22 Jan 2024 Kate Elizabeth O’Donnell · Prevention of Future Deaths report Teesside and Hartlepool
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Concerns raised 12 Inaccurate recording of clinical communications in case notes View source Failure to physically assess the patient by a doctor before discharge View source Inadequate nursing documentation of vomiting, pain and pain scores View source Failure to respond to reported pain with pain relief or medical escalation View source Lack of consultant urologist knowledge of surgery classification and SIGN guidelines View source Incorrect prescribing of prophylactic antibiotics after urology surgery View source Failure to provide families with deterioration warning signs and actions at discharge View source Failure to recognise the recommendation for prophylactic antibiotics in gastro-intestinal surgery View source Failure to provide prophylactic antibiotics for gastro-intestinal surgery View source Failure of operation planning to ensure colorectal surgeon attendance View source Insufficient vigilance and recognition of post-operative presentation View source Failure to review pre-surgery urine test results View source See 9 more concerns
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Kate Elizabeth O’Donnell · 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
Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of clinical communications in case notes
Wider context from the report “8. Case notes included details of a meeting on 14.03.22 which did not taken place and was a telephone call .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to physically assess the patient by a doctor before discharge
Wider context from the report “6. Kate was not physically assessed by a doctor prior to discharge .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate nursing documentation of vomiting, pain and pain scores
Wider context from the report “7. The nursing notes did not include relevant information , to include Kate vomiting and that she was in pain . The pain scores were understated .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to respond to reported pain with pain relief or medical escalation
Wider context from the report “9. The nursing team did not respond to repeated statements that Kate was in pain -she was not offered pain relief nor was medical help sought .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant urologist knowledge of surgery classification and SIGN guidelines
Wider context from the report “3. The consultant urologist was not aware of the classification of surgeries and didn’t know that surgery could be clean-contaminated . He did not know of the SIGN guidelines and that prophylactic antibiotics were highly recommended for this type of gastro-intestinal surgery.
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Incorrect prescribing of prophylactic antibiotics after urology surgery
Wider context from the report “2. The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with deterioration warning signs and actions at discharge
Wider context from the report “10. The family were not provided with information upon discharge as to what signs to look out for and what steps to take if Kate was to deteriorate .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the recommendation for prophylactic antibiotics in gastro-intestinal surgery
Wider context from the report “3. The consultant urologist was not aware of the classification of surgeries and didn’t know that surgery could be clean-contaminated. He did not know of the SIGN guidelines and that prophylactic antibiotics were highly recommended for this type of gastro-intestinal surgery .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prophylactic antibiotics for gastro-intestinal surgery
Wider context from the report “4. The consultant urologist overlooked the provision of prophylactic antibiotics for the gastro-intestinal surgery .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of operation planning to ensure colorectal surgeon attendance
Wider context from the report “1. Planning for the operation was poor and resulted in the non-attendance of a colorectal surgeon at the surgery .
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient vigilance and recognition of post-operative presentation
Wider context from the report “5. There was insufficient vigilance and recognition given to Kate’s post-operative presentation , considering Kate’s vulnerabilities, comorbidities, and extensive past involvement with the medical teams.
” 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 James Cook University Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review pre-surgery urine test results
Wider context from the report “2. The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations