Concerns raised 4 Lack of documentation or process demonstrating rearrangement of care View source Failure to rearrange required care before arranging transportation home View source Failure to ensure access to an alarm pendant or mobile phone for summoning help View source Failure to require notification of safe return to the hospital or care company View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Samuel Joseph BROOKES · 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
Samuel Joseph Brookes was discharged home after a hospital admission following a fall and long lie, but his required care was not rearranged. He was immobile, lived alone, and was left unattended for two weeks without access to his pendant alarm or mobile phone; he was then found unresponsive and deceased. The principal concerns were the failure to arrange and document his care, the lack of a process requiring confirmation of his safe return, and his inability to raise an alarm or call for help.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation or process demonstrating rearrangement of care
Wider context from the report “(2) There was no record or documentation or process to show or demonstrate that the care had been 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 the Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to rearrange required care before arranging transportation home
Wider context from the report “(1) The hospital arranged for Mr Brookes transportation home without rearranging the required care as set out in paragraph 4 above.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure access to an alarm pendant or mobile phone for summoning help
Wider context from the report “(4) Mr Brookes did not have his alarm pendant around his neck and nor was his mobile phone available (it was in another room) . Accordingly when Mr Brookes got into difficulty he could not raise the alarm or call for help .
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to require notification of safe return to the hospital or care company
Wider context from the report “(3) The transport company were responsible for transportation only and were not required to notify either the hospital, or if known, the care company of Mr Brookes’ safe return . It proceeded on the basis or assumption that care would have restarted within 4 hours or sooner.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the discharge-planning SOP, including care-agency confirmation, failed-discharge escalation and documentation requirements.
Verbatim wording from the response “Recommendation / Area for Improvement Identified: Discharge team to review and up-date the discharge planning Standard operating procedure (SOP) (previously Complex Discharge Operational Policy) to specific requirements of safe discharge.” Source location Response from The Dudley Group NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate pendant-alarm requirements to patient transport providers and establish cross-system governance for transport-related incidents.
Verbatim wording from the response “Action 4
Recommendation / Area for Improvement Identified: When discharging patients, transport company to be made aware when the patient has pendant alarm and that this must be left within reach when leaving the property.” Source location Response from The Dudley Group NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require discharge checklists containing safety information to accompany patients and inform transport crews about emergency equipment and alarm access.
Verbatim wording from the response “Communication to be sent out to all matrons and teams detailing that the nurse discharge checklist is to be printed and handed to transport company and sent with the discharged patient on discharge. Communication to detail that the discharge checklist must include key patient safety details, pendant alarm information, mobility status and to utilise the free text box with any other important information for the transferring crew (to include availability of mobile phone). This communication should include the necessary checks to be completed by transferring crews to ensure patients have necessary equipment in reach to make emergency calls/have access to pendant alarms. | Interim Divisional Chief Nurse - Medicine” Source location Response from The Dudley Group NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train discharge-team staff on accurate clinical-record documentation and required care-agency contact details.
Verbatim wording from the response “Recommendation / Area for Improvement Identified: Improve discharge team documentation in clinical record to evidence safe discharge” Source location Response from The Dudley Group NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct routine spot-check audits of discharge documentation and continue monthly assurance reporting.
Verbatim wording from the response “Action Agreed: Routine spot check audits to be scheduled and undertaken by Directorate Manager to ensure documentation requirement is evidenced in the clinical record and provide assurance action acknowledged” Source location Response from The Dudley Group NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Some patient transport safety actions fall outside the Trust’s scope.
Verbatim wording from the response “Some of the actions identified regarding patient transport, fall out of scope of the Trust. These will be taken forward by our Deputy Chief Operating Officer and Head of Site Operations and discussed with relevant integrated care system partners in relation to contractual obligations for ensuring patients discharged home are safe and have access to the agreed methods of communication e.g. mobile telephone, pendant alarm (should they have or require one).” Source location Response from The Dudley Group NHS Foundation Trust
Open published response
19 Sep 2018 Hubert Kelly · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Absence of permanent medically qualified staff in the waiting area View source Excessive waiting times for patients to be seen by clinicians in the emergency department View source Failure to provide meaningful interaction with patients awaiting further assessment View source Lack of suitable space or resources for patients awaiting further assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hubert Kelly · 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
Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of permanent medically qualified staff in the waiting area
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area ;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive waiting times for patients to be seen by clinicians in the emergency department
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally , with patients waiting to be seen by clinicians for up to seven hours .
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide meaningful interaction with patients awaiting further assessment
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable space or resources for patients awaiting further assessment
Wider context from the report “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors ;
2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area;
3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional assistance to the Emergency Department during periods of high demand.
Verbatim wording from the response “demonstrates that the interest of patients is prioritised. At times of high demand there is a new process of providing additional help to the Emergency Department too.” Source location Hubert-Kelly-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an Emergency Department escalation plan and an in-reach process.
Verbatim wording from the response “The Trust has implemented an escalation plan and a process of in-reach with ED and increased physician presence. We attached a weekly return which documents the impact of this and” Source location Hubert-Kelly-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a nationally recognised triage tool and audit triage timeliness and quality.
Verbatim wording from the response “The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.” Source location Hubert-Kelly-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the triage area to increase patient capacity, privacy and dignity.
Verbatim wording from the response “The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.” Source location Hubert-Kelly-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase physician presence in the Emergency Department.
Verbatim wording from the response “The Trust has implemented an escalation plan and a process of in-reach with ED and increased physician presence. We attached a weekly return which documents the impact of this and” Source location Hubert-Kelly-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide rapid patient observations during periods of high demand.
Verbatim wording from the response “The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.” Source location Hubert-Kelly-Response
Open published response
27 Jul 2018 Mrs Natalie Billingham · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Delays in assessing available blood results View source Failure to administer antibiotics at an earlier stage View source Failure to recognise the development of sepsis View source Inadequate communication 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
Mrs Natalie Billingham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in assessing available blood results
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available . There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer antibiotics at an earlier stage
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the development of sepsis
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication
Wider context from the report “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis.
” Open source report
1 May 2018 Mrs Christine Withers · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Inadequate nursing communication with families expressing concerns about patient deterioration View source Failure to perform recommended repeat blood tests for potassium-level monitoring View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Christine Withers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Christine Withers, a 72-year-old woman with small cell carcinoma of the lung, was admitted with low potassium levels and died on 17 November 2017 after her condition deteriorated rapidly. Concerns identified during the inquest included that repeat blood tests were not performed to measure potassium levels despite a recommendation to do so, and inadequate communication by nursing staff with her family about her decline.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate nursing communication with families expressing concerns about patient deterioration
Wider context from the report “2. There was inadequate communication by nursing staff with the family who expressed concerns about the decline in Mrs Withers.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform recommended repeat blood tests for potassium-level monitoring
Wider context from the report “1. Evidence emerged during the inquest that no repeat blood tests were performed to measure the potassium levels despite this being recommended by the Consultant at the ward round in the morning .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete in-house palliative care competencies for Ward C4 staff, including communication with patients, families and carers.
Verbatim wording from the response “In response to this sad event all the staff within Ward C4 are working with our palliative care champion to complete the in-house palliative care competencies which comprehensively covers communication with patients, families and carers.” Source location 2018-0127-Response-by-Dudley-Group-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Present the revised hypokalaemia guideline at the scheduled July Medicine Audit and Governance Meeting.
Verbatim wording from the response “The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.” Source location 2018-0127-Response-by-Dudley-Group-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the revised hypokalaemia guideline to all Trust medical staff.
Verbatim wording from the response “The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.” Source location 2018-0127-Response-by-Dudley-Group-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publicise the revised hypokalaemia guideline on the Trust intranet.
Verbatim wording from the response “The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.” Source location 2018-0127-Response-by-Dudley-Group-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and approve the adult hypokalaemia management guideline as a consistent clinical tool.
Verbatim wording from the response “The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.” Source location 2018-0127-Response-by-Dudley-Group-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Records documented multiple family conversations, and staff considered communication effective, despite the family appearing dissatisfied with some answers.
Verbatim wording from the response “2. There was inadequate communication by nursing staff with the family who expressed concerns about the decline in Mrs Withers.” Source location 2018-0127-Response-by-Dudley-Group-NHS-Trust
Open published response
30 Nov 2017 Mr Philip John Powell · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Poor communication in ordering Debrisoft View source Delays in ordering Debrisoft View source Poor systems for ordering Debrisoft and unclear process and responsibility View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Philip John Powell · 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
Mr Philip John Powell, an 83-year-old man with Parkinson’s disease, dementia and a history of strokes, developed a stage 3 pressure ulcer that became infected and deteriorated rapidly. He died after developing sepsis and bronchopneumonia; concerns included delays in ordering Debrisoft and poor communication and systems around the ordering process.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication in ordering Debrisoft
Wider context from the report “1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which would have helped in managing the wound.
2. In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion about the process and overall responsibility.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ordering Debrisoft
Wider context from the report “1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which would have helped in managing the wound.
2. In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion about the process and overall responsibility.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor systems for ordering Debrisoft and unclear process and responsibility
Wider context from the report “1. Evidence emerged during the inquest that there were delays in ordering Debrisoft which would have helped in managing the wound.
2. In addition, there was evidence of poor communication and poor systems in place in ordering Debrisoft with confusion about the process and overall responsibility .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with the Debrisoft representative to address prescription problems through GP surgeries.
Verbatim wording from the response “Community nurses have stock items of Debrisoft (1 box of 5) in nursing bags at all times. | | 31/12/2017 | The 5 localities have placed orders with procurement. |
| Communication | 5 | ████████ (Matron) | Meeting held on 21 January 2017 with the CCG to discuss delays in community nursing prescription requests | | 21/01/2018 | Meeting held 22/01/18. CCG gave assurance that they would discuss this matter with GPs |
| Communication | 6 | ████████ (Matron) | Meeting held with the Debrisoft Rep to discuss the issues when raising a prescription through the GP surgery. | | 16/01/2018 | Debrisoft Rep is liaising with GP surgeries and local pharmacies in order to cascade educational advice regarding product and FP10. Trust has follow up meeting with rep 06/02/18 to ensure revised processes are working |” Source location 2017-0352-Response-by-Dudley-Group-NHS-Trust_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Meet with the CCG to discuss delays in community nursing prescription requests.
Verbatim wording from the response “Community nurses have stock items of Debrisoft (1 box of 5) in nursing bags at all times. | | 31/12/2017 | The 5 localities have placed orders with procurement. |
| Communication | 5 | ████████ (Matron) | Meeting held on 21 January 2017 with the CCG to discuss delays in community nursing prescription requests | | 21/01/2018 | Meeting held 22/01/18. CCG gave assurance that they would discuss this matter with GPs |
| Communication | 6 | ████████ (Matron) | Meeting held with the Debrisoft Rep to discuss the issues when raising a prescription through the GP surgery. | | 16/01/2018 | Debrisoft Rep is liaising with GP surgeries and local pharmacies in order to cascade educational advice regarding product and FP10. Trust has follow up meeting with rep 06/02/18 to ensure revised processes are working |” Source location 2017-0352-Response-by-Dudley-Group-NHS-Trust_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make Debrisoft a mandatory stock item, procure it through established channels, and equip district nurse bags with one box of five.
Verbatim wording from the response “| Action Theme | Action number | By whom | Current progress | Status | Due Date | Assurances |
| Communication | 1 | ████████ (Deputy Matron) | Meeting held 4 December 2017 with community nursing senior leads - to discuss the Coroner’s Regulation 28 PFD report | | 04/12/2017 | Minutes of the meeting can be retrieved from the O Drive on the shared drive |
| Communication | 2 | ████████ (Deputy Matron) | Meeting held 20 December 2017 with Chief Nurse to discuss Regulation 28 PFD report | | 20/12/2017 | Completion of Action Plan and Debrisoft Pathway |
| Communication | 3 | ████████ | Debrisoft management pathway devised and populated | | 20/01/2018 | Minutes of the meeting – Debrisoft Pathway attached |
| Delays ordering Debrisoft | 4 | ████████ | In order to ensure there are no delays Debrisoft is now a stock item and ordered through procurement.” Source location 2017-0352-Response-by-Dudley-Group-NHS-Trust_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a follow-up meeting with the Debrisoft representative to check whether revised prescription processes are working.
Verbatim wording from the response “Community nurses have stock items of Debrisoft (1 box of 5) in nursing bags at all times. | | 31/12/2017 | The 5 localities have placed orders with procurement. |
| Communication | 5 | ████████ (Matron) | Meeting held on 21 January 2017 with the CCG to discuss delays in community nursing prescription requests | | 21/01/2018 | Meeting held 22/01/18. CCG gave assurance that they would discuss this matter with GPs |
| Communication | 6 | ████████ (Matron) | Meeting held with the Debrisoft Rep to discuss the issues when raising a prescription through the GP surgery. | | 16/01/2018 | Debrisoft Rep is liaising with GP surgeries and local pharmacies in order to cascade educational advice regarding product and FP10. Trust has follow up meeting with rep 06/02/18 to ensure revised processes are working |” Source location 2017-0352-Response-by-Dudley-Group-NHS-Trust_Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Devise and populate a Debrisoft management pathway for community nursing staff.
Verbatim wording from the response “| Action Theme | Action number | By whom | Current progress | Status | Due Date | Assurances |
| Communication | 1 | ████████ (Deputy Matron) | Meeting held 4 December 2017 with community nursing senior leads - to discuss the Coroner’s Regulation 28 PFD report | | 04/12/2017 | Minutes of the meeting can be retrieved from the O Drive on the shared drive |
| Communication | 2 | ████████ (Deputy Matron) | Meeting held 20 December 2017 with Chief Nurse to discuss Regulation 28 PFD report | | 20/12/2017 | Completion of Action Plan and Debrisoft Pathway |
| Communication | 3 | ████████ | Debrisoft management pathway devised and populated | | 20/01/2018 | Minutes of the meeting – Debrisoft Pathway attached |
| Delays ordering Debrisoft | 4 | ████████ | In order to ensure there are no delays Debrisoft is now a stock item and ordered through procurement.” Source location 2017-0352-Response-by-Dudley-Group-NHS-Trust_Redacted
Open published response
30 May 2017 Kenneth Evans · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to arrange thromboprophylaxis View source Failure to undertake effective risk assessment of developing blood clots View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kenneth Evans · 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
Kenneth Evans was admitted to hospital after a mechanical fall and fractured pubic ramus, and subsequently developed an extensive pulmonary embolism. He died on 11 March 2017 after cardiac arrest and continued clinical deterioration. The inquest identified that thromboprophylaxis and an effective blood-clot risk assessment had not been arranged, with missed opportunities to administer heparin.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange thromboprophylaxis
Wider context from the report “1. Evidence emerged during the inquest that thromboprophylaxis was not arranged and no effective risk assessment of developing blood clots was undertaken.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake effective risk assessment of developing blood clots
Wider context from the report “1. Evidence emerged during the inquest that thromboprophylaxis was not arranged and no effective risk assessment of developing blood clots was undertaken .
” 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 Clarify that Evergreen is covered by the Trust’s VTE assessment policy.
Verbatim wording from the response “The Evergreen area is an intermediate care area where patients are admitted following discharge from the acute trust. These beds are utilised for patients who need nursing care but who are otherwise medically fit (analogous to nursing home patients). Following this incident we have made it clear to all staff that Evergreen is part of our services and thus subject to our Trust policy on VTE assessments.” Source location 2017-0175-Response-by-The-Dudley-Group-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss the need for VTE assessments with medical teams.
Verbatim wording from the response “Awareness of the need for VTE assessments has been discussed with our medical teams and following your letter to the Trust is timetabled to be raised again at the next mandatory Medicine Audit meeting with this specific case being presented to the multidisciplinary teams attending.” Source location 2017-0175-Response-by-The-Dudley-Group-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise VTE assessment awareness at the next mandatory Medicine Audit meeting and present this case to attending multidisciplinary teams.
Verbatim wording from the response “Awareness of the need for VTE assessments has been discussed with our medical teams and following your letter to the Trust is timetabled to be raised again at the next mandatory Medicine Audit meeting with this specific case being presented to the multidisciplinary teams attending.” Source location 2017-0175-Response-by-The-Dudley-Group-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The established and audited Trust policy, including staff training and compliance monitoring, is considered sufficient to ensure VTE assessments across hospital areas.
Verbatim wording from the response “I have enclosed the Trust’s policy for venous thromboprophylaxis (VTE) for your information, as part of the Policy there is detail on how we monitor compliance with this Policy (contained within Appendix 1 of the Policy).” Source location 2017-0175-Response-by-The-Dudley-Group-NHS-Trust
Open published response
24 Jan 2017 Mr Ronald Compson · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Poor communication with the family about falls View source Poor recording of vomiting episodes View source Failure to contact the on-call doctor View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Ronald Compson · 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
Mr Ronald Compson, who had Parkinson’s disease, was admitted to hospital after confusion and drowsiness and later sustained an unwitnessed fall with a head injury. He subsequently became unresponsive and died from a subdural haematoma; concerns included failure to notify a doctor, vomiting episodes with poor record keeping, and poor communication with his family about the fall.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication with the family about falls
Wider context from the report “3. There was poor communication to the family about the initial fall .
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor recording of vomiting episodes
Wider context from the report “2. There were two separate incidents of vomiting and poor record keeping of when these occurred .
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the on-call doctor
Wider context from the report “1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on call Doctor.
” 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 Complete a root cause analysis investigation into the failures concerning doctor contact, vomiting records, and family communication.
Verbatim wording from the response “The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.” Source location 2018-0030-Response-by-Dudley-Group-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigation found no nerve centre system failure; the failure to contact a doctor resulted from human error entering incorrect patient details.
Verbatim wording from the response “The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.” Source location 2018-0030-Response-by-Dudley-Group-NHS-Trust
Open published response
26 Oct 2016 Alfie Rose · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure of the NORSE system to make all entries visible View source Insufficient guidance and education on neurological referrals in outlying hospitals View source Failure to communicate relevant clinical information between hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfie Rose · 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
Alfie Rose, aged 17, died on 09 June 2016 following deterioration from obstructive hydrocephalus, severe brain injury and brain stem death. The report identified poor communication between the two hospitals and inadequate guidance and education for clinicians in outlying hospitals as principal concerns. The inquest concluded that earlier detailed MRI scanning, admission and treatment at the Queen Elizabeth Hospital neurosurgical unit would, on balance, have avoided his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the NORSE system to make all entries visible
Wider context from the report “1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance and education on neurological referrals in outlying hospitals
Wider context from the report “2. Education. It is important the clinicians in outlying hospitals understand how neurological referrals should be made and when. Better guidance and education is needed for outlying hospitals.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant clinical information between hospitals
Wider context from the report “1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen.
” 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 Conduct meetings between QEHB and RHH clinical staff to identify communication and referral-system improvements.
Verbatim wording from the response “It is important to reflect on the effectiveness of any system when there has been a significant clinical incident. To that end the following meetings have been held to identify areas of concern that could be improved:” Source location 2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.
Verbatim wording from the response “Issues Identified:” Source location 2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the agreed cross-Trust action plan to address identified safety concerns.
Verbatim wording from the response “A detailed action plan has been developed (attached to this letter) and the actions have been agreed by both UHB and DGFT. We have commenced on the delivery of these actions and recorded our progress on the action plan for you information.” Source location 2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Open published response
3 Jun 2015 Mr Frederick White · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Failure of triage to undertake further and detailed assessment of spinal injury risk View source Delays in diagnosing suspected spinal cord injury View source Failure to immobilise patients with suspected spinal cord injury during initial examination and assessment 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
Mr Frederick 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
Mr Frederick White suffered a fall at a retirement home on 29 March 2015, sustaining a traumatic spinal cord injury, and died on 2 April 2015. The report identified concerns about failures to recognise symptoms of spinal injury and to immobilise him initially and at hospital, with the inquest finding that these collective failures contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of triage to undertake further and detailed assessment of spinal injury risk
Wider context from the report “(2) Evidence emerging from the inquest suggested that the initial failure to immobilise the patient continued when he arrived at Hospital and the triage process failed to adequately assess the risk again . It appears the triage process is heavily reliant upon the handover from the paramedic crew without further and detailed assessment .
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in diagnosing suspected spinal cord injury
Wider context from the report “(3) It wasn't until five hours after the initial fall that a suspected spinal cord injury was diagnosed .
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to immobilise patients with suspected spinal cord injury during initial examination and assessment
Wider context from the report “(1) Spinal injuries are relatively uncommon but have the potential to cause significant morbidity and mortality if not managed effectively. Mr White was an elderly patient who was at risk of falling during the course of the inquest evidence emerged showing that he had sustained a traumatic injury of significant blunt force trauma. He also gave a description of feelings of numbness and lack of sensation in his legs and there was also a drop in blood pressure, which should have prompted a conservative approach in treating the patient by applying immobilisation on suspicion of spinal cord injury during his initial examination and assessment .
” Open source report
2 Apr 2014 Mr John Dodd · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Failure to report a documented temperature rise to medical staff View source Failure to check INR for a patient taking Warfarin View source Failure to medically reassess the patient before discharge View source Delays in first assessment by medically qualified staff in A&E View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr John Dodd · 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
Mr John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.
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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report a documented temperature rise to medical staff
Wider context from the report “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall.
There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff . This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team.
There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check INR for a patient taking Warfarin
Wider context from the report “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall .
There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team.
There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to medically reassess the patient before discharge
Wider context from the report “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall.
There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen , Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team.
There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis.
” 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 Dudley Group NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in first assessment by medically qualified staff in A&E
Wider context from the report “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall.
There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team.
There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23 . It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis.
” 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 Hold regular Emergency Department board rounds so each patient is discussed with senior medical staff.
Verbatim wording from the response “• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.” Source location 2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reconfigure the electronic clinical information system to create a visible consultant alert when vital signs fall outside normal parameters.
Verbatim wording from the response “• The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patient’s vital signs fall outside normal parameters.” Source location 2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a guideline requiring routine INR checks for patients taking vitamin-K antagonist anticoagulants after a fall.
Verbatim wording from the response “• A written guideline will be developed to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants, such as warfarin.” Source location 2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an electronic-system prompt to indicate when abnormal observations need communicating to senior staff.
Verbatim wording from the response “• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.” Source location 2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations