1 May 2024 Jordan George James Fogg Howarth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Lack of joint clinical decision-making about withholding antibiotics View source Lack of multidisciplinary assessment of complex patient cases View source Failure to refer patients with a NEWS2 score of 5 and no ceiling of care to the CC Outreach team View source Unclear responsibility for continuity of care View source Failure of senior nursing staff to identify missed CC Outreach referrals View source Failure to document the ICU consultant’s rationale for examination and admission decisions View source Failure to put alternative treatments in place when antibiotics are withheld View source Failure to document consultant clinical discussions View source See 5 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
Jordan George James Fogg Howarth · 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
Jordan George James Fogg Howarth, a fit and healthy 25-year-old, was admitted to hospital on 3 April 2023 with an unexplained and deteriorating condition. He was not escalated for critical care review as required, and although a later review identified that he needed urgent ICU admission, this was delayed; he suffered a cardiac arrest on 6 April 2023 and could not be resuscitated. The principal concerns included inadequate coordination and continuity of care, failure to follow escalation policy, insufficient documentation of clinical decisions, and a lack of multidisciplinary discussion.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of joint clinical decision-making about withholding antibiotics
Wider context from the report “1. The inquest heard evidence that whilst there was input into Jordan’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics . The inquest was told that this decision was reached by the microbiology team and as a consequence, antibiotics were withheld without further alternative treatments being put in place despite how unwell he was and despite the fact that the treating clinicians were unclear about the cause of his deterioration.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of multidisciplinary assessment of complex patient cases
Wider context from the report “5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients with a NEWS2 score of 5 and no ceiling of care to the CC Outreach team
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team . The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for continuity of care
Wider context from the report “5. The inquest heard that despite the complexity of his case there was no evidence of a multi-disciplinary discussion/approach to assess his position fully and that it was unclear who was responsible for the continuity of his care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of senior nursing staff to identify missed CC Outreach referrals
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team .
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document the ICU consultant’s rationale for examination and admission decisions
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point . All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to put alternative treatments in place when antibiotics are withheld
Wider context from the report “1. The inquest heard evidence that whilst there was input into Jordan’s care from both the microbiologist and the consultant physician there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics. The inquest was told that this decision was reached by the microbiology team and as a consequence, antibiotics were withheld without further alternative treatments being put in place despite how unwell he was and despite the fact that the treating clinicians were unclear about the cause of his deterioration.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document consultant clinical discussions
Wider context from the report “2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes.
3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team.
4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes.
” Open source report
21 Dec 2020 Joseph Brindley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure of imaging review processes to identify fractures View source Insufficient availability of qualified radiologists for imaging review 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
Joseph Brindley · 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
Joseph Brindley was admitted to hospital after a fall and was later found unresponsive at home on 16 May 2020. He died in hospital from the consequences of an intracranial bleed exacerbated by anticoagulation. The report raised concerns that rib fractures were not identified on CT and X-rays despite being visible, and that it was unclear what specific steps had been taken to prevent similar failures in recognising such injuries.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of imaging review processes to identify fractures
Wider context from the report “The inquest heard that the CT scan and the X-rays were said to have been examined carefully. However, the fractures were not identified. Availability of radiologists due to a shortage of qualified radiologists locally and nationally meant that radiographers as well as radiologists were involved in the reviews that did not identify the fractures . The final review where the fractures were not picked up was said to have included careful comparison with the earlier X-ray. The Trust has made HMC aware of review processes which seek to enhance clinical skills and avoid errors. However, it is unclear what steps have been taken to tackle and avoid the specific concerns that arose in this case where 3 qualified members of staff did not recognise the injury .
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of qualified radiologists for imaging review
Wider context from the report “The inquest heard that the CT scan and the X-rays were said to have been examined carefully. However, the fractures were not identified. Availability of radiologists due to a shortage of qualified radiologists locally and nationally meant that radiographers as well as radiologists were involved in the reviews that did not identify the fractures. The final review where the fractures were not picked up was said to have included careful comparison with the earlier X-ray. The Trust has made HMC aware of review processes which seek to enhance clinical skills and avoid errors. However, it is unclear what steps have been taken to tackle and avoid the specific concerns that arose in this case where 3 qualified members of staff did not recognise the injury.
” Open source report
17 May 2019 Mellin Beard · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Significant reliance on agency nurses for ward staffing View source Failure to provide timely referrals for discharged patients requiring community nursing services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mellin Beard · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mellin Beard, who had complex health problems including spinal cord compression and reduced mobility, developed pressure sores that later deteriorated despite care. He died on 16 October 2018 from left ventricular failure due to ischaemic and hypertensive heart disease, with infected pressure sores among the contributing health problems. Concerns included delays in referrals for community nursing after hospital discharge and significant reliance on agency nurses.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Significant reliance on agency nurses for ward staffing
Wider context from the report “2. The Ward Manager of Ward 31 confirmed in her evidence that, at the time of the care provided to Mr Beard, there was only one permanent substantive registered nurse working on the ward, with the vast majority of shifts being fulfilled by agency workers ;
Whilst the Ward Manager gave evidence of significant improvements to recruitment and retention of nursing staff on the ward, and of additional actions her and her team have introduced to promote consistency amongst agency staff, it is a matter of concern that there is still significant reliance on agency nurses (with the financial and continuity of care implications which can arise from that) within the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely referrals for discharged patients requiring community nursing services
Wider context from the report “1. A member of the Trust’s community nursing team gave evidence to the effect that it was ‘common’ not to receive timely referrals in respect of patients who were discharged from hospital and required community nursing services . Whilst it was apparent from the evidence before the court as a whole that this concern does not relate solely to patients who have been receiving in-patient care at Tameside General Hospital, and that some improvements have been made with the introduction of an e-discharge system, it is a matter of particular concern that this problem continues to subsist at the Trust in particular due to the integrated care model as between acute and community services the organisation purports to espouse;
” Open source report
10 Jan 2019 Michael William Flynn · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 13 Failure to communicate deterioration between ward doctors and nursing staff View source Failure to review patients and escalate care when EWS trigger points require it View source Failure to escalate when requested clinical reviews do not occur View source Failure to provide or rearrange consultant review after the post operative area View source Failure to monitor and incorporate observations into an EWS in the post operative recovery area View source Delayed doctor review during clinical deterioration View source Failure to complete and repeat EWS observations at required intervals View source Failure to reference fluid balance charts when prescribing further fluids View source Failure to complete fluid balance charts and calculate fluid position View source Unavailability of ICU outreach support due to staffing shortages View source Failure of consultants to communicate about patients with ward staff View source Failure of registrars to review patients during ward visits View source Failure to explore alternative escalation routes when ICU outreach is unavailable 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.
×
AI-generated summary
Michael William Flynn · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate deterioration between ward doctors and nursing staff
Wider context from the report “5. The ward was staffed by ward doctors throughout the day but there was no documentation to suggest communication between the ward doctors and nursing staff in relation to Mr Flynn and his deteriorating picture
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review patients and escalate care when EWS trigger points require it
Wider context from the report “2. The trust had a clear protocol regarding monitoring and trigger points for regularity and escalation in relation to EWS. Whilst Mr Flynn was a patient on the orthopaedic unit the Trust policy was not adhered to . For example the inquest heard that in the 18 hours preceding his death he did not see a doctor and was not reviewed despite the EWS scores requiring this to happen .
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate when requested clinical reviews do not occur
Wider context from the report “8. The inquest was told that the nursing notes indicated that drs had been asked to review Mr Flynn but that this was not reflected in the clinical notes. When requested reviews documented in the nursing notes did not happen there was no evidence of further escalation.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide or rearrange consultant review after the post operative area
Wider context from the report “6. Mr Flynn was not seen by a consultant after he left the post operative area. A ward round should have taken place the day after his operation but did not take place because the consultant was otherwise engaged. No arrangements were made for it to be rearranged.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and incorporate observations into an EWS in the post operative recovery area
Wider context from the report “1. There was no monitoring of Mr Flynn's EWS in the post operative recovery area. Observations were taken randomly but not incorporated into an EWS. Trust policy was that this should have happened. Staff dealing with Mr Flynn therefore were unaware of his EWS scores. On arrival at the ward his initial score was 11 under the EWS system .He arrived with a standard care plan.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Delayed doctor review during clinical deterioration
Wider context from the report “4. He was only seen by a Doctor when a crash call went out and not in the period when there was a deteriorating clinical picture contrary to the Trust policy.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and repeat EWS observations at required intervals
Wider context from the report “3. His final two EWS scores did not include all relevant information despite a visibly clinically deteriorating position. His penultimate EWS was recorded at midnight. That was five (and did not include blood pressure). A further score should have been taken 15-30 minutes later. It was not and no further scores were taken for a further 4 hours and 50 minutes. At 04.50 his score was recorded at 10. He then became unresponsive.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to reference fluid balance charts when prescribing further fluids
Wider context from the report “10. A fluid balance chart was requested and fluids prescribed. It was not completed fully and in particular the necessary calculations to understand Mr Flynn's fluid position were not made. The trust policy was not followed regarding completion. The doctor who saw Mr Flynn on the morning of 16th July 2018 prescribed further fluids without reference to the fluid charts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete fluid balance charts and calculate fluid position
Wider context from the report “10. A fluid balance chart was requested and fluids prescribed. It was not completed fully and in particular the necessary calculations to understand Mr Flynn's fluid position were not made . The trust policy was not followed regarding completion. The doctor who saw Mr Flynn on the morning of 16th July 2018 prescribed further fluids without reference to the fluid charts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of ICU outreach support due to staffing shortages
Wider context from the report “9. The trust had an ICU out reach team whose role was to support units such as the orthopaedic unit. However the team was not available when contacted due to staffing issues. Alternative escalations routes were not explored.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of consultants to communicate about patients with ward staff
Wider context from the report “7. There was no evidence that the consultant had communicated with staff about Mr Flynn or that the relevant registrar had reviewed Mr Flynn on visits to the 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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of registrars to review patients during ward visits
Wider context from the report “7. There was no evidence that the consultant had communicated with staff about Mr Flynn or that the relevant registrar had reviewed Mr Flynn on visits to the 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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to explore alternative escalation routes when ICU outreach is unavailable
Wider context from the report “9. The trust had an ICU out reach team whose role was to support units such as the orthopaedic unit. However the team was not available when contacted due to staffing issues. Alternative escalations routes were not explored.
” Open source report
19 Apr 2018 Adrian Jennings · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of a clear system for joined-up discharge planning between primary and secondary mental health services View source Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance View source Unavailability of identified mental health support services because they were not commissioned View source Failure to use one Trust-wide IT system for information sharing between professionals involved in 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adrian Jennings · 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
Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for joined-up discharge planning between primary and secondary mental health services
Wider context from the report “2.there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health 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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance
Wider context from the report “4. Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system. Any trust operating the Lorenzo system will struggle to capture this information at booking in
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of identified mental health support services because they were not commissioned
Wider context from the report “3. a need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service ; and
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to use one Trust-wide IT system for information sharing between professionals involved in care
Wider context from the report “1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust , which impacted on information sharing between professionals involved in his care ;
” Open source report
21 Dec 2017 Margaret Ellen Postill · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure to evaluate patients after return View source Lack of detail in decision-making documentation View source Poor-quality documentation of second visits View source Failure to complete evaluation or assessment sheets View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Margaret Ellen Postill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Ellen Postill, a resident with dementia at Sunnyside Care Home, fell twice on 2 May 2017 and later developed seizures after a subdural hematoma was identified. She deteriorated over the following weeks, was moved to palliative care, and died on 31 May 2017. Concerns included the lack of evaluation and completed assessment sheets after her return to the care home, and poor-quality documentation at Tameside Hospital concerning the second visit and decision-making.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to evaluate patients after return
Wider context from the report “1. There did not appear to have been any evaluation of Mrs Postill after her return on 2nd May 2017 . In particular no evaluation/assessment sheets were completed.(Home)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of detail in decision-making documentation
Wider context from the report “2. The document held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making .(TGH)
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Poor-quality documentation of second visits
Wider context from the report “2. The document held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.(TGH)
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete evaluation or assessment sheets
Wider context from the report “1. There did not appear to have been any evaluation of Mrs Postill after her return on 2nd May 2017. In particular no evaluation/assessment sheets were completed .(Home)
” Open source report
5 Jun 2017 Derrick Lawrence Brocklehurst · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to recover care notes when care ceased View source Failure to provide discharge summaries to GPs after emergency department attendance View source Lack of documentation of carer visits 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
Derrick Lawrence Brocklehurst · 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
Derrick Lawrence Brocklehurst was admitted to hospital after being found immobile and incontinent at home, with grade 4 pressure ulcers, and died on 2 December 2016 from a pulmonary embolus. Concerns included missing records of carer visits and the absence of a discharge summary from the hospital to the GP after his A&E attendance.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recover care notes when care ceased
Wider context from the report “1. There was no documentation available of the carer visits. The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide discharge summaries to GPs after emergency department attendance
Wider context from the report “2. No discharge summary was provided by Tameside General Hospital to the GP after the deceased was seen in A and E.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of carer visits
Wider context from the report “1. There was no documentation available of the carer visits. The care provided and any issues with the provision of care could not be established. They were not recovered by Social Services when care stopped. There was no system for recovery of care notes when care ceased.
” Open source report
8 Dec 2016 Rachal Marie Murphy · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to undertake annual liver function tests View source Failure to review CAF documentation View source Lack of clarity about referral routes and acceptance by Psychological services View source Delays in reporting EEGs View source Delays in allocation of cases within Early Help Services View source Lack of understanding of cases suitable for CAMHS referral View source Lack of GP involvement in inter-agency case handling View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rachal Marie Murphy · 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
Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake annual liver function tests
Wider context from the report “1. There was a failure to undertake annual liver function tests in 2014 and 2015
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review CAF documentation
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this 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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about referral routes and acceptance by Psychological services
Wider context from the report “1. There was a lack of understanding between medical professionals as to the means by which someone could be referred to Psychological services and whether there was a unclear message from Psychological services as to whether they were accepting referrals .
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in reporting EEGs
Wider context from the report “3. There was as significant delay in the reporting of Rachals EEG and the Court heard that this remained the case in respect of reporting of EEGs at the time of the Inquest .
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in allocation of cases within Early Help Services
Wider context from the report “1. The Court heard that there was a significant delay in the allocation of cases within Early Help Services and from the evidence the Court was not satisfied that this had been resolved .
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of cases suitable for CAMHS referral
Wider context from the report “2. Lack of understanding amongst medical professionals as to the cases which may or may not be suitable for referral to CAMHS .
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of GP involvement in inter-agency case handling
Wider context from the report “2. The CAF documentation was completely overlooked and simply placed in the medical records as read only which led to no GP involvement in the inter-agency framework and handling of this case .
” Open source report
13 Jan 2014 Barbara White · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to escalate staffing shortages to the Night Nurse Practitioner View source Failure to maintain sufficient information in medical records after staff handover View source Failure to carry out required clinical and nursing observations View source Failure to escalate to a consultant View source Failure to provide further clinical consideration after requested tests View source Failure to accurately record PARS scores View source Insufficient and unfamiliar nursing staff on the Surgical Unit 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
Barbara White · 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
Barbara White presented to Tameside Hospital with symptoms consistent with biliary colic, deteriorated after 9 December 2012, and died on 2 January 2013 despite intensive care intervention. Concerns included a 12-hour lack of clinical and nursing observations, an incorrectly recorded PARS score, staff shortages and inadequate escalation, and insufficient handover information about outstanding investigations.
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate staffing shortages to the Night Nurse Practitioner
Wider context from the report “3. There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December. There was only one auxiliary nurse who was not familiar with the Surgical Unit. This Unit is one step down from the High Dependency Unit and the patients require a high level of nursing care. However, there was a lack of escalation of this issue to the Night Nurse Practitioner .
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient information in medical records after staff handover
Wider context from the report “4. There was a lack of information in the patient’s medical records following the handover from the day staff to the night staff . Following the review of Mrs White on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant. At the Inquest I heard evidence from Dr ████████ who was the SHO on duty during the night and who had received the handover from the day staff. Her evidence was that she had no recollection of Mrs White being mentioned at the handover and was unaware that there were outstanding investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required clinical and nursing observations
Wider context from the report “1. There was a lack of clinical observations for a period of 12 hours on the 9th December. In addition no nursing observations were carried out during this period of time .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate to a consultant
Wider context from the report “4. There was a lack of information in the patient’s medical records following the handover from the day staff to the night staff. Following the review of Mrs White on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant . At the Inquest I heard evidence from Dr ████████ who was the SHO on duty during the night and who had received the handover from the day staff. Her evidence was that she had no recollection of Mrs White being mentioned at the handover and was unaware that there were outstanding investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide further clinical consideration after requested tests
Wider context from the report “4. There was a lack of information in the patient’s medical records following the handover from the day staff to the night staff. Following the review of Mrs White on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant. At the Inquest I heard evidence from Dr ████████ who was the SHO on duty during the night and who had received the handover from the day staff. Her evidence was that she had no recollection of Mrs White being mentioned at the handover and was unaware that there were outstanding investigations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Tameside General Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record PARS scores
Wider context from the report “2. At 6 am Mrs White’s PARS score was recorded as 2 when this should have been 5 which if correctly recorded would have led to medical intervention.
” Open source report × Source evidence
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 General Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient and unfamiliar nursing staff on the Surgical Unit
Wider context from the report “3. There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December. There was only one auxiliary nurse who was not familiar with the Surgical Unit . This Unit is one step down from the High Dependency Unit and the patients require a high level of nursing care. However, there was a lack of escalation of this issue to the Night Nurse Practitioner.
” 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