24 May 2022 Michael Nestor WYSOCKYJY · Prevention of Future Deaths report Norfolk
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Concerns raised 2 Lack of escalation arrangements for outstanding x-ray requests View source Inability to offload ambulances promptly, delaying access to x-ray View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.
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Michael Nestor WYSOCKYJY · Prevention of Future Deaths report
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Report summary
Michael Nestor WYSOCKYJY became unwell on 20 September 2021 and was taken to Queen Elizabeth Hospital, where delays occurred before a chest x-ray was performed. A large right-sided pneumothorax was identified shortly before he suffered cardiac arrest and was pronounced dead. Concerns related to delays in ambulance offloading and the lack of clear escalation arrangements to ensure requested x-rays were completed in a busy emergency department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation arrangements for outstanding x-ray requests
Wider context from the report “2. The need for an x-ray remains with the nurse, nurse in charge and/or doctor. If an x-ray is not carried out, the request remains with the nurse, nurse in charge and/or doctor and it was not clear from the evidence there is anything in place to ensure this is escalated and the x-ray takes place . This is something that can be missed in a busy department .
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to offload ambulances promptly, delaying access to x-ray
Wider context from the report “1. The ED was busy at the time and unable to offload ambulances . An x-ray cannot be carried out on an ambulance and must wait until the patient is in ED. If the patient remains on the ambulance for several hours this can delay the x-ray taking place .
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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 Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.
Verbatim wording from the response “Response:
The Emergency Department does operate a system whereby two hourly rounds are conducted for patients in the department. This is carried out by the Band 7 nurse in charge and involves a checklist of clinical and other criteria to ensure that if clinically indicated, appropriate escalation takes place. The intention is that amongst all the other parameters if an investigation such as imaging or blood tests is awaited, this should also be escalated if there is a need to do so. However, it is correct to say that at the time of the inquest the check list contained no specific reference to investigations. The checklist has therefore been upgraded to include this (new version attached with the amendment highlighted).” Source location Response from NHS Queen Elizabeth Hospital Kings's Lynn
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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 Physical constraints prevent X-rays on ambulances; no alternative exists beyond careful clinical assessment during busy periods.
Verbatim wording from the response “Response:
It is correct to say that an X-ray cannot be undertaken on an ambulance because the radiology equipment that generates ionising radiation is insufficiently mobile and too large to be used in this setting. If it is thought by the assessing clinician who goes on to the ambulance that a patient’s need for an X-ray is urgent or an emergency, that patient will be prioritised to be removed from the vehicle as soon as possible. Although conditions for patients are not ideal whilst waiting to enter the Emergency Department, in this way their clinical needs in terms of urgent imaging remain the same as if the patient had already been transferred into the department.” Source location Response from NHS Queen Elizabeth Hospital Kings's Lynn
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9 May 2018 KIRSTY ELIZABETH TOLLEY · Prevention of Future Deaths report Norfolk
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Concerns raised 3 Failure to escalate EWS scores of 3 for medical review and increased observations View source Failure to assess and record Early Warning Scores three times per day View source Failure to carry out daily blood tests to monitor haemoglobin levels View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Conduct ongoing audits of NEWS2 documentation and escalation.
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Action
Appoint a NEWS2 Champion.
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Action
Provide staff with support to understand and use the current escalation system.
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Action
Implement NEWS2 with new documentation, training and escalation procedures, supported by communications and a November 2018 go-live.
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KIRSTY ELIZABETH TOLLEY · Prevention of Future Deaths report
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Report summary
Kirsty Elizabeth Tolley had several health problems and was admitted to Queen Elizabeth Hospital with severe anaemia and a high temperature. She was later found unresponsive in bed on 19 November 2017 and was declared dead despite resuscitation. Concerns included blood tests not being carried out daily as required, incomplete Early Warning Score monitoring, and a lack of documented escalation or additional observations when scores reached 3; the medical cause of death was unascertained.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate EWS scores of 3 for medical review and increased observations
Wider context from the report “(3) Evidence was heard that if EWS reaches 3, then this should be escalated to a doctor who should review the patient and set a plan. Observations should be increased to 4 times per hour with further review. The EWS reached 3 on 4 occasions (including the occasion when the EWS was not completed in the records – 17 February) and there is no evidence that any additional action was taken. In particular on the 17 February no observations/EWS for over 17 hours.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and record Early Warning Scores three times per day
Wider context from the report “(2) Early Warning Scores (EWS) are required to be assessed and recorded 3 times per day. This was not done at lunchtime on 11 February nor evening time on 17 February 2017. No reason has been given for this.
” 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 Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out daily blood tests to monitor haemoglobin levels
Wider context from the report “(1) Miss Tolley had a history of anaemia and had received a blood transfusion in 2016. On admission the Care Plan required blood tests to be taken daily to check haemoglobin levels. These were carried out on 10th, 13th, 14th and 16th (not daily) and showed decreasing levels. Ferinject was administered on 16th February. No blood tests to check haemoglobin levels were carried out after that date (except whilst in cardiac arrest). Blood tests were not carried out daily as required in the Care Plan , despite the requirement for monitoring, her history, the decreasing level of haemoglobin, and Ferinject being administered. There is no reason given in the Care Plan. Evidence was heard with regard to a Regulation 28 Report, that haemoglobin levels are not checked in the few days after Ferinject is administered as its effect is not seen straight away. This was not raised as a reason for not carrying out blood tests in evidence at the inquest. This was not recorded as a reason in the medical records.
Sadly, not only did this not give treating Doctors a picture of Miss Tolley's anaemia during her lifetime but has also meant there is a vacuum of evidence with regard to the medical cause of death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct ongoing audits of NEWS2 documentation and escalation.
Verbatim wording from the response “This will be followed by an ongoing audit to ensure appropriate documentation and audit of escalation.” Source location 2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
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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 Appoint a NEWS2 Champion.
Verbatim wording from the response “May 16 Appointment of NEWS2 Champion” Source location 2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
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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 Provide staff with support to understand and use the current escalation system.
Verbatim wording from the response “The staff, both nursing and medical, working in that clinical area have received support to ensure that they understand and are able to use the current escalation system.” Source location 2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
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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 NEWS2 with new documentation, training and escalation procedures, supported by communications and a November 2018 go-live.
Verbatim wording from the response “The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.” Source location 2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
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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 Widespread retraining on older escalation procedures will not occur before NEWS2 implementation because it could cause confusion.
Verbatim wording from the response “The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.” Source location 2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
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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 Medical plans may appropriately change without formally addressing each earlier entry unless there is a serious reason to question the initial opinion.
Verbatim wording from the response “Upon the patient’s admission the admitting consultant, ████████, wrote in his management plan that Kirsty was to have daily bloods. That plan clearly varied subsequently but his initial plan was based upon his clinical assessment at the time. I think it important to note that our admission document (Clerking Proforma) is not regarded as a rigid tool, perhaps as is seen with documentation like the Waterlow assessment or falls risk tools, for example. From the medical point of view the plan may, and should, change as different doctors subsequently review the patient and or the condition or working diagnoses change. In fact I would expect subsequent doctors visiting a patient always to have in mind an inquisitive and challenging approach to initial working diagnoses and management plans, and be prepared to alter them.” Source location 2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
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27 Oct 2014 JACKSON TERRY SELLERS MITCHELL · Prevention of Future Deaths report Norfolk
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Concerns raised 1 Extravasation of concentrated feeding fluid from low-lying UVCs View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Introduce an X-ray review checklist requiring senior clinicians to review and sign all X-rays, including those checking line and tube positions.
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AI-generated summary
JACKSON TERRY SELLERS MITCHELL · 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
Jackson Terry Sellers Mitchell was born prematurely at 31 weeks and received parenteral nutrition through an umbilical venous catheter. He developed abdominal distension, deteriorated despite treatment and transfer to another hospital, and died on 10 May 2014. The post-mortem attributed his death to intraperitoneal extravasation of parenteral nutrition solution associated with umbilical vein catheterisation; concerns included the catheter's lower position and the need for further investigation into catheter positioning and fluid extravasation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Extravasation of concentrated feeding fluid from low-lying UVCs
Wider context from the report “The damage found to Jackson's liver at post mortem does not appear to be from the tip of the catheter but from the concentrated feeding fluid that was passing through it .
Evidence was given that the ideal placement for a UVC tip is at the level of the diaphragm at approximately T9-T10 vertebral level. The UVC in this case was found to be in a lower lying position, but one which is presently acceptable to 80% of Doctors.
There is a presently unpublished study from Southampton which found 16 cases of extravasation of fluid from UVC over a 2 year period. Extravasation was shown following routine screening of ultra sound scans, although in the study there were no fatalities. Most of the complications in the study occurred with low lying catheters .
Further investigation is being carried out into the positioning of catheters and problems of extravasation of the fluid from UVC.
” 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 Introduce an X-ray review checklist requiring senior clinicians to review and sign all X-rays, including those checking line and tube positions.
Verbatim wording from the response “This action plan has since been followed up and expanded upon. Locally the learning from the internal investigation and the outcome from the Inquest were discussed and shared at the paediatric governance meetings. A new X-ray review checklist was introduced which requires that all X-rays undertaken have to be reviewed and signed by a senior clinician. This includes those X-rays which are taken to check on the position of lines and tubes. This will ensure that it will always be a senior clinician that approves the position of lines.” Source location 2014-0468-Response-by-The-Queen-Elizabeth-Hospital-NHS-Trust
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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 Current King’s Lynn practice already complies with the revised regional umbilical venous catheterisation recommendations.
Verbatim wording from the response “In advance of any work that is being done nationally, the regional guidelines for umbilical venous catheterisation are currently being revised by ████████ at the Norfolk and Norwich University Hospital and a draft set of guidelines has been circulated to all the paediatric teams in the region for consultation and comment. Once those comments have all been received and any amendments made, these guidelines will be subject to ratification and will be implemented throughout the region. In the interim, practice here at King’s Lynn is already in accordance with these new recommendations.” Source location 2014-0468-Response-by-The-Queen-Elizabeth-Hospital-NHS-Trust
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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 BAPM is responsible for leading the clinical development of the national framework for central venous lines, with NHS England providing support.
Verbatim wording from the response “Nationally, ████████ the Patient Safety Lead for Maternity and the Newborn at NHS England, convened a meeting in October last year in conjunction with the British Association of Perinatal Medicine (BAPM) to discuss the formation of a small group to review current practice and formulate new national guidance. The group is intending to review the literature on the matter and utilise the clinical experience of clinicians who have experienced difficulties with using venous lines, to produce a Framework for practice for all central venous lines. The clinical aspect of this work will be led by BAPM but NHS England will support by providing any relevant safety facts and by assisting with the dissemination of the Framework once completed.” Source location 2014-0468-Response-by-The-Queen-Elizabeth-Hospital-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations