Concerns raised 1 Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments 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
Sheila Winifred Ridgway · 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 Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.
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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
Wider context from the report “1) Communication between specialty consultants – lack of any system to ensure that communication occurs between the treating consultants as to the necessity for identifying and documenting any potential ongoing risks when specialty specific treatments are being contemplated or planned for the different specialities simultaneously
” Open source report
13 Mar 2015 Barbara Joan Harrison · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of clear authorisation for postoperative physiotherapy View source Unsafe physiotherapy involving forceful blowing after surgery View source Failure to monitor and respond promptly to postoperative neck and facial swelling View source Unavailability of a functioning fibre-optic endoscopic light source during critical surgery View source Failure to maintain appropriate communication and privacy around critical incidents 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
Barbara Joan Harrison · 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 Joan Harrison was admitted on 5 February 2015 for surgery after worsening swallowing and regurgitation symptoms, and subsequently developed significant surgical emphysema and undetected mediastinitis. Concerns included potentially harmful postoperative physiotherapy, failed attempts to site an endotracheal tube due in part to unavailable fibre-optic equipment, inadequate lighting during critical surgery, distress caused to her family, and delayed recognition of swelling around her neck and face.
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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of clear authorisation for postoperative physiotherapy
Wider context from the report “1. After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter. This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site. It is unclear as to who ordered this physiotherapy , as ████████ the surgeon and ████████ the anaesthetist both indicated that they did not do so and would not have done so .
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Unsafe physiotherapy involving forceful blowing after surgery
Wider context from the report “1. After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter . This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site . It is unclear as to who ordered this physiotherapy, as ████████ the surgeon and ████████ the anaesthetist both indicated that they did not do so and would not have done so.
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and respond promptly to postoperative neck and facial swelling
Wider context from the report “5. After the first surgery had taken place, the family noticed there was a rapid and very obvious swelling around the neck and face of Mrs Harrison . Why did the nurses not note this and act upon it earlier?
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a functioning fibre-optic endoscopic light source during critical surgery
Wider context from the report “2. During surgery to repair the oesophageal pouch, there were a total of three attempts to site an endo-tracheal tube and on each occasion it failed. Part of the reason for this was that it was found that the batteries for the fibre optic tube were flat and inoperable. No replacement could be found.
3. ████████ averred that “we never got a light source at all ” during the operation. This is an unacceptable situation during a critical operative procedure. He then went on to say “ The need for an endoscope was critical and this is now a panic situation with the possibility of something going catastrophically wrong”
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain appropriate communication and privacy around critical incidents
Wider context from the report “4. Whilst the patient was in theatre for the emergency procedure, her family were advised to wait in the restaurant or reception areas of the hospital . As they were waiting, they heard one of the porters shout out “we have got a cardiac arrest in theatre.” This caused them extreme distress and alarm.”
” Open source report
8 Apr 2014 Frederick William Hall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Failure to maintain complete, accurate and timely clinical records View source Deficiencies in communication of clinical information between staff View source Delays in seeking clinical review of deteriorating patients View source Lack of skill and training in passing NG tubes View source Lack of senior staff knowledge of NG tube availability and storage location View source Failure to respond promptly to Consultant instructions View source Erratic monitoring of patients' conditions View source Insufficient nursing and medical staffing capacity for ward demands 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.
×
AI-generated summary
Frederick William Hall · 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
Four days after a right hemicolectomy, Frederick William Hall was taken for a CT scan without the nasogastric tube that had been ordered to decompress his distended abdomen. He vomited and aspirated gastric contents, developing aspiration pneumonia. The concerns included inadequate training in passing nasogastric tubes, failures to follow clinical instructions, poor monitoring and communication, inadequate record-keeping, and insufficient staffing for the demands on the wards.
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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete, accurate and timely clinical records
Wider context from the report “6. General note-keeping was not of the requisite standard as exemplified by:-
(a) The poor quality of the fluid balance chart and the observation/NEWS chart.
(b) The fact that there were no nursing entries made in the patient's records between midday and 8.40 pm , during which time a number of significant events had occurred.
(c) Retrospective nursing notes were made which were inaccurate and incomplete.
(d) The required ORDER of the tasks as ordered by the Consultant was different from that actually written in the notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in communication of clinical information between staff
Wider context from the report “5. There were clear and significant deficiencies in communication between and among various staff members ; incomplete information was passed from one RMO to the other on shift hand-over ; the Consultant was not given full information when being spoken to by telephone ; the radiology department were not fully appraised as to the patient's fragile condition . Most notably the RMO did not tell the Consultant that he (the RMO) intended to go to treat another patient on another ward before addressing the passing of the NG tube as instructed.
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking clinical review of deteriorating patients
Wider context from the report “3. The monitoring of, and response to, the patient's condition seemed somewhat erratic. Both the surgeon and the senior nurse agreed that "an earlier review" should have been sought and that observations should have been taken more promptly following the patient having chest pains.
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of skill and training in passing NG tubes
Wider context from the report “1. There seemed to be a lack of skill and/or training amongst the general nursing and medical staff in the passing of NG Tubes . However, it was noted that the ITU staff regularly insert such tubes and one would question whether there should be an agreed procedure whereby they should be asked to undertake this task throughout the 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of senior staff knowledge of NG tube availability and storage location
Wider context from the report “2. There was a degree of ignorance amongst the senior staff (medical and nursing) as to the availability of NG Tubes, and specifically as to their storage location within the 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to respond promptly to Consultant instructions
Wider context from the report “4. There was a lack of response (or timely response) to the instructions given by the Consultant. On the night of the 30th September the Consultant ordered an NG tube passed before the scan was carried out. This did not happen. On the 29th September the Consultant had also ordered an NG tube be passed if the patient "starts vomiting or not relieved"; this was not acted on, nor did the nursing staff seek to gain the advice/help of the Consultant or the RMO .
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Erratic monitoring of patients' conditions
Wider context from the report “3. The monitoring of, and response to, the patient's condition seemed somewhat erratic. Both the surgeon and the senior nurse agreed that "an earlier review" should have been sought and that observations should have been taken more promptly following the patient having chest pains .
” 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 The Alexandra Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing and medical staffing capacity for ward demands
Wider context from the report “7. Whilst 'on paper' the staffing levels were adequate, in fact due to the specific demands on the wards during that period, there was a need for more nursing /medical staff to be available . What measures are in place to address this type of situation?
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations