Concerns raised 2 Lack of guidance on respiratory fitness to fly after trauma View source Lack of a recurrent national audit of emergency oxygen View source
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AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The deceased suffered serious traumatic injuries in an accidental fall in Pakistan, including flail chest and a subdural haemorrhage that were not initially diagnosed, and later deteriorated during her flight to the United Kingdom. She was admitted to hospital in Manchester, but despite medical management her condition deteriorated and she died on 26 July 2019. The substantive concerns included inconsistent oxygen prescribing and documentation, wider risks from over- or under-oxygenation, and the absence of guidance addressing fitness to fly after trauma with respiratory implications.
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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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on respiratory fitness to fly after trauma
Wider context from the report “4. The BTS have already issued guidance for passengers travelling with respiratory conditions; namely, the BTS Clinical Statement on air travel for passengers with respiratory disease (https://thorax.bmj.com/content/77/4/329). However, this guidance does not cover trauma, as in this case . Whether or not guidance would be appropriate to issue to determine whether or not a person was fit to fly from a respiratory perspective in the context of the trauma – Consideration should be given to formulating such guidance which can then be circulated more widely including to the airline industry
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Lack of a recurrent national audit of emergency oxygen
Wider context from the report “1. That the HQIP should consider undertaking in liaison with the BTS a further review and audit in relation to delivering a recurrent national audit of emergency oxygen . This update will also be able to use learning from recent clinical practice (including the Covid pandemic) and the developments in treatment.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct audit and provide tools supporting implementation of emergency oxygen guidance.
Verbatim wording from the response “Since the BTS publication of the first guideline on emergency oxygen use in 2008 and the subsequent update in 2017, BTS has conducted a programme of audit and provided tools to support education and implementation of the guideline recommendations. This information is freely available on our website (https://www.brit-thoracic.org.uk/quality-improvement/clinical-resources/oxygen/).” Source location Response from British Thoracic Society
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Civil Aviation Authority should address the guidance gap for determining whether trauma patients are fit to fly.
Verbatim wording from the response “We note the reference to the BTS Clinical Statement on air travel for passengers with respiratory disease. As outlined above this document provides guidance for clinicians who advise those with respiratory disease in planning air travel. This document does not include specific guidance for patients who have suffered trauma or surgical interventions. We note that there is guidance for health care professionals in relation to surgery available through the CAA: Surgical conditions | Civil Aviation Authority (caa.co.uk)
We suggest that it would seem appropriate that this gap in guidance in relation to trauma patients would best be addressed by the CAA in any further revision of its guidance.” Source location Response from British Thoracic Society
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England selects NCAPOP topics, so HQIP cannot independently commission a national audit of emergency oxygen.
Verbatim wording from the response “HQIP commission, manage and develop the National Clinical audit and patients outcome programme (NCAPOP) under contract from and on behalf of NHS England and the Welsh Government. All clinical topics in the Programme are selected by NHS England. At present, none of the currently commissioned NCAPOP topics cover the prescription of emergency oxygen.” Source location Response from British Thoracic Society
Open published response
20 Apr 2021 Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 6 Insufficient undergraduate teaching on the health effects of air pollution View source Insufficient postgraduate education on the health effects of air pollution View source Insufficient detail and monitoring capacity for air quality information View source Insufficient professional guidance on communicating the health effects of air pollution View source Low public awareness of sources of national and local pollution information View source National Particulate Matter limits exceeding WHO guideline levels View source See 3 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ella Adoo-Kissi-Debrah · 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
Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.
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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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Insufficient undergraduate teaching on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Insufficient postgraduate education on the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail and monitoring capacity for air quality information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government. The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors .
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional guidance on communicating the health effects of air pollution
Wider context from the report “(3) The adverse effects of air pollution on health are not being sufficiently communicated to patients and their carers by medical and nursing professionals. The evidence at the inquest was that this needs to be addressed at three levels:
a. Undergraduate. I am informed that undergraduate teaching is the responsibility of the GMC, Health Education England and the NMC.
b. Postgraduate. I am informed that postgraduate education is the responsibility of the Royal Colleges, in this case the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, and the NMC.
c. Professional guidance. In this case relevant organisations are NICE and the British Thoracic Society.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Low public awareness of sources of national and local pollution information
Wider context from the report “(2) There is a low public awareness of the sources of information (such as UK-Air website) about national and local pollution levels. Greater awareness would help individuals reduce their personal exposure to air pollution. It was clear from the evidence at the inquest that publicising this information is an issue that needs to be addressed by national as well as local government . The information must be sufficiently detailed and this is likely to require enlargement of the capacity to monitor air quality, for example by increasing the number of air quality sensors.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation National Particulate Matter limits exceeding WHO guideline levels
Wider context from the report “(1) The national limits for Particulate Matter are set at a level far higher than the WHO guidelines. The evidence at the inquest was that there is no safe level for Particulate Matter and that the WHO guidelines should be seen as minimum requirements. Legally binding targets based on WHO guidelines would reduce the number of deaths from air pollution in the UK.
” 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 Produce an updated position statement on air quality and lung health.
Verbatim wording from the response “BTS strongly supports the communication of the effects of air pollution by health care professionals to patients and carers. We intend to build upon the work undertaken to date in the following ways over the coming year:” Source location 2021-0113-Response-from-British-Thoracic-Society-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and publish evidence-based asthma management guidance addressing environmental factors, including air pollution, through the BTS/SIGN/NICE joint guideline.
Verbatim wording from the response “The 2019 edition of the BTS/SIGN Guideline states that “Increased asthma symptoms in young children (mean age ≤9) have been linked, in observational studies, to exposure to air pollutants, including particulates, nitrogen dioxide, sulphur dioxide and ozone” (para 6.2.4): https://www.brit-thoracic.org.uk/quality-improvement/guidelines/ (asthma/). BTS and SIGN are now working in partnership with the National Institute for Health and Care Excellence (NICE) to produce a joint guideline on the management of asthma. Work will begin on the new joint guideline later in 2021, the scope of which will include reference to environmental factors including air pollution and with a planned publication date in 2023.” Source location 2021-0113-Response-from-British-Thoracic-Society-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide signposting to air-pollution and respiratory-health resources through the Respiratory Futures partner website.
Verbatim wording from the response “It is of prime importance that health care professionals are aware of resources that can be used to inform patients and carers, and the BTS partner website “Respiratory Futures” provides signposting to resources on air pollution and respiratory health.” Source location 2021-0113-Response-from-British-Thoracic-Society-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide scientific and clinical input to NICE information development through stakeholder consultation, including guidance on indoor and outdoor air pollution.
Verbatim wording from the response “In addition, BTS provides regular scientific and clinical input to the development of information produced by NICE via the stakeholder consultation process, most notably in relation to guidance on indoor and outdoor air pollution.” Source location 2021-0113-Response-from-British-Thoracic-Society-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue raising awareness of poor air quality’s effects on lung health through guidance, conferences, short courses and expert input to stakeholders.
Verbatim wording from the response “BTS strongly supports the communication of the effects of air pollution by health care professionals to patients and carers. We intend to build upon the work undertaken to date in the following ways over the coming year:” Source location 2021-0113-Response-from-British-Thoracic-Society-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Government and other policymakers must regulate pollution-generating activity to significantly reduce air pollution risks to public health.
Verbatim wording from the response “The Society will do all it can to inform, educate and support respiratory health care professionals in this area, but we wish to emphasise that the risk of air pollution to public health will only be significantly reduced if government and other policy makers act in order to regulate pollution generating activity.” Source location 2021-0113-Response-from-British-Thoracic-Society-Redacted
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1 Aug 2014 Gerald Trevor WERRETT · Prevention of Future Deaths report Avon
View report summary
Concerns raised 7 Failure to examine patients prior to chest drain insertion View source Incorrect interpretation of the cardiac silhouette View source Misinterpretation of chest x-rays View source Failure to use a lead anatomical marker when taking chest x-rays View source Failure by clinicians to identify incorrectly labelled chest x-rays View source Failure to consider both chest x-rays View source Incorrect labelling of chest x-rays View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Gerald Trevor WERRETT · 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
Gerald Trevor Werrett was admitted to hospital with an infective exacerbation of chronic obstructive airways disease and other co-morbidities. During treatment, a chest drain was mistakenly inserted on the left instead of the right after chest X-rays were inverted, mislabelled and misinterpreted. The inquest concluded that he died from bilateral bronchopneumonia, chronic obstructive airways disease and ischaemic heart disease, with his death contributed to by the misplaced chest drain; concerns included failures in X-ray marking, labelling, interpretation, review and examination before insertion.
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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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Failure to examine patients prior to chest drain insertion
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain .
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Incorrect interpretation of the cardiac silhouette
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Misinterpretation of chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Failure to use a lead anatomical marker when taking chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Failure by clinicians to identify incorrectly labelled chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Failure to consider both chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled, and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered .
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 British Thoracic Society; that does not assign responsibility.
PFD Monitor interpretation Incorrect labelling of chest x-rays
Wider context from the report “Chest drains are inserted by a number of medical disciplines and clearly this event has shown that basic failures can have catastrophic consequences, the areas identified during the inquest included:
1. A lead anatomical marker was not used when taking the chest x-ray
2. Both chest x-rays were incorrectly labelled , and this error was not identified by the clinician
3. The chest x-ray that was looked at was misinterpreted
4. Both chest x-rays were not considered.
5. The cardiac silhouette was not interpreted correctly
6. Mr. Werrett was not examined prior to the insertion of the chest drain.
” 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 Publish and make freely accessible updated pleural disease guidance covering safe chest-drain insertion.
Verbatim wording from the response “In 2010 the British Thoracic Society published an 82 page update on management of pleural disease which includes safe insertion of chest drains (Thorax 2010 (August) Vol. 65, supplement 2). This publication is freely available in most medical libraries and, more importantly, is available on the British Thoracic Society website which is open to all individuals. It is one of the most frequently visited sections of the Society’s website.” Source location 2014-0355-Response-by-British-Thoracic-Society
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations