19 May 2025 Emmy Russo · Prevention of Future Deaths report Essex
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Concerns raised 2 Failure to provide complete information on the risks of induction and continuing pregnancy beyond 41 weeks View source Failure to ensure consistent understanding and escalation of concerns about labouring mothers and CTG traces for doctor review View source
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AI-generated summary
Emmy Russo · 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
Emmy Russo was born in very poor condition after a hypoxic injury shortly before birth and died following severe hypoxic-ischaemic brain injury. The report raised concerns about information given to patients considering induction beyond 41 weeks and about inconsistent escalation of concerns regarding labouring mothers and CTG traces for medical review. The inquest identified missed opportunities to deliver Emmy sooner.
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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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete information on the risks of induction and continuing pregnancy beyond 41 weeks
Wider context from the report “(1) The evidence of the current information given to patients at 40 weeks’ pregnant on the decision over whether to accept the offer of an induction from 41 weeks does not reflect NICE guidance on the information needed by patients to make an informed choice on induction . Whilst it provides details of the risks associated with induction, it does not provide information on the risks of continuing with pregnancy beyond 41 weeks .
” 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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure consistent understanding and escalation of concerns about labouring mothers and CTG traces for doctor review
Wider context from the report “(2) The evidence given at inquest indicated a lack of understanding and/or consistency over when concerns about labouring mothers and/or the CTG trace should be escalated for doctor review . Evidence was given on the measures put in place to address issues with escalation, including “Teach or Treat” and “AID” tools, however, there was limited evidence that these are understood by the working midwives and/or advertised to them by way of regular reminders .
” 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 Implement snap audits and regular audits of antenatal records documenting induction-of-labour discussions.
Verbatim wording from the response “06 In regards to future plans, the Trust plans to implement regular audits of antenatal records of Induction of Labour discussions. It is anticipated that these audits will take place from October 2025, once the new Patient Information Leaflet has fully been embedded. In the interim, snap Audits will take place to monitor compliance.” Source location Response from Princess Alexandra Hospital NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make Birthrights-informed decision-making training mandatory for Consultants, resident doctors and Midwives.
Verbatim wording from the response “10 Whilst we understand that the above concern was directed at ensuring that patients are informed the risks of prolonged gestation in particular, the Trust continues to work with Birthrights to provide training to clinicians. As discussed at Inquest, Birthrights is an organisation focused on supporting patients right to choose and enabling individuals to make informed decisions about their care. The Trust plans to make this training mandatory for all Consultants, resident doctors and Midwives, with a view to start in January 2026, having been optional to this point.” Source location Response from Princess Alexandra Hospital NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hire a Labour Ward, Obstetric and Simulation Lead to provide CTG interpretation and escalation simulations.
Verbatim wording from the response “14 In addition to this, the Trust is currently hiring a Labour Ward, Obstetric and Simulation Lead. As part of this role, the Consultant Obstetrician appointed will be responsible for providing simulations to the team which will include issues of both CTG interpretation and escalation.” Source location Response from Princess Alexandra Hospital NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish an updated induction-of-labour leaflet explaining the risks of continuing pregnancy beyond 41 weeks.
Verbatim wording from the response “The evidence of the current information given to patients at 40 weeks’ pregnant on the decision over whether to accept the offer of an induction from 41 weeks does not reflect NICE guidance on the information needed by patients to make an informed choice on induction. Whilst it provides details of the risks associated with induction, it does not provide information on the risks of continuing with pregnancy beyond 41 weeks.” Source location Response from Princess Alexandra Hospital NHS Foundation Trust
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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 Participate in the Labour Ward Coordinator Education and Development Framework to strengthen escalation leadership and skills.
Verbatim wording from the response “17 Further to this, the Trust is actively participating in the Labour Ward Coordinator Education and Development Framework. This is a national programme, focused on strengthening the leadership of Labour Ward Coordinators. The framework aims to enhance the quality of care provided in Labour Wards and will strengthen clinicians skills to escalate care appropriately.” Source location Response from Princess Alexandra Hospital NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed consistent use of Teach or Treat and AID escalation tools through relaunch messaging, training, case-based learning and safety-huddle reinforcement.
Verbatim wording from the response “The evidence given at inquest indicated a lack of understanding and/or consistency over when concerns about labouring mothers and/or the CTG trace should be escalated for doctor review. Evidence was given on the measures put in place to address issues with escalation, including “Teach or Treat” and “AID” tools, however, there was limited evidence that these are understood by the working midwives and/or advertised to them by way of regular reminders.” Source location Response from Princess Alexandra Hospital NHS Foundation Trust
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10 Jun 2024 Margaret Ann PILGRIM · Prevention of Future Deaths report Essex
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Concerns raised 4 Failure to book fracture clinic follow-up View source Failure to treat identified fractures View source Failure to provide pain relief and consider a care package at discharge View source Failure to communicate identified fractures in discharge information View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Margaret Ann PILGRIM · 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
Margaret Ann Pilgrim died at Princess Alexandra Hospital on 29 June 2023 from congestive cardiac failure and bronchopneumonia, against a background of frailty, after an unwitnessed fall at home caused a fractured clavicle. The fracture was reported on an X-ray during her hospital admission but was not noted on her discharge summary. Concerns included the absence of treatment, pain relief, care-package consideration and fracture-clinic follow-up, and the failure to inform the patient, her family or GP about the fracture.
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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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to book fracture clinic follow-up
Wider context from the report “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
(2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
” 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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to treat identified fractures
Wider context from the report “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
(2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
” 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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide pain relief and consider a care package at discharge
Wider context from the report “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
(2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
” 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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate identified fractures in discharge information
Wider context from the report “Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged.
(1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package
(2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked
(3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic.
” 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 Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
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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 emergency department's process for subsequent image review to assess its robustness and alignment with national practice.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
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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 fracture was minimally displaced and would not have required restricted mobilisation or orthopaedic follow-up if identified.
Verbatim wording from the response “- The fracture was not identified prior to the patient being discharged, due to the minimal displacement, which was reviewed by ED clinical team and not radiologist. Had the fracture been identified and orthopaedic advice sought, they would have recommended the patient to mobilise without restriction. No follow up would have been deemed necessary with this fracture.” Source location Response from Princess Alexandra Hospital
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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 A care package was not considered necessary because the assessment found that the patient did not meet the relevant threshold.
Verbatim wording from the response “- The patient was advised to stay in the ED overnight in order to be seen by the REACT (Rapid Emergency Assessment Care Team) prior to her discharge so that she could be assessed for a potential package of care. Their assessment was that at the time she did not meet the threshold for this however some additional equipment was provided and ordered for her.” Source location Response from Princess Alexandra Hospital
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No analgesia was considered necessary because neither the patient nor her daughter requested it at discharge and shoulder pain was not subsequently reported.
Verbatim wording from the response “- Aside from when the patient was initially admitted there was no reference to the patient complaining of pain in her shoulder by either the medical team or the therapists who” Source location Response from Princess Alexandra Hospital
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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 existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.
Verbatim wording from the response “- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.” Source location Response from Princess Alexandra Hospital
Open published response
14 Mar 2024 Ernest Smith · Prevention of Future Deaths report Essex
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Concerns raised 4 Delays in medical review of acute clinical deterioration View source Failure to follow the Sepsis Protocol View source Delays in commencing antibiotics for infected haematoma View source Delays in consultant review 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.
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AI-generated summary
Ernest Smith · 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
Ernest Smith died in hospital from sepsis associated with hospital-acquired pneumonia and an infected haematoma, which developed after prophylactic anticoagulation. Concerns included delays in medical and consultant reviews, delayed antibiotics for the infected haematoma, and failure to follow the Sepsis Protocol.
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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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical review of acute clinical deterioration
Wider context from the report “a. Medical review requested on 10 March by nurses due to concerns about the acute development of bilateral bruising on Mr Smith's legs. This request was chased by nurses on 11 March and was not conducted until the evening of 12 March.
b. A further medical review was conducted in the early hours of 13 March as Mr Smith was in pain and had developed a leg haematoma.
c. It took 3 days for consultant review of Mr Smith. On 13 March Mr Smith was reviewed by a consultant from another ward and prophylactic anticoagulation was discontinued.
” 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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Sepsis Protocol
Wider context from the report “d. Mr Smith was medically reviewed and considered fit for discharge on 30 March. A tissue viability nurse review that day noted an infected leg haematoma and recommended a surgical referral for consideration of washout and debridement.
e. Antibiotics for the infected haematoma were not commenced until 3 April.
f. Sepsis was highlighted by the Trust surgical team on 3 April and the Sepsis Protocol was not followed.
” 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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing antibiotics for infected haematoma
Wider context from the report “d. Mr Smith was medically reviewed and considered fit for discharge on 30 March. A tissue viability nurse review that day noted an infected leg haematoma and recommended a surgical referral for consideration of washout and debridement.
e. Antibiotics for the infected haematoma were not commenced until 3 April.
f. Sepsis was highlighted by the Trust surgical team on 3 April and the Sepsis Protocol was not followed.
” 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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in consultant review
Wider context from the report “a. Medical review requested on 10 March by nurses due to concerns about the acute development of bilateral bruising on Mr Smith's legs. This request was chased by nurses on 11 March and was not conducted until the evening of 12 March.
b. A further medical review was conducted in the early hours of 13 March as Mr Smith was in pain and had developed a leg haematoma.
c. It took 3 days for consultant review of Mr Smith. On 13 March Mr Smith was reviewed by a consultant from another ward and prophylactic anticoagulation was discontinued.
” Open source report
5 Feb 2016 Isla Peyton LORD · Prevention of Future Deaths report Bedfordshire and Luton
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Concerns raised 1 Failure to coordinate an agreed delivery plan between tertiary and local hospitals 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
Isla Peyton LORD · 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
Isla Peyton LORD was born at Harlow Hospital on 4 November 2012 and suffered an immediate post-natal collapse after delivery, resulting in a hypoxic brain injury. She was transferred to Luton and Dunstable Hospital, where treatment was withdrawn following discussions with her parents, and she died on 8 November 2012. The principal concern was the lack of liaison between the hospitals about the delivery plan after possible heart anomalies were identified.
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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 Princess Alexandra Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to coordinate an agreed delivery plan between tertiary and local hospitals
Wider context from the report “1. During the course of the evidence it became apparent that once the possibility of heart anomalies was identified at University College Hospital in London (UCLH), there was no liaison between Princess Alexandra Hospital in Harlow and UCLH as to the plan for the delivery of the baby . It was simply agreed that UCLH were content for her to be delivered at the local hospital with a referral being made to Great Ormond Street Hospital after delivery . In order to prevent deaths in the future there needs to be a review of the system that exists between the tertiary hospitals and Princess Alexandra Hospital as to how to formulate an Agreed Delivery Plan for both mother and baby.
” 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 Amend the obstetric ultrasound policy to require consultants to obtain and clearly document agreed delivery and neonatal care plans.
Verbatim wording from the response “1. The Standard Operating Policy for obstetric ultrasound scanning has been amended to include that consultants in charge of patients referred for second opinion in tertiary centres should request a detailed plan for delivery of the mother and care of the baby. The policy also requests the consultants to document the plan clearly in the patient’s hand held notes and hospital notes.” Source location I-lord-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the amended policy by adding it to the Trust guidelines folder and notifying obstetric doctors.
Verbatim wording from the response “2. The new policy has been added to the Trust guidelines folder accessible by all clinicians.” Source location I-lord-Response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations