Concerns raised 1 Unavailability of mechanical thrombectomy services outside 9.00am to 5.00pm 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
Keith REYNOLDS · 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
Keith Reynolds underwent carotid artery stenting followed by coronary artery bypass and mitral valve repair. He subsequently suffered an ischaemic stroke after the stent became blocked by a blood clot and died on 14 November 2024. The report raises concern that mechanical thrombectomy was unavailable outside 9.00am to 5.00pm because of insufficient neuroradiologists, potentially preventing treatment for some patients.
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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of mechanical thrombectomy services outside 9.00am to 5.00pm
Wider context from the report “(1) A mechanical thrombectomy service is not available in the region outside of 9.00am to 5.00pm due to insufficient neuroradiologists being available to run such a service . I am told that this issue is listed on the Newcastle Upon Tyne Hospitals NHS Foundation Trust's 'Risk Register' and that a business plan has been submitted to NHS England in relation to funding for additional clinicians. However, at the present time, should patients currently require a mechanical thrombectomy outside of the hours of 9.00am to 5.00pm, such a service would not be available to them and this could result in their death despite this potentially being preventable were such a service available.
” 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 Implemented a joint interventional neuroradiologist rota with James Cook University Hospital, providing sufficient neuroradiologist capacity for 24/7 service delivery.
Verbatim wording from the response “Current Position
The Trust has an established MT Steering Group which includes senior representation from clinicians and operational managers within the neuroradiology, stroke medicine, and perioperative departments. The group meets monthly and has agreed a plan for achieving a 24/7 MT service at the RVI which would serve all patients in NENC. As we have agreed to implement a joint INR rota with colleagues at James Cook University Hospital, we currently have enough INRs in place to deliver this 24/7 service. As we would be more than doubling our operational hours and accepting additional stroke patients from other hospitals, we would need to recruit other clinical staff to support service expansion. The limiting factor to expansion is solely the approval of funding to support this recruitment.” Source location Response from Newcastle upon Tyne Hospitals 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 Established a multidisciplinary Mechanical Thrombectomy Steering Group to develop and oversee a plan for achieving 24/7 service provision.
Verbatim wording from the response “Current Position
The Trust has an established MT Steering Group which includes senior representation from clinicians and operational managers within the neuroradiology, stroke medicine, and perioperative departments. The group meets monthly and has agreed a plan for achieving a 24/7 MT service at the RVI which would serve all patients in NENC. As we have agreed to implement a joint INR rota with colleagues at James Cook University Hospital, we currently have enough INRs in place to deliver this 24/7 service. As we would be more than doubling our operational hours and accepting additional stroke patients from other hospitals, we would need to recruit other clinical staff to support service expansion. The limiting factor to expansion is solely the approval of funding to support this recruitment.” Source location Response from Newcastle upon Tyne Hospitals 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 Reviewed the clinical model and service costs, then submitted a revised 24/7 Mechanical Thrombectomy model and costing to NHS England.
Verbatim wording from the response “Following this the commissioners requested that the Trust review their clinical model (working with Salford on this to look at their model) and to review the cost of service provision.” Source location Response from Newcastle upon Tyne Hospitals NHS Foundation 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 Approval and funding for expanded mechanical thrombectomy services must be provided by NHS England and commissioners.
Verbatim wording from the response “NHS England has emphasised that Trusts must operate within their allocated budget, such that additional services must be adequately funded by commissioners prior to approval. As of October 2025 we continue to await a response from the commissioners to our proposal for the Trust to expand to a 24/7 service. If we were to receive approval, we would envisage being able to implement an 8am to 8pm service within 6 weeks, with progression to a 24/7 service in the following 6 months.” Source location Response from Newcastle upon Tyne Hospitals 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 The Trust cannot expand mechanical thrombectomy to 24/7 without adequate funding to recruit additional clinical staff.
Verbatim wording from the response “Current Position
The Trust has an established MT Steering Group which includes senior representation from clinicians and operational managers within the neuroradiology, stroke medicine, and perioperative departments. The group meets monthly and has agreed a plan for achieving a 24/7 MT service at the RVI which would serve all patients in NENC. As we have agreed to implement a joint INR rota with colleagues at James Cook University Hospital, we currently have enough INRs in place to deliver this 24/7 service. As we would be more than doubling our operational hours and accepting additional stroke patients from other hospitals, we would need to recruit other clinical staff to support service expansion. The limiting factor to expansion is solely the approval of funding to support this recruitment.” Source location Response from Newcastle upon Tyne Hospitals NHS Foundation Trust
Open published response
Concerns raised 1 Lack of policy or guidance for microbiological swabbing when re-suturing wounds View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nicola MULLISS · 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
Nicola Mulliss died on 18 February 2025 after a wound infection following meningioma surgery spread and caused staphylococcal meningitis, disrupting the blood supply to her brain. The principal concern was that no wound swab was taken when it was re-sutured, so the infection might not have been detected and treated before it spread; such testing was not policy or guidance at the time.
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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of policy or guidance for microbiological swabbing when re-suturing wounds
Wider context from the report “In evidence I was told that had a swab been taken for microbiological analysis when the wound was re-sutured , it was possible that the Staphylococcus Aureus infection could have been detected at this earlier juncture and treatment investigated before the infection spread and resulted in the fatal staphylococcal meningitis. However, I was told that it is not policy / guidance for such testing to be undertaken so this did not occur.
” 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 Strengthen pathways for timely cultures, including wound swabs, and prompt antibiotics when infection is suspected.
Verbatim wording from the response “Following your correspondence, I can confirm that we will strengthen our pathways to ensure that when a patient is suspected of having an infection, appropriate cultures are undertaken in a timely manner, including wound swabs and that where clinically appropriate, patients are commenced promptly on antibiotics. Compliance with these standards is regularly monitored, and we will also consider additional ways to strengthen these safeguards.” Source location Response from Newcastle upon Tyne Hospitals NHS Foundation 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 Universal swabbing of leaking wounds is not clinically appropriate because leakage is often normal and positive cultures may cause unnecessary antibiotic use.
Verbatim wording from the response “Having reviewed your comments, we can confirm that it is not clinically appropriate to take swabs of all leaking wounds. Wounds leak for a number of reasons, frequently as a result of the natural healing process. Serous or haemorrhous fluid leaks (as occurred” Source location Response from Newcastle upon Tyne Hospitals NHS Foundation Trust
Open published response
Concerns raised 4 Poor vascular ward communication when post-operative concerns are raised View source Failure of the community team to consistently record key clinical assessment information View source Inconsistency between hospital and community teams about post-discharge procedures and points of access View source Absence of documented discharge advice on points of access for concerns or complications View source See 1 more concern
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
William Nichols · 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
William Nichols underwent a femoral endarterectomy and developed a deep patch infection, followed by a catastrophic haemorrhage from the right femoral artery. The report identifies concerns about inconsistent communication between hospital and community teams, insufficient documented discharge advice, poor communication about bleeding concerns, and inadequate community-team record keeping.
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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor vascular ward communication when post-operative concerns are raised
Wider context from the report “(3) Poor communication from the vascular ward when concerns were raised post-operatively , particularly the concern about bleeding in the wound 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the community team to consistently record key clinical assessment information
Wider context from the report “(4) Poor record keeping from the community team which meant that key clinical assessment information was not consistently recorded .
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between hospital and community teams about post-discharge procedures and points of access
Wider context from the report “(1) Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding).
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of documented discharge advice on points of access for concerns or complications
Wider context from the report “(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding).
” 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 Deliver ward-based training on escalating patient calls and include escalation training in vascular study days and junior doctor induction.
Verbatim wording from the response “It has been agreed with the Vascular Nurse Clinical Educator to deliver ward based training regarding the escalation of patient calls to the ward. This has also been incorporated into the vascular study days and junior Medical staff at induction.” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
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 Conduct daily vascular ward handovers with senior clinical staff and review recent registrar referral calls for consultant oversight.
Verbatim wording from the response “• The Vascular team have introduced a daily morning ward handover meeting attended by, as a minimum, the Consultant of the week, the Surgeon of the week and the outgoing and incoming on call registrars. In addition to patients admitted, all referral calls to the on-call registrar made in the previous 24 hours are discussed thus providing consultant oversight of decisions made and advice given.” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
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 Standardize documentation of wound calls, discharge advice and ward reviews, including changes communicated to community teams.
Verbatim wording from the response “• Calls from patients about their wounds and the advice given to them should be documented as an entry on e-Records by either the specialist nursing team, or the on-call vascular registrar (or both if they are both involved in the advice), and this entry should be made as close to the time of the call as possible.” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
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 Operate a 24-hour vascular call-triage pathway directing wound concerns to specialist nurses or the on-call vascular registrar.
Verbatim wording from the response “• If patients call the ward with a concern about their wound during normal working hours, the ward will direct the call to the specialist vascular nursing team, for their initial advice.” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
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 patients and community clinicians with written post-discharge wound information, contact points, escalation advice and urgent bleeding instructions.
Verbatim wording from the response “Patients in advance of admission to hospital for their surgery are to be provided with a Femoral Endarterectomy Patient Information Leaflet providing full explanation of their pathology along with the proposed surgery, post operative course and potential complications. The course of action to be taken by patient, community nursing team or GP being provided with the relevant contact points along with phone number to call (see Appendix 1). This is in addition to providing the same information to the patient on discharge in a leaflet Wound care following arterial surgery (see Appendix 2) and in written communication in the discharge summary headed as “Information to Patient” (see Appendix 3).” Source location Response from Newcastle Upon Tyne Hospitals NHS Foundation
Open published response
3 Jul 2017 Sheila Mary Hynes · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 5 Remounting of the valve contrary to the manufacturer’s instructions for use View source Failure to discuss and record the rationale for departing from the manufacturer’s instructions for use View source Lack of awareness among the primary surgeon and operating team of the risks of departing from the manufacturer’s instructions for use View source Failure to involve and record discussions with the primary surgeon before remounting the valve View source Assignment of valve remounting to an untrained and inexperienced scrub nurse View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sheila Mary Hynes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheila Mary Hynes died after an aortic and mitral valve replacement procedure in which a mechanical aortic valve was remounted in an inverted position and re-implanted. The resulting acute heart damage led to her death. Concerns included remounting the valve contrary to the manufacturer’s instructions, inadequate awareness of the associated risks, and directing a scrub nurse without relevant training or experience to remount it.
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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Remounting of the valve contrary to the manufacturer’s instructions for use
Wider context from the report “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use.
Concerns arising are:
a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded.
b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount.
c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded.
d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss and record the rationale for departing from the manufacturer’s instructions for use
Wider context from the report “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use.
Concerns arising are:
a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded.
b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount.
c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded.
d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among the primary surgeon and operating team of the risks of departing from the manufacturer’s instructions for use
Wider context from the report “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use.
Concerns arising are:
a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded.
b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount.
c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded.
d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve and record discussions with the primary surgeon before remounting the valve
Wider context from the report “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use.
Concerns arising are:
a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded.
b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount.
c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded.
d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Assignment of valve remounting to an untrained and inexperienced scrub nurse
Wider context from the report “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use.
Concerns arising are:
a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded.
b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount.
c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded.
d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue.
” Open source report
Concerns raised 9 Failure to provide longitudinal management of recurring asthma exacerbations View source Failure to recognise deterioration in respiratory condition View source Failure to enable appropriate referrals to the tertiary paediatric service View source Failure to ensure understanding of the purpose and limits of asthma plans View source Lack of a long-term management plan for chronic asthma View source Lack of effective communication between primary and secondary care services View source Lack of a coordinating record of recurrent asthma presentations View source Failure to assign overall clinical management responsibility View source Failure to refer paediatric asthma patients to tertiary respiratory specialists View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Tamara Mills · 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
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide longitudinal management of recurring asthma exacerbations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family .
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise deterioration in respiratory condition
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enable appropriate referrals to the tertiary paediatric service
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust . The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure understanding of the purpose and limits of asthma plans
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a long-term management plan for chronic asthma
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes .
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication between primary and secondary care services
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment .
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a coordinating record of recurrent asthma presentations
Wider context from the report “1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family.
2. There was :-
i) No co-ordinating record of these occasions
ii) No analysis of the frequency or circumstances of the events
iii) No analysis of the medication or level of medication prescribed
iv) No determination of its effectiveness the frequency or regularity of its use
v) No appreciation of the deteriorating nature of her respiratory condition
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign overall clinical management responsibility
Wider context from the report “3. Despite the presence of a significant number of health care professional involved in her care and some frequently, no single individual assumed management for her care overall
4. In the absence of no one individual assuming responsibility for her care, there was no plan directed towards her long term management and care identifying the chronic nature of her condition, seeking a sustained and balanced level of treatment, control and resolution of the recurring episodes.
5. Insofar as planning occurred it was in the last six months of her life and was in the form of an emergency plan directed towards the next and apparently accepted inevitable acute event, but not as a part of the necessary strategy to control and avoid such events.
6. Not only did those advised of such a plan fail to understand its limited objective they misinterpreted its purpose and consoled themselves in the false belief there was a purposeful strategy designed to protect this child in the long term.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer paediatric asthma patients to tertiary respiratory specialists
Wider context from the report “8. Two further areas of concern presented, inter related but independently significant and critical in this matter :
A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment.
B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics.
i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient.
ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care
and
iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation
9. Tamara was never formally referred to this level of service .
” Open source report
24 Nov 2014 William Walter Jackson · Prevention of Future Deaths report North and West Cumbria
View report summary
Concerns raised 2 Failure to review CT scan images before providing specialist advice View source Lack of formal recording of sudden clinical interactions 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
William Walter Jackson · 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
William Walter Jackson was diagnosed with severe aortic disease and underwent aortic valve and ascending-aorta replacement surgery in June 2013. After becoming unwell in August, a CT scan showed haemorrhage in the descending aorta, but the report did not identify features of a contained rupture; he died on 4 September 2013. The concerns included the lack of a formal record of advice from the Freeman Hospital, uncertainty about whether the CT images were reviewed, and the potential risk to patients from how such advice was given.
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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review CT scan images before providing specialist advice
Wider context from the report “(1) The CIC records showed that an A&E doctor had spoken to a Specialist Cardio Thoracic Registrar at the Freeman Hospital. Inquiries of the Freeman showed that there was no record/ recollection of this contact.
(2) I understand there is no system at the Freeman to formally record sudden interactions. This means no traceable record and no means by which the Freeman doctor could be identified let alone recall the advice given.
(3) The advice appears to have been given without the Freeman doctor actually seeing the CT scan. Has the images been reviewed it is possible that the true state of the deceased’s health would have been ascertained.
(4) Independent of the issue of an enquiry being able to establish what advice was given at the time; there is a risk that the way such advice appears to have been given could place patients lives at risk.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formal recording of sudden clinical interactions
Wider context from the report “(1) The CIC records showed that an A&E doctor had spoken to a Specialist Cardio Thoracic Registrar at the Freeman Hospital. Inquiries of the Freeman showed that there was no record/ recollection of this contact.
(2) I understand there is no system at the Freeman to formally record sudden interactions . This means no traceable record and no means by which the Freeman doctor could be identified let alone recall the advice given.
(3) The advice appears to have been given without the Freeman doctor actually seeing the CT scan. Has the images been reviewed it is possible that the true state of the deceased’s health would have been ascertained.
(4) Independent of the issue of an enquiry being able to establish what advice was given at the time; there is a risk that the way such advice appears to have been given could place patients lives at risk.
” 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 Further develop the recording system to prompt documentation of key items, including radiological images viewed when providing an opinion.
Verbatim wording from the response “(ii) Further planned actions:” Source location 2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-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 Include electronic-system recording requirements in the induction programme for newly recruited and rotating staff.
Verbatim wording from the response “(ii) Further planned actions:” Source location 2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-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 Implement an electronic system to record details of advice provided to healthcare professionals at other hospitals.
Verbatim wording from the response “(i) Actions already taken:” Source location 2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-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 Ensure the Cardiothoracic Surgical Team consistently uses the electronic system for external requests for medical opinions.
Verbatim wording from the response “• An electronic system is now in place within Cardiothoracic Surgery to record details of advice given when medical opinion is sought by a healthcare professional in another hospital.” Source location 2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
Open published response
Concerns raised 5 Failure to communicate relevant postoperative risks and complications to community carers View source Inadequate systematic assessment of physical symptoms View source Failure to measure and record community patients’ vital signs View source Failure of surgical teams to maintain ongoing oversight after discharge View source Lack of a discharge plan for possible pelvic infection View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Keith Fleming · 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
Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.
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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant postoperative risks and complications to community carers
Wider context from the report “The General Practitioner and consequently the nursing staff were not aware of that the anastomosis of the bowel carried out during the original operation ( 2007) had dehised. Nor were they aware of an internal area of abscess adjacent to the repaired stoma site , only discovered on post mortem and together leading to a catastrophic infection within the deceased particularly and significantly in the area of his left buttock. The reality was the infection within the otherwise pelvic area had tracked through the pelvis into the area of the left buttock.
It was the presence of the swelling of this area of the buttock which was to alert the deceased’ wife several days after his discharge home to the growing crisis and resulted in her summoning her husband’s GP Dr.████████. The Doctor immediately recognized the symptoms, arranged for the deceased’ emergency admission to the South Tyneside District Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate systematic assessment of physical symptoms
Wider context from the report “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded.
Physical symptoms were noted but only on a generalized – impressionistic basis - tiredness, responsiveness to questions and discussion – level of activity and mobility – diet.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to measure and record community patients’ vital signs
Wider context from the report “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded.
Physical symptoms were noted but only on a generalized – impressionistic basis - tiredness, responsiveness to questions and discussion – level of activity and mobility – diet.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of surgical teams to maintain ongoing oversight after discharge
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” 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 Newcastle Upon Tyne Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a discharge plan for possible pelvic infection
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” 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