Source location 2015-0043-Response-by-Tameside-Hospital-NHS-Trust
Open published response
24 Nov 2014 HAROLD PENNY · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to require radiology to urgently report findings to treating clinicians View source Failure to require radiology to rectify identified problems where possible 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
HAROLD PENNY · 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
HAROLD PENNY was admitted to hospital on 12 June 2014 and died on 20 June after investigations found a grossly distended bladder and a misplaced urinary catheter. The principal concern was that there was no system requiring radiology staff to rectify such problems where possible or urgently report them to treating clinicians.
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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 require radiology to urgently report findings to treating clinicians
Wider context from the report “There seems to be no system in place to require the radiology department either to rectify the situation themselves if that is possible, nor to urgently report back to the treating clinicians in a case where, for example, they find that a urinary catheter has become displaced and is causing a blockage.
” 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 require radiology to rectify identified problems where possible
Wider context from the report “There seems to be no system in place to require the radiology department either to rectify the situation themselves if that is possible , nor to urgently report back to the treating clinicians in a case where, for example, they find that a urinary catheter has become displaced and is causing a blockage.
” 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 Review the Trust’s IT infrastructure to ensure it supports timely documentation and communication of significant radiological findings.
Verbatim wording from the response “Department examinations the same day. Where there are urgent findings (where medical evaluation is needed within 24 hours) the expectation will be that these are reported within four hours, the time frame depending on the nature of the imaging findings. Priority is given to inpatients, urgent requests and unexpected significant findings. The Trust’s objective is to document significant radiological findings and ensure they are communicated in a timely and unequivocal fashion. The Trust is reviewing its IT infrastructure to ensure this support is in place.” Source location 2014-0507-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 Ratify a radiology requesting and reporting policy defining responsibilities, documentation requirements, escalation processes and reporting timeframes.
Verbatim wording from the response “Work is being undertaken in this area at the Trust as part of the Sign up to Safety campaign which was launched by the Secretary of State for Health on 24 June 2014 with a mission to strengthen patient safety in the NHS. A draft ‘Radiology Requesting and Reporting Policy’ has been produced by the Trust and is currently going through our governance procedures.” Source location 2014-0507-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 Review frameworks for tracking and following up all radiology reports and ensure they are robust.
Verbatim wording from the response “As set out above, the policy that we are in the process of ratifying, places a great deal of responsibility with the Radiologists within the Trust. However, it is important to note the responsibilities of the referring clinicians also. It is their responsibility to ensure that they have in place a robust system to enable tracking and follow up of all radiology reports. One of the focus areas of the RGSG is to review frameworks for tracking and follow up of all radiology reports and ensure these are robust. Once received, reports should be legibly signed, dated and filed in a permanent patient record with a clear indication of any action taken following receipt of the report. It is the responsibility of the referring clinician to ensure this takes place and individual systems in place will be subject to regular audit.” Source location 2014-0507-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 Operate the Results Governance Steering Group to implement and continuously improve results-governance processes, with monthly meetings.
Verbatim wording from the response “A Results Governance Steering Group (RGSG) was also developed in October 2013 and is one of ten project teams that report to the Tameside Hospital Patient Safety Programme Board (PSPB) as part of the ‘Keeping patients safe and reducing harm’ programme. The RGSG met for the first time on 4 November 2014 and is concerned with ensuring that the Trust has clinical and operational processes to adequately support effective results governance. The scope of this group is to ensure that effective results governance processes are in place to timely recognition and escalation of abnormal clinical results. The 2014-2015 objectives of this group specifically include improving the standards of results governance from both a report and service delivery perspective. The group has completed an initial review of processes and is now meeting monthly to ensure implementation and continuous improvement.” Source location 2014-0507-Response-by-Tameside-Hospital-NHS-Trust
Open published response
17 Nov 2014 Elsie Mallalie u · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Failure to activate intravenous antibiotic infusions View source Failure to make appropriate resuscitation and critical-care escalation decisions View source Insufficient qualified ward staffing capacity for patient workload and complexity View source Failure to conduct timely and continuous patient observations View source Placement of patients in inappropriate wards View source Failure to accurately calculate and use patient observation scores View source Lack of staff training to use high flow oxygen equipment View source Failure to adequately record essential patient care in medical and nursing notes View source See 5 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. 9
Action
Develop and pilot integrated health records across specialties to improve information sharing and prevent loss of vital information.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 November 2014. View source
Action
Reduce agency-staff use, address substantive vacancies and maintain registered nursing levels.
Stated completedThe respondent said that this action was complete when they made their response on 17 November 2014. View source
Action
Replace PARS with NEWS, train Trust staff in NEWS scoring, provide an escalation guide and maintain refresher training as needed.
Stated completedThe respondent said that this action was complete when they made their response on 17 November 2014. View source
Action
Train orthopaedic doctors, including during junior-doctor induction, on senior approval, documentation and appropriate ward transfers.
Stated completedThe respondent said that this action was complete when they made their response on 17 November 2014. View source
Action
Communicate requirements to consider staffing levels and skills before transfers between specialties or ward areas.
Stated completedThe respondent said that this action was complete when they made their response on 17 November 2014. View source
Action
Review current record-keeping training to reinforce clarity and completeness.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 November 2014. View source
Action
Provide high-flow oxygen training for Ward 41 staff through scheduled equipment-trainer sessions and interim physiotherapist support.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 November 2014. View source
Action
Assess staffing through ward-based accreditation and unannounced walk rounds.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 November 2014. View source
Action
Monitor staffing levels and skill mix through daily reporting, assurance processes, escalation arrangements and senior nursing support.
Stated completedThe respondent said that this action was complete when they made their response on 17 November 2014. View source See 6 more actions
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AI-generated summary
Elsie Mallalie u · 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 Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to activate intravenous antibiotic infusions
Wider context from the report “5. A Consultant agreed with my conclusion that this patient was “written off” and that a DNAR should not have been placed and that she could have been escalated to ITU/HDU where the infection which in fact led to her death, might have been treatable. Whilst on ward 41 she was administered antibiotics for this condition but the nursing staff had failed to “turn on “the drip delivering the drug .
” 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 appropriate resuscitation and critical-care escalation decisions
Wider context from the report “5. A Consultant agreed with my conclusion that this patient was “written off” and that a DNAR should not have been placed and that she could have been escalated to ITU/HDU where the infection which in fact led to her death, might have been treatable. Whilst on ward 41 she was administered antibiotics for this condition but the nursing staff had failed to “turn on “the drip delivering the drug.
” 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 qualified ward staffing capacity for patient workload and complexity
Wider context from the report “4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions . There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10)
” 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 timely and continuous patient observations
Wider context from the report “4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift . A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10)
” 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 Placement of patients in inappropriate wards
Wider context from the report “1. During the course of her relatively short stay in the hospital she was moved to Ward 41 which, as agreed in evidence by senior medical staff, was an inappropriate ward for her .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately calculate and use patient observation scores
Wider context from the report “4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier . Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10)
” 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 staff training to use high flow oxygen equipment
Wider context from the report “2. She was entirely dependent on high flow oxygen, but none of the staff on ward 41 was trained to use this equipment .
” 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 record essential patient care in medical and nursing notes
Wider context from the report “3. The medical and nursing notes on ward 41 were woefully inadequate , and failed to record some of the most basic care which was, or ought to have been, given .
” 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 Develop and pilot integrated health records across specialties to improve information sharing and prevent loss of vital information.
Verbatim wording from the response “There is also a proposal for integrated health records and for a pilot project to take place for each specialty within the Trust. A task and finish group is currently exploring this but to date ITU, Outreach and AMU began trialling integrated notes in November 2014. Integrated health records are now standard across most Trusts and should safeguard against vital information being lost as well as having a more universal and systematic approach to sharing information. Overall, it will provide a more transparent and robust approach throughout the Trust.” Source location 2014-0501-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 Reduce agency-staff use, address substantive vacancies and maintain registered nursing levels.
Verbatim wording from the response “Response
The staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs Mallalieu was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained.” Source location 2014-0501-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 Replace PARS with NEWS, train Trust staff in NEWS scoring, provide an escalation guide and maintain refresher training as needed.
Verbatim wording from the response “With regards the failure to take observations during the night shift; this occurred because a member of the nursing staff unfortunately miscalculated the PARS score, which meant that Mrs Mallalieu did not have her observations taken as she would have done if scoring had been correct. Since Mrs Mallalieu’s treatment the PARS scoring system has been replaced by a different system called NEWS and Trust staff have been trained in the use of it. A quick reference NEWS escalation and response guide has also been made available to all staff. The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration.” Source location 2014-0501-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 Train orthopaedic doctors, including during junior-doctor induction, on senior approval, documentation and appropriate ward transfers.
Verbatim wording from the response “Response
Following detailed investigations, action has been taken to minimise the risk of inappropriate transfer occurring in the future. Training has been provided to doctors in the Orthopaedic Department to make them aware of the following:” Source location 2014-0501-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 Communicate requirements to consider staffing levels and skills before transfers between specialties or ward areas.
Verbatim wording from the response “We have taken action to address this by communicating to all staff that where possible, staffing levels and skills must be considered prior to transfer between specialties and / or ward areas, to ensure that patients continue to receive the appropriate level of care. Additionally, a schedule of training has been put in place for the staff on Ward 41 regarding high-flow oxygen, although it is rarely used by staff on Ward 41. Training by the Trust’s equipment trainer has progressed and sessions will be on the wards where all staff would be able to attend as appropriate. In the meantime, the physiotherapists are also providing staff with training on the wards when there is a patient requiring high flow oxygen. Following feedback, we know that the physiotherapists are being very supportive in this interim role.” Source location 2014-0501-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 Review current record-keeping training to reinforce clarity and completeness.
Verbatim wording from the response “Response
The Trust’s internal investigation identified deficiencies in the record keeping in this case and is undertaking a review of its current training on record keeping standards. Such training will reinforce the need for clarity and completeness.” Source location 2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide high-flow oxygen training for Ward 41 staff through scheduled equipment-trainer sessions and interim physiotherapist support.
Verbatim wording from the response “We have taken action to address this by communicating to all staff that where possible, staffing levels and skills must be considered prior to transfer between specialties and / or ward areas, to ensure that patients continue to receive the appropriate level of care. Additionally, a schedule of training has been put in place for the staff on Ward 41 regarding high-flow oxygen, although it is rarely used by staff on Ward 41. Training by the Trust’s equipment trainer has progressed and sessions will be on the wards where all staff would be able to attend as appropriate. In the meantime, the physiotherapists are also providing staff with training on the wards when there is a patient requiring high flow oxygen. Following feedback, we know that the physiotherapists are being very supportive in this interim role.” Source location 2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess staffing through ward-based accreditation and unannounced walk rounds.
Verbatim wording from the response “Staffing is also being assessed as part of ward based accreditation and unannounced walk rounds.” Source location 2014-0501-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 Monitor staffing levels and skill mix through daily reporting, assurance processes, escalation arrangements and senior nursing support.
Verbatim wording from the response “Nurse staffing levels are being monitored through multiple assurance sources including the Trust Board Hard Truths paper. Additionally, the Trust’s Board is actively monitoring staff levels and the skill mix across the Trust. This involves staff levels being considered daily alongside daily staffing level reports and bed management, which involves the Deputy Director of Nursing. There is also a focus on reporting low staffing levels following which there is an escalation process involving the individual nurse in-charge, the senior nurse, the Divisional Head of Nursing and the Director of Nursing. This will also enable senior nurse intervention and support where required.” Source location 2014-0501-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 written off; the DNAR decision was appropriate and escalation to ventilation remained reasonable under responsible medical opinion.
Verbatim wording from the response “Response
Although, as addressed above, Mrs Mallalieu should not have been transferred to Ward 41 from the Trauma Unit it is certainly not the case that she was “written off”. Nevertheless, admittedly she was a very ill patient with a poor prognosis and this was supported by the Trust’s commissioned independent expert report of ████████ Consultant Geriatrician which was sent to your offices prior to the inquest.” Source location 2014-0501-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 Ward 41 staffing levels met national guidelines, although the ward was busy and further action addressed agency use and substantive vacancies.
Verbatim wording from the response “Response
The staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs Mallalieu was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained.” Source location 2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Open published response
27 Oct 2014 Agnes Mary Hannan · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 13 Lack of availability of prior hospital notes and treatment records to Emergency Department staff View source Delays in scanning Emergency Department paper records into electronic systems View source Failure to communicate medical and nursing diagnoses and decisions to families View source Failure to seek advice from the patient's long-term treating specialist service View source Failure to monitor intravenous cannula connections and hydration delivery View source Failure to use a clear process for determining the responsible consultant View source Use of unexplained initials and abbreviations in hospital notes View source Failure to ensure full and meaningful discussion before initiating the End-of-Life Care Pathway View source Failure to carry out or record required nursing observations View source Poor communication between hospital staff and patients and families View source Inadequacy of medical and nursing notes View source Unavailability of CT scanning for the Emergency Department out of normal hours View source Failure to hand over patient information between staff View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Agnes Mary Hannan · 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
Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of prior hospital notes and treatment records to Emergency Department staff
Wider context from the report “1. There was an actual, or perceived, lack of availability of the hospital notes and records of previous diagnoses and treatments by hospital doctors, for the staff working in the Emergency Department .
” 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 scanning Emergency Department paper records into electronic systems
Wider context from the report “9. I was told in evidence that it takes up to three months for the paper records of the ED to be scanned electronically . This means that recent notes may not be available on the computer screens for the staff in the ED .
” 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 medical and nursing diagnoses and decisions to families
Wider context from the report “7. The communication of Medical/nursing diagnoses and decisions to the family, was extremely poor and frequently did not happen . An example of this was the failure by the staff to explain the critical nature of Mrs Hannan’s condition, so that the grandson of the deceased failed to be able to come and see his grandmother in hospital before she died.
” 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 seek advice from the patient's long-term treating specialist service
Wider context from the report “4. Whilst it was, or should have been apparent that she was already under the long term care of ████████ no-one made any attempt to speak with him or his department for advice .
” 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 monitor intravenous cannula connections and hydration delivery
Wider context from the report “2. On one occasion whilst she was an in-patient, Mrs Hannan who was desperately ill and needing intra-venous hydration, was found to be lying in a soaking wet bed because the tube leading to her cannula had become dislodged and disconnected. The nursing staff had failed to notice this problem . The doctors in evidence, acknowledged that her lack of hydration would inevitably have worsened her already thrombosed veins.
” 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 clear process for determining the responsible consultant
Wider context from the report “10. When a patient is admitted there is little or no logic as to determining which Consultant shall be in charge . In this case she was allocated under the care of ████████ who was not even in the hospital for the first two days of her admission and in fact who NEVER actually saw 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 Use of unexplained initials and abbreviations in hospital notes
Wider context from the report “5. Throughout the hospital notes for this patient, there is widespread use of initials and abbreviations . On at least one occasion in court, none of the medical/nursing staff present could explain to me what the abbreviation in the notes meant .
” 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 full and meaningful discussion before initiating the End-of-Life Care Pathway
Wider context from the report “11. The End-of-Life Care Pathway must be initiated only after full and meaningful discussion with the patient and/or her family . In the present case there was no evidence to show that any such discussion had taken place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out or record required nursing observations
Wider context from the report “6. This patient needed very careful monitoring at all times and yet there was a period of 24 hours when no nursing observations were carried out or recorded .
” 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 hospital staff and patients and families
Wider context from the report “3. There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst hospital staff . There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently 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 Inadequacy of medical and nursing notes
Wider context from the report “3. There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst hospital staff. There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently 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 Unavailability of CT scanning for the Emergency Department out of normal hours
Wider context from the report “8. I was told that there is no CT scanner facility available for the use of the ED out of normal hours . This meant that a scan was delayed/missed and led to a delay in diagnosis of her underlying 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 Failure to hand over patient information between staff
Wider context from the report “3. There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst hospital staff. There was evidence of a lack of handover between staff , and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate.
” Open source report
14 Oct 2014 Alan Charles Peck · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to connect syringe drivers for delivery of prescribed medication View source Failure to maintain syringe-driver medication delivery during hospital-to-hospice transfer View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alan Charles Peck · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Charles Peck had been an inpatient at Tameside Hospital for approximately six weeks, underwent a hemi-colectomy, and was then discharged to Willow Wood Hospice. Concerns were raised that his syringe driver was not connected while he was on the surgical ward and that he was deprived of medication during transfer to the hospice.
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 connect syringe drivers for delivery of prescribed medication
Wider context from the report “1. Whilst a patient on the surgical ward at Tameside Hospital, it was noted by his family that although he was prescribed medication to be delivered by syringe driver, the said driver was unconnected under the patient’s bed thus meaning that the essential drugs and analgesia were not being delivered to him .
” 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 syringe-driver medication delivery during hospital-to-hospice transfer
Wider context from the report “2. When he was discharged and transferred from the hospital to the hospice, a nurse grabbed the syringe driver which was attached to his bed , and said that that could not be transferred with him . He was thus deprived of his medications for the duration of that transfer
” Open source report
13 Oct 2014 Mary Fenton · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 12 Failure to assess patients’ mental capacity View source Failure to document unavailable consent or self-consenting rationale View source Unavailability of specialist cardiology advice outside normal hours View source Fragility of the national pharmaceutical supply chain View source Lack of adequate facilities to manage complications of pacing placement View source Unavailability of skilled and qualified staff to fit pacing wires View source Delays in inserting pacing wires View source Failure to obtain consent to treatment View source Failure to document patients’ mental capacity View source Severe shortages of Isoprenaline View source Unavailability of echocardiography facilities after 5.00pm View source Failure of communication between staff, patients and families View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mary 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
Mary Fenton was admitted to Tameside Hospital on 26 April 2014 needing an urgent heart pacemaker and died on 30 April 2014 after delays and missed opportunities. Concerns included limited cardiology cover and facilities, shortages of Isoprenaline, failures relating to capacity and consent, delays in inserting pacing wires, inadequate facilities to manage complications, and poor communication.
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 assess patients’ mental capacity
Wider context from the report “4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document unavailable consent or self-consenting rationale
Wider context from the report “5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting” . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of specialist cardiology advice outside normal hours
Wider context from the report “1. Although Tameside Hospital holds itself out as performing pacemaker insertions, both temporary and permanent, no Cardiology Consultant is on call after 5.00pm or at week-ends . There is therefore no-one available to the junior staff having the requisite levels of skill and expertise to advise . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragility of the national pharmaceutical supply chain
Wider context from the report “9. The National pharmaceutical supply chain was described in evidence by a Chief Pharmacist as being “very fragile” (For Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate facilities to manage complications of pacing placement
Wider context from the report “8. It was demonstrated by the evidence that if there should be a situation where the placing of the pacing causes unforeseen problems (e.g. by causing bleeding within the pericardium leading to cardiac tamponade) there is a lack of adequate facilities to address that situation . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of skilled and qualified staff to fit pacing wires
Wider context from the report “6. Despite this being a major District General Hospital providing cardiology cover for a large proportion of the population of Greater Manchester, there is no-one with the skill or qualification to fit “temporary/permanent” pacing wires . (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in inserting pacing wires
Wider context from the report “7. There were inexcusably and potentially catastrophic delays in inserting the pacing wires (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent to treatment
Wider context from the report “5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting”. (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document patients’ mental capacity
Wider context from the report “4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Severe shortages of Isoprenaline
Wider context from the report “3. This patient was being kept alive by the use of Isoprenaline. It transpires that there were severe shortages of this drug in the hospital but also nationally . I was told that this drug is produced as an unlicensed drug by NHS Pharmaceutical Productions. If so why do they not ensure sufficient supply? (For Tameside Hospital and for The Secretary of State)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of echocardiography facilities after 5.00pm
Wider context from the report “2. After 5.00pm there is no facility for an echocardiogram to be performed at the hospital. (For Tameside Hospital)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between staff, patients and families
Wider context from the report “10. There was very poor communication between staff and other staff, and between staff and the family of the deceased and the patient herself (e.g. in relation to DNAR notice, “consent” forms etc.) (Tameside Hospital).
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the DNACPR policy to require discussion, clear communication and checking of understanding.
Verbatim wording from the response “In May 2014 the DNACPR policy was reviewed in line with R (on the application of David Tracey) v Cambridge University Hospitals NHS Foundation Trust [2014] to involve discussion with patients/their families. A DVD was created and is available on the Trust's intranet. The review of the policy was promoted through screensavers, to inform staff of the new policy.” Source location 2014-0443-Response-by-Tameside-Hospital
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 Relocate and equip a cardiac pacing room in theatre 4 for in-hours and out-of-hours cardiac procedures.
Verbatim wording from the response “There is also now a cardiac pacing room in theatre 4 and all equipment therein is operational. Relocation took place in September 2014 and this facility provides an in-hours and out of hours provision for all cardiac procedures, revisions and repairs and all Cardiologists are capable of carrying out emergency cardiac ultrasound to deal with very rare complications. Also, the old pacing room that the Trust was making use of is no longer required for pacing and the Trust is currently considering whether this could be used to expand the CCU area.” Source location 2014-0443-Response-by-Tameside-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide 24-hour Consultant Cardiologist cover for emergency temporary pacing through an operational on-call rota.
Verbatim wording from the response “Following the Inquest into Mrs Fenton’s death a review was undertaken by the Trust into the provision of pacing procedures out of hours. The Lead of the Cardiology Department was charged with organising an on call rota for pacing wires. The rota became operational on the 10 November 2014 and provides for a Consultant Cardiologist on-call to cover all emergency temporary pacing and pathway. The service is available 24 hours per day, every day of the year. The on-call rota for temporary pacing wires is shared with the hospital switchboard and CCU. The rota provides for out of hours cover by the following Consultant Cardiologists – ████████ ████████. This is currently being provided with nursing support via the Night Nurse Practitioner and Level 2 / CCU nursing staff on shift.” Source location 2014-0443-Response-by-Tameside-Hospital
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 safe Critical Care medication storage, regular staff checks and pharmacist audits.
Verbatim wording from the response “The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage” Source location 2014-0443-Response-by-Tameside-Hospital
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 Temporary Pacing Wire Pathway.
Verbatim wording from the response “As a result of the review a Temporary Pacing Wire Pathway has also been created, a copy of which is attached.” Source location 2014-0443-Response-by-Tameside-Hospital
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 existing Pharmacy Department pathways for managing medicines shortages.
Verbatim wording from the response “Please be assured that the Trust finds any shortage of drugs unacceptable and we are doing everything within our power to ensure such shortages do not impact upon the care our patients receive. The Trust does have a strong contingency plan in place and in the case of Mrs Fenton this was evidenced by the incident itself where the Trust utilised local networks to ensure continuity of supply. Following the inquest into the death of Mrs Fenton, the Trust has reviewed all existing pathways to the Pharmacy Department and we cannot identify a case where the Trust has not been able either a medicine experiencing a shortage or a clinically appropriate and suitable agreed alternative for a patient.” Source location 2014-0443-Response-by-Tameside-Hospital
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 out-of-hours CRI provision and explore procurement of a portable echocardiogram machine.
Verbatim wording from the response “Currently, the provision of echocardiogram services is undertaken as a day case service between the hours of 9.00am and 5.00pm and this existing service is provided by the specialist CRI technicians. Due to the existing capacity and demand for the service, the existing provision can only currently provide an in hours service. Echocardiograms are and have been undertaken by qualified Consultants and Staff Grade Doctors as and when required. Going forward, the recent external cardiology service review and your concerns following the inquest into the death of Mrs Fenton have formed the basis for a service review specifically around the provision of CRI services. As part of this review, the procurement of a portable echocardiogram machine and out of hour provision is being explored as part of the wider service developments.” Source location 2014-0443-Response-by-Tameside-Hospital
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 and provide a bedside patient-safety booklet for patients and relatives.
Verbatim wording from the response “The Trust is striving to improve communication between clinicians, patients and family members. The Trust has created a bedside booklet, available for patients and relatives – “Patient Safety – Keeping you safe during your stay in hospital”. This empowers patients and their families to ask questions.” Source location 2014-0443-Response-by-Tameside-Hospital
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 Employ a specialist nurse in adult safeguarding, mental capacity and deprivation of liberty safeguards.
Verbatim wording from the response “The Trust has employed a specialist nurse in safeguarding adults, MCA and DOLS to support medical and nursing staff and to ensure that a thorough and correct assessment relating to mental capacity is completed and that any decisions made are in the best interests of the patient. During 2013/14 the Trust has seen a significant increase in activity (146%) and profile of adult safeguarding. Therefore, an assertive training programme has been put in place and we have seen over 828 staff trained to date. The Trust’s solicitor, Weightmans have also been utilised in providing training and they have provided an extensive training course throughout the year titled “The Legal Principles of the Mental Health Act; Mental Capacity Act and Deprivation of Liberty”.” Source location 2014-0443-Response-by-Tameside-Hospital
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 Reiterate the medicines-shortage protocol to the Pharmacy Department.
Verbatim wording from the response “Also, the Trust does have a protocol in place which is followed when any shortage arises. This involves conducting a risk assessment to evaluate the potential effect of the shortage and the assessment takes account of the estimated duration of the shortage; usage figures; the availability of suitable alternative products; and the potential risk to patients. As you will appreciate, not all shortages will need further action but where the risk assessment supports further work on a long term critical shortage, the Trust’s Pharmacy Department makes an estimate of the stock in hand within the entire organisation and of the time period this will cover. Where limited stock might lead to a restriction being placed on the use of a medicine, then this restriction will be discussed and agreed with the most relevant and appropriate Senior Doctor within the Trust.” Source location 2014-0443-Response-by-Tameside-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out refresher training on mental-capacity, consent and communication policies.
Verbatim wording from the response “As to the actions of the particular staff involved in the care of Mrs Fenton, and with particular reference to the assessment and documentation of mental capacity, consent and communication, we have reminded the clinicians of the relevant policies and advised them that we will be rolling out refresher training. All Cardiology staff have also been informed by the Lead Consultant Cardiologist that no usage of Isoprenaline should be permitted in the CCU / Ward 31 without the consent of a Consultant Cardiologist / the on-call Cardiologist for pacing out of hours.” Source location 2014-0443-Response-by-Tameside-Hospital
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 Replenish the Trust’s Isoprenaline stock following the national shortage.
Verbatim wording from the response “The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage” Source location 2014-0443-Response-by-Tameside-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver an assertive adult safeguarding and mental-capacity training programme to Trust staff.
Verbatim wording from the response “The Trust has employed a specialist nurse in safeguarding adults, MCA and DOLS to support medical and nursing staff and to ensure that a thorough and correct assessment relating to mental capacity is completed and that any decisions made are in the best interests of the patient. During 2013/14 the Trust has seen a significant increase in activity (146%) and profile of adult safeguarding. Therefore, an assertive training programme has been put in place and we have seen over 828 staff trained to date. The Trust’s solicitor, Weightmans have also been utilised in providing training and they have provided an extensive training course throughout the year titled “The Legal Principles of the Mental Health Act; Mental Capacity Act and Deprivation of Liberty”.” Source location 2014-0443-Response-by-Tameside-Hospital
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 stocks, contingency arrangements and local networks are considered sufficient to maintain medicines or suitable alternatives during shortages.
Verbatim wording from the response “The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage” Source location 2014-0443-Response-by-Tameside-Hospital
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 capacity and demand mean echocardiography can currently be provided only during daytime hours, while out-of-hours provision is being explored.
Verbatim wording from the response “Currently, the provision of echocardiogram services is undertaken as a day case service between the hours of 9.00am and 5.00pm and this existing service is provided by the specialist CRI technicians. Due to the existing capacity and demand for the service, the existing provision can only currently provide an in hours service. Echocardiograms are and have been undertaken by qualified Consultants and Staff Grade Doctors as and when required. Going forward, the recent external cardiology service review and your concerns following the inquest into the death of Mrs Fenton have formed the basis for a service review specifically around the provision of CRI services. As part of this review, the procurement of a portable echocardiogram machine and out of hour provision is being explored as part of the wider service developments.” Source location 2014-0443-Response-by-Tameside-Hospital
Open published response
10 Mar 2014 Afifa Qaisar · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Unavailability of an agitator for on-site platelet preparation View source Unavailability of platelets on site for transfusion View source Failure to verify actual intravenous drug delivery when recording drug administration View source Unavailability of a Gum-elastic Bougie Airway on the crash trolley View source Failure to notify the RMO on duty of patients requiring notification View source Failure to catheterise patients receiving intravenous fluids when required View source Delays in acting on identified requirements for platelet and Hb support View source Failure to appropriately assess and manage a non-running saline infusion View source Failure to commence fluid balance charts for patients receiving intravenous fluids View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Afifa Qaisar · 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
Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.
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 an agitator for on-site platelet preparation
Wider context from the report “4. I heard evidence that she required platelets to be transfused but there was a considerable delay in these being made available “because “they are not kept on site”, and in any event there is no ‘agitator’ on site for their preparation .
” 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 platelets on site for transfusion
Wider context from the report “4. I heard evidence that she required platelets to be transfused but there was a considerable delay in these being made available “because “they are not kept on site” , and in any event there is no ‘agitator’ on site for their preparation.
” 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 actual intravenous drug delivery when recording drug administration
Wider context from the report “1. During the course of the event it became apparent that the time of delivery/administration of various drugs was of the utmost importance. The nursing staff had completed the records to say that the drugs had been ‘given’. The Ward manager accepted that this simply meant that the drip had been ‘put up’ and did not confirm that the drug had actually been delivered into the vein of the patient. The husband of the patient contended that the ‘bag’ remained full and that he did not see any evidence that its contents were in fact administered to 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 Unavailability of a Gum-elastic Bougie Airway on the crash trolley
Wider context from the report “2. During resuscitation the staff wished to use a “Gum –elastic Bougie Airway” but when they looked they found it was not available on the ‘crash trolley’ .
” 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 notify the RMO on duty of patients requiring notification
Wider context from the report “3. It transpired that this patient was NEVER notified to the RMO on duty as should be 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 Failure to catheterise patients receiving intravenous fluids when required
Wider context from the report “6. Despite the fact that this patient was receiving (apparently) i.v. fluids, at no time was a fluid balance chart commenced nor was the patient catheterised . The Ward manager agreed that both of these failings were unacceptable .
” 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 acting on identified requirements for platelet and Hb support
Wider context from the report “7. It was acknowledged early in the patient’s passage through the hospital that she would need platelets and Hb support , yet it took over four and a half hours for anything to be done about this .
” 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 appropriately assess and manage a non-running saline infusion
Wider context from the report “5. When the husband of the deceased drew to the attention of the staff that the saline infusion appeared not to be ‘running’ so he was told by the nurse to “hold her arm straight” to enable it to do so . He and I, and the Ward manager, felt that this was entirely inappropriate .
” 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 commence fluid balance charts for patients receiving intravenous fluids
Wider context from the report “6. Despite the fact that this patient was receiving (apparently) i.v. fluids, at no time was a fluid balance chart commenced nor was the patient catheterised. The Ward manager agreed that both of these failings were unacceptable .
” Open source report
5 Mar 2014 Nellie Travis · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of an objectively assessed falls risk assessment tool 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
Nellie Travis · 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
Nellie Travis was admitted to hospital for anaemia and fell while rising from her bed on 2 October 2013, breaking her hip. The report raised concerns that the hospital’s Falls Risk Assessment tool was completed by a non-Trust bank nurse, was highly subjective, and needed to be replaced by a more objective assessment tool.
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 an objectively assessed falls risk assessment tool
Wider context from the report “During the course of the evidence I was told that there is a Falls Risk Assessment tool used by the hospital, but in this case it had been completed and assessed by a ‘bank nurse’ who was not an employee of the Trust. The evidence given by the senior member of the nursing staff was to the effect that the operation of the Falls Risk Assessment Tool is very subjective and depends upon an individual opinion of the nurse completing it as to how high the falls risk is shown to be . It was agreed that such a document is of very little use at all and that a more objectively assessed tool needs to be adopted .
” Open source report
30 Jan 2014 Leslie Alfred Pates · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Breakdown in communication between the hospital and the family View source Failure to consider the family’s views before discharge planning and implementation View source Failure to hold the required pre-discharge meeting with the family View source Lack of a pressure-relieving mattress at discharge home View source Discharge home with severe pressure sores View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Leslie Alfred Pates · 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
Leslie Alfred Pates was admitted to hospital, discharged home against his family’s wishes, and later transferred to a nursing home before being readmitted to hospital in a deteriorated condition. The principal concerns were failures in communication and discharge planning, including the absence of a family meeting, insufficient consideration of the family’s views, and discharge with severe pressure sores without a pressure-relieving mattress.
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 Breakdown in communication between the hospital and the family
Wider context from the report “1. There has been a complete breakdown in effective communication between the hospital and the family of the deceased .
” 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 consider the family’s views before discharge planning and implementation
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient .
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress.
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his 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 Failure to hold the required pre-discharge meeting with the family
Wider context from the report “5. The required “meeting” between Social Services and the family prior to discharge from hospital, simply never took place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside and Glossop Integrated Care NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a pressure-relieving mattress at discharge home
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient.
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress .
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his 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 Discharge home with severe pressure sores
Wider context from the report “2. Neither the hospital staff nor the social services staff took any, or any proper, account of the wishes and views of the family prior to the discharge home of the patient.
3. The patient who was aged 80 years was sent home with severe pressure sores and without the facility of a pressure relieving mattress.
4. Tameside Social Services failed completely or adequately to consider the views of the family of the deceased before determining and bringing into effect a plan for his discharge.
” 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 Create ward and departmental information boards and posters to improve access to the ITT.
Verbatim wording from the response “In addition, the profile of the ITT team is being raised through public awareness and increased visibility and open access” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure care plans are accurately prepared, shared with patients and consenting next of kin, and agreed before discharge.
Verbatim wording from the response “All plans of care for patients must be shared with the patient and, with patient’s consent, their next of kin and agreed before discharge.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formulate complex care plans for all parties to agree before patients return home.
Verbatim wording from the response “A complex care plan has been formulated for all parties to agree the patient is supported and fully ready for home.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document through IAS/EIS systems that ITT cases have been discussed with patients and designated carers.
Verbatim wording from the response “The Team leader to ensure through the computer systems between social services and the Trust (IAS/EIS systems) that there is documented evidence that all Integrated Transfer Team (ITT) cases have been discussed with patients and their designated carers.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ITT access through a social worker six days weekly and a Clinical Discharge Facilitator seven days weekly.
Verbatim wording from the response “• The team has a social worker available 6 days a week to patients and relatives and a Clinical Discharge Facilitator (CDF) available seven days a week, from 0800-2000hrs to speak with patients, staff and relatives for advice.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and publish a “Leaving our Care” leaflet for patients and carers.
Verbatim wording from the response “A Leaflet has been produced and is in publication process for patients and carers about “Leaving our Care”.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a discharge checklist confirming MDT engagement with patients and families before discharge.
Verbatim wording from the response “To improve effective communication between the Integrated Transfer Team and the patients and their immediate carers/family regarding the discharge plan, the following actions are being taken.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide patients and families opportunities to discuss discharge plans and a dedicated social-worker contact number.
Verbatim wording from the response “To ensure the patients and families wishes are fully raised and given full consideration in the discharge process the following actions have been undertaken:” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess and document equipment needs for patients returning home with care packages, using timely referrals and discharge checklist meetings.
Verbatim wording from the response “All patients returning home with care package will have their equipment needs assessed and documented in hospital.” Source location 2014-0043-Response-by-Tamside-Hospital-NHS
Open published response
14 Jan 2014 John Joseph Malone · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Failure of discharge documentation to include vital admission and discharge information 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
John Joseph Malone · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Joseph Malone suffered two falls at home, the second on 24 October 2013, which led to a subdural haematoma; the inquest concluded that he died an accidental death. Concern was raised that the hospital discharge letter was woefully short on detail and omitted vital information for his GPs, and that he fell within three days of discharge.
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 discharge documentation to include vital admission and discharge information
Wider context from the report “I took evidence from the two GP's caring for the deceased and they showed to me, inter alia, a discharge letter from your hospital dated 21st October 2013 a copy of which I append hereto. You will note that this document is woefully short on detail and has significant omissions of vital information for the GP's . On page one of the report there are no details given as to Admission date, admission ward, admission method, admission source, discharge destination or discharge date . The patient sustained a fall within 3 days of his discharge and this led to or exacerbated his subdural haemorrhage.
” Open source report
7 Jan 2014 James Hadfield Withers · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Failure to verify the correct DNAR status View source Missing medical and nursing notes View source Failure to involve or update the family about DNAR decisions View source Poor communication between clinical staff and with the patient’s family View source Delays in requested cardiologist attendance View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
James Hadfield Withers · 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 Hadfield Withers died on 27 January 2013 after surgery for invasive colonic adenocarcinoma, with the inquest recording congestive cardiac failure associated with diseased heart and the stress of the operation. Concerns included a five-day delay in cardiology review, missing medical and nursing notes, incorrect recording of DNAR status, 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 verify the correct DNAR status
Wider context from the report “4. One of the doctors admitted that he had assumed an incorrect DNAR status based on the fact that he had two separate pieces of paper in his pocket and had looked at the wrong 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 Missing medical and nursing notes
Wider context from the report “2. Various of the medical/nursing notes appear to have gone missing
” 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 involve or update the family about DNAR decisions
Wider context from the report “3. The patient’s DNAR status was fixed without any reference to/discussion with his family. Whilst it is appreciated that this decision is for the doctor alone, good practice would require that the family be kept up to date with all such decisions
” 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 clinical staff and with the patient’s family
Wider context from the report “5. There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of 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 Delays in requested cardiologist attendance
Wider context from the report “1. There was a delay of five days between the Cardiologist being requested to see the patient and actually attending the patient.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations