22 Feb 2024 Kim Georgina STROUD · Prevention of Future Deaths report Norfolk
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Concerns raised 3 Failure to accurately record medication administration View source Failure to provide timely continence and personal hygiene care View source Failure to safely administer and supervise medication for delirious patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Kim Georgina STROUD · 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
Kim Georgina Stroud was admitted to hospital for a bladder tumour procedure that had previously been cancelled five times, became unwell with a chest infection and later tested positive for covid, and died suddenly on 11 October 2022. Concerns included medication being left unsupervised despite delirium, with tablets signed for as administered, and inadequate personal care when she was found heavily soiled with urine and faeces.
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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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record medication administration
Wider context from the report “Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication.
Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table. These had been signed for as given. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being poisoned, clearly not supervised in taking these either. It was extremely unsafe to give tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked them up.
On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves. Also wash faeces from her body.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely continence and personal hygiene care
Wider context from the report “Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication.
Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table. These had been signed for as given. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being poisoned, clearly not supervised in taking these either. It was extremely unsafe to give tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked them up.
On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves. Also wash faeces from her body.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to safely administer and supervise medication for delirious patients
Wider context from the report “Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication.
Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table . These had been signed for as given. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being poisoned, clearly not supervised in taking these either . It was extremely unsafe to give tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked them up.
On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves. Also wash faeces from her body.
” Open source report
18 Jul 2023 Colin Vincent GREENWAY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 6 Failure to monitor patients at higher risk of embolus after initial clerking View source Failure of junior doctors to prescribe correctly in accordance with guidelines View source Failure to maintain pharmacist medication-error checking as an available procedural control View source Failure of consultants to monitor junior doctors prescribing new medications View source Lack of continuity of care across successive consultants View source Failure to complete VTE assessments during patient clerking View source See 3 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
Colin Vincent GREENWAY · 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
Colin Vincent Greenway became ill with gastroenteritis after returning from Cyprus and was admitted to hospital with acute kidney injury and infection. He was prescribed enoxaparin at half the usual dose despite documented risk factors and renal function above the threshold for dose reduction, and he later died from a pulmonary embolism. The concerns included incorrect junior prescribing, incomplete VTE assessments, inadequate senior oversight and continuity of care, and limited pharmacy checking.
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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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients at higher risk of embolus after initial clerking
Wider context from the report “Patients at higher risk of an embolus not being monitored correctly or at all after initial clerking.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of junior doctors to prescribe correctly in accordance with guidelines
Wider context from the report “Junior doctors incorrect prescribing despite clear guidelines.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain pharmacist medication-error checking as an available procedural control
Wider context from the report “Consultants stating it is the pharmacists’ job to check for errors when there is only a 3 day service by pharmacists to do this and it is intended as a safety net not procedure only .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of consultants to monitor junior doctors prescribing new medications
Wider context from the report “Consultants not accepting that it is their responsibility to monitor what their junior doctors are doing when prescribing new medications for patients.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of continuity of care across successive consultants
Wider context from the report “3 different consultants seeing the same patient over 3 days , no continuity of care.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to complete VTE assessments during patient clerking
Wider context from the report “VTE assessments not being completed on clerking a patient just on the electronic medicines prescription which is much less detailed.
” Open source report
25 Nov 2022 Bonnie Rose WEBSTER · Prevention of Future Deaths report Norfolk
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Concerns raised 3 Delays in administering prescribed antibiotics View source Failure to communicate clearly and ensure understanding of the whole situation View source Failure to use the emergency bleep system to alert the paediatric team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Bonnie Rose WEBSTER · 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
Bonnie Rose Webster was born by emergency caesarean section in a poor condition on 9 February 2022, required resuscitation and neonatal treatment, and died the following day after her condition deteriorated. Concerns included communication with her parents about the seriousness of the situation, a delay in giving prescribed antibiotics, and paediatric staff being alerted on foot rather than through the emergency bleep system.
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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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Delays in administering prescribed antibiotics
Wider context from the report “2. Antibiotics were prescribed at the initial review meeting at 09.35 hours. These were not given until 12.30 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; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate clearly and ensure understanding of the whole situation
Wider context from the report “1. The evidence of Mr and Mrs Webster is they were unaware of the seriousness of the situation . Caesarian Section was discussed but was not advised or recommended at the meeting at 06.50 hours. This was clearly a traumatic meeting and Mr and Mrs Webster were upset which would have impacted on their ability to understand and take in important information . In such a situation clear language and ensuring an understanding of the whole situation is paramount
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to use the emergency bleep system to alert the paediatric team
Wider context from the report “3. Evidence was heard that staff alerted the paediatric team on foot, rather than using the emergency "bleep" system .
” Open source report
9 Aug 2021 Terence Robert TUTTLE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Lack of early mental health review View source Lack of early dietician assessment View source Inability to care for mentally unwell patients with physical health problems who are refusing to eat View source Failure to adequately assess under the Mental Capacity Act View source Failure to act on recorded weight loss View source Lack of recognition of serious harm View source Failure to include family members in care View source See 4 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
Terence Robert TUTTLE · 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
Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.
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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Lack of early mental health review
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of early dietician assessment
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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; that does not assign responsibility.
PFD Monitor interpretation Inability to care for mentally unwell patients with physical health problems who are refusing to eat
Wider context from the report “4.Inability to care for a mentally unwell patient with physical health problems , including gastric problems, who is refusing to eat .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess under the Mental Capacity Act
Wider context from the report “3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recorded weight loss
Wider context from the report “2.Inaction when Mr Tuttle was losing weight even though his intake was recorded no-one acted upon 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; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of serious harm
Wider context from the report “6. Apparent lack of recognition that serious harm did occur for this patient who was described as appearing cachexic .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to include family members in care
Wider context from the report “5.Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation.
” Open source report
11 Nov 2020 Margaret Lilian SALES · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Lack of completion of required records View source Failure of on-call medical staff to respond reliably to requests to attend patients View source Failure to communicate required follow-up arrangements to GPs at discharge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Margaret Lilian SALES · 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 Lilian Sales, who was frail and had several comorbidities, was admitted to hospital on 13 December 2019 and died on 4 January 2020 after her health deteriorated. Concerns included incomplete records, difficulties contacting on-call medical staff, and a failure to request GP monitoring of her capillary blood glucose after discharge. The inquest concluded that she died from aspiration pneumonia, the cause of which was not clear from the evidence.
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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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Lack of completion of required records
Wider context from the report “1. Evidence was heard that Records were not always completed as required. It is understood clinical teams have been notified of this and the records are being audited. There was no evidence as to the outcome of those audits and any further action taken.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of on-call medical staff to respond reliably to requests to attend patients
Wider context from the report “2. Nurses had difficulty in contacting front line on call medical staff on two occasions. Several members were contacted before anyone attended. Bleeps are now to be provided to all on call medical staff. However, some of the team had bleeps and still did not respond to the requests to attend the patient.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate required follow-up arrangements to GPs at discharge
Wider context from the report “3. On a previous discharge from hospital, it was noted Mrs Sales had been referred to the Home Enteral Nutrition service for monitoring and follow up and that in situations such as this, requests will be placed with the GP. However, no such request had been placed with the GP. The Discharge Letter in fact stated: "Actions for the GP: No recommendations" . As a result, the GP did not monitor Mrs Sales’ capillary blood glucose following discharge.
” Open source report
17 Sep 2019 Tyla Katherine Joan COOK · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to organise a multi-disciplinary learning event on emergency non-technical skills View source Failure to maintain up-to-date written care and crisis plans View source Delays in Eating Disorder Service assessment due to caseload capacity View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Tyla Katherine Joan COOK · 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
Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.
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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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to organise a multi-disciplinary learning event on emergency non-technical skills
Wider context from the report “3. The Review carried out by the West Norfolk Clinical Commissioning Group in May 2019 recommended a multi-disciplinary learning event involving participants from Norfolk and Suffolk Foundation Trust, Queen Elizabeth Hospital, Norfolk County Council and East of England Ambulance Service Trust be developed and implemented to train staff on how to apply good non-technical skills (teamwork, leadership, task prioritisation and communication) when responding to an emergency. At the inquest it became clear no steps have been taken to organise this event and there is confusion as to who is responsible for arranging this learning event . The Care providers indicated it was the West Norfolk Clinical Commissioning Group. The West Norfolk Clinical Commissioning Group do not appear to accept responsibility for organisation of the event. Tyla died on 15 November 2017. The West Norfolk Clinical Commissioning Group Review was published 8 May 2019. No steps have been taken with regard to this learning event , save East of England Ambulance Service Trust has been in contact with the West Norfolk Clinical Commissioning Group. There is concern that a multi-disciplinary learning event will not be organised and will not take place .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain up-to-date written care and crisis plans
Wider context from the report “2. There was no written up-to-date care and crisis plans in place . The most recent written care plan related to Tyla being an inpatient at the Dragonfly Unit, from where he was discharged on 9 August 2017. The written plans were therefore several months out of date . This is against Trust Policy. Evidence was heard that at a CETR meeting on 6 November 2017 a period of a further 3 months was requested to prepare an up to date written care plan. In the event, and despite the family’s repeated requests for plans in writing, it was decided the care plan could be commenced by 30 November 2017, on the basis Tyla’s input into the Care Plan was important and it would take time to gain his meaningful input. The evidence was that there were oral plans in place which were relayed to the parents (including at times of distress), who continued to request plans in writing. The high level of distress and anxiety within Tyla’s home was recognised. An interim written plan was not considered nor that a written plan may have helped the family in providing support to Tyla. Steps have been taken by the Trust to recognise when up to date written plans are not in place and it is understood staff have undergone some work in improving the quality of care plans. However in this case an active decision was made not to update the written plan for some time . Further the evidence did not reveal any insight into the support a written plan could have given the family to support Tyla.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays in Eating Disorder Service assessment due to caseload capacity
Wider context from the report “1. It was agreed at the CETR meeting on 9 August 2017 that Tyla was to be seen by the Eating Disorder Service. He was not seen until 25 October 2017 . The evidence was the 11 week delay in seeing Tyla was due to a heavy caseload and the practitioner having to remove other cases from his caseload before he was able to work with Tyla ;
” Open source report
2 Aug 2019 Carol Anne JENNINGS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 4 Failure to act on tissue viability referrals when referral information is incomplete View source Inadequate wound assessment and record keeping View source Insufficient Tissue Viability Nurse capacity to deal with referrals View source Failure to chase up tissue viability referrals View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Carol Anne JENNINGS · 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
Carol Anne Jennings had multiple comorbidities and was admitted to hospital on 10 January 2019. She developed infected leg ulcers, deteriorated, began end-of-life care on 25 January, and died on 31 January 2019; the inquest recorded septicaemia, infected leg ulcers and hospital-acquired pneumonia as the medical causes of death. Concerns included the handling and follow-up of a Tissue Viability Nurse referral and inadequate wound record keeping.
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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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to act on tissue viability referrals when referral information is incomplete
Wider context from the report “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented.
” 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; that does not assign responsibility.
PFD Monitor interpretation Inadequate wound assessment and record keeping
Wider context from the report “2. The evidence revealed a lack of and/or inadequate record keeping . Mrs Jennings was admitted to hospital on 10 January 2019 and there is no detailed record describing the wound until 21 January 2019 and no measurement of the wound until 23 January 2019 . There are no photographs of the wound. A wound assessment form was not completed. At the resumed inquest no steps had been taken to ensure full and proper record keeping .
” 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; that does not assign responsibility.
PFD Monitor interpretation Insufficient Tissue Viability Nurse capacity to deal with referrals
Wider context from the report “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all . At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to chase up tissue viability referrals
Wider context from the report “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward . A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented.
” Open source report
18 Mar 2019 Peter David KNIGHT · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Delays in completing the policy for transferring oxygen-dependent patients View source Failure to commence a trial of new patient-transfer documentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter David KNIGHT · 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
Peter David Knight, who had idiopathic pulmonary fibrosis and was dependent on oxygen, was not connected to portable cylinder oxygen during transfer to a ward and became hypoxic before dying later that evening. The report raised concern about delays in completing and trialling a revised policy for transferring oxygen-dependent 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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Delays in completing the policy for transferring oxygen-dependent patients
Wider context from the report “At the inquest I was satisfied that the Trust took the concerns raised seriously and was in the process of reviewing its Policy with regard to the transfer of patients, particularly those who are oxygen dependant . It was anticipated the Policy would be completed by the end of February 2019. In the circumstances, I wrote to the Trust asking them to write to me by 15 March 2019 with full details of the Policy. Not having heard from the Trust, my Officer contacted the Trust today. A response has been received indicating that new documentation has now been generated but a trial into its use has not yet commenced. Although it is stated that a trial is due to be started within the week and that if effective, implementation will be ratified by end of April, I am concerned that the inquest concluded in January 2019 and the Policy was not completed in the timescale indicated and agreed at the inquest and its trial has not yet commenced.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to commence a trial of new patient-transfer documentation
Wider context from the report “At the inquest I was satisfied that the Trust took the concerns raised seriously and was in the process of reviewing its Policy with regard to the transfer of patients, particularly those who are oxygen dependant. It was anticipated the Policy would be completed by the end of February 2019. In the circumstances, I wrote to the Trust asking them to write to me by 15 March 2019 with full details of the Policy. Not having heard from the Trust, my Officer contacted the Trust today. A response has been received indicating that new documentation has now been generated but a trial into its use has not yet commenced . Although it is stated that a trial is due to be started within the week and that if effective, implementation will be ratified by end of April, I am concerned that the inquest concluded in January 2019 and the Policy was not completed in the timescale indicated and agreed at the inquest and its trial has not yet commenced .
” Open source report
6 Feb 2019 RUTH PATRICIA WHITMORE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to ensure staff designated as in charge understand their responsibilities View source Failure to ensure staff designated as in charge are competent for that role View source Failure to conduct robust and thorough incident investigations View source Failure to ensure support is in place for staff designated as in charge View source Failure to assure the adequacy and thoroughness of incident investigations 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
RUTH PATRICIA WHITMORE · 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
Ruth Patricia Whitmore, who had multiple comorbidities, sustained a large haematoma when her leg became caught in a bed rail during hospital care on 7 January 2018. Her condition deteriorated after community care and readmission, and she died on 13 April 2018; concerns included inadequate handover of responsibility and an initial investigation that was not robust or sufficiently thorough.
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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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff designated as in charge understand their responsibilities
Wider context from the report “(1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed to be in charge to tell them of this , without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff designated as in charge are competent for that role
Wider context from the report “(1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed to be in charge to tell them of this, without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct robust and thorough incident investigations
Wider context from the report “(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient. No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events.
It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure support is in place for staff designated as in charge
Wider context from the report “(1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed to be in charge to tell them of this, without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to assure the adequacy and thoroughness of incident investigations
Wider context from the report “(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient. No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events.
It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough.
” Open source report
21 Dec 2018 William Clifford ATHERTON · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Failure to recognise and act on warning signs of bowel obstruction View source Failure to carry out nursing observations while patients await discharge View source Incorrect completion of early warning score documentation View source Failure to escalate treatment when early warning scores require it View source Failure to recognise worsening condition from blood results View source Failure to provide medical review after ward rounds View source Inconsistent completion and scoring of early warning scores across departments View source See 4 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
William Clifford ATHERTON · 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 Clifford Atherton was admitted to hospital on 29 May 2017 with abdominal symptoms, urinary retention and poor kidney function. He was discharged despite worsening renal function and deterioration, and died after returning severely unwell with vomiting of faecal matter, a distended abdomen and severe pain; the reported cause was bowel obstruction. Concerns included the lack of senior medical review and nursing observations, failure to recognise warning signs and worsening blood results, and inconsistent early warning score documentation and escalation.
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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and act on warning signs of bowel obstruction
Wider context from the report “That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon . His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out nursing observations while patients await discharge
Wider context from the report “That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it.
” 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; that does not assign responsibility.
PFD Monitor interpretation Incorrect completion of early warning score documentation
Wider context from the report “That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate treatment when early warning scores require it
Wider context from the report “That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place . That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise worsening condition from blood results
Wider context from the report “That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results . That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to provide medical review after ward rounds
Wider context from the report “That no medical review of Mr Atherton took place after the ward round on 30th . That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it.
” 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; that does not assign responsibility.
PFD Monitor interpretation Inconsistent completion and scoring of early warning scores across departments
Wider context from the report “That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it.
” Open source report
16 Mar 2017 James Charles MALLETT · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 11 Absence of patient care plans View source Delays and failures in escalating serious patient deterioration to senior medical staff View source Insufficient nursing knowledge and experience for patients following serious injury View source Failure to carry out regular and timely neurological observations View source Absence of falls planning and prevention View source Failure of hospital systems to identify nurses lacking the competence or training for basic observations View source Failure to follow hospital protocol for neurological observation frequency View source Failure to make contemporaneous nursing records View source Failure of nursing staff to carry out accurate neurological observations View source Failure to maintain nursing observation of high-risk patients View source Failure to use available movement-alert and fall-prevention equipment View source See 8 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
James Charles MALLETT · 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
James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.
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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Absence of patient care plans
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward . There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delays and failures in escalating serious patient deterioration to senior medical staff
Wider context from the report “(2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient . The nursing staff, who were described by Sr Snowden as a "junior workforce" did not seem to understand the seriousness of the injury and did not seek senior help from the night team . The nursing staff did not carry out regular and/or timely neurological observations.
” 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; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing knowledge and experience for patients following serious injury
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett . There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out regular and timely neurological observations
Wider context from the report “(2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient. The nursing staff, who were described by Sr Snowden as a "junior workforce" did not seem to understand the seriousness of the injury and did not seek senior help from the night team. The nursing staff did not carry out regular and/or timely neurological observations .
” 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; that does not assign responsibility.
PFD Monitor interpretation Absence of falls planning and prevention
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention , there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital systems to identify nurses lacking the competence or training for basic observations
Wider context from the report “5) There do not appear to be systems in place at the hospital which are sufficient to recognise when nurses are so inexperienced and/or lacking in training that they cannot undertake basic observations on a patient following an injury of this kind.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to follow hospital protocol for neurological observation frequency
Wider context from the report “(3) The nursing staff made no contemporaneous notes for a period of five hours on the system so there was little information about the timings of their actions. The doctor did not arrive until over two hours later but did order an urgent CT scan, however when he had the results he then ordered neurological observations be done every two hours which is not as per hospital protocol .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to make contemporaneous nursing records
Wider context from the report “(3) The nursing staff made no contemporaneous notes for a period of five hours on the system so there was little information about the timings of their actions . The doctor did not arrive until over two hours later but did order an urgent CT scan, however when he had the results he then ordered neurological observations be done every two hours which is not as per hospital protocol.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to carry out accurate neurological observations
Wider context from the report “[1] It became clear during evidence that the nursing staff on duty on 13 November 2016 were not able to understand and carry out proper neurological observations . This became evident when on one set of observations the nurse assessed Mr Mallett's Glasgow Coma scale (GCS) as 3 (lowest score possible) and yet still had equal power in all four limbs which would not have been possible to assess. Some of the observations contradicted each other with no one nurse assessing the patient as 6 on the GCS.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nursing observation of high-risk patients
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement. The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to use available movement-alert and fall-prevention equipment
Wider context from the report “4) The nursing staff on duty do not appear to have the requisite knowledge or experience to nurse patients such as Mr Mallett. There was no falls planning or prevention, there was no care plan in place on this ward. There was no use of items such as sensor.crash pads, or equipment which can be attached to patients to warn of movement . The nurse who was stationed in that 6 bed bay because Mr Mallett and others in there were at particular risk, left her post and then Mr Mallett was found on the floor.
” Open source report
24 Dec 2015 CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 5 Failure to risk assess and make safe the physical environment before patient access View source Failure of staff to understand required patient-observation practices View source Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E View source Failure to record information gained from patient observations correctly View source Failure of escort policy and planning to address inter-service patient transfers 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
CHRISTOPHER JONATHAN HIGGINS · 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
Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.
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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to risk assess and make safe the physical environment before patient access
Wider context from the report “(3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette . It is understood that since Mr Higgins' death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death . Other ways of making the area safe are still under consideration .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand required patient-observation practices
Wider context from the report “(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient . This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E
Wider context from the report “(4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E , as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area , having already self-harmed and shown signs of paranoia.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to record information gained from patient observations correctly
Wider context from the report “(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure of escort policy and planning to address inter-service patient transfers
Wider context from the report “(2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police . In particular, Mr Higgins who had been acting in an unpredictable, and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him . The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins;
” Open source report
24 Dec 2014 DAVID JOHN MOUNTAIN · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to fully investigate recognised risks following pacemaker insertion View source Delayed availability of echocardiogram results View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
DAVID JOHN MOUNTAIN · 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
David John Mountain was found to have a slow heart rate, underwent permanent pacemaker insertion on 20 June 2014, and developed chest pain on the way home after discharge. He deteriorated and died on 23 June 2014; the report raised concern that bleeding and vascular damage were not fully investigated promptly and that echocardiogram results showing a mild to moderate bleed around the heart were unavailable until after his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Failure to fully investigate recognised risks following pacemaker insertion
Wider context from the report “Despite having had a permanent pacemaker inserted on 20 June 2014 and Mr Mountain developing chest pain on 21 June 2014, the risks recognised on the consent form, including risk of bleeding and vascular damage were not fully investigated and an Echocardiogram was not performed until afternoon of 23 June 2014 . The results, which showed a mild to moderate bleed around the heart, were not available until after Mr Mountain’s death.
” 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; that does not assign responsibility.
PFD Monitor interpretation Delayed availability of echocardiogram results
Wider context from the report “Despite having had a permanent pacemaker inserted on 20 June 2014 and Mr Mountain developing chest pain on 21 June 2014, the risks recognised on the consent form, including risk of bleeding and vascular damage were not fully investigated and an Echocardiogram was not performed until afternoon of 23 June 2014. The results, which showed a mild to moderate bleed around the heart, were not available until after Mr Mountain’s death.
” Open source report
11 Sep 2014 ANN MARY WELLS · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Unsafe positioning of light switches beside beds View source Lack of risk assessment for room placement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
ANN MARY WELLS · 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
Ann Mary Wells, a resident of Julian Hospital, fell in her room on 21 November 2013 while attempting to access the wall beside her bed, sustaining a fractured pelvis and later dying on 28 December 2013. The concerns identified were the positioning of the light switch beside her bed and the absence of a risk assessment for placing her in that room.
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 Queen Elizabeth Hospital, King's Lynn; that does not assign responsibility.
PFD Monitor interpretation Unsafe positioning of light switches beside beds
Wider context from the report “(1) A light switch was positioned on the wall beside Mrs Wells’ bed (see attached a photograph). Mrs Wells was 77 years of age, frail with scoliosis, osteoarthritis and a history of falls. In light of the fact that she had been diagnosed with dementia and had a sitting position in bed, it could have been reasonably foreseen that she might attempt to reach for the light switch . Her fall resulted in a fractured pelvis and subsequent complications.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for room placement
Wider context from the report “(2) No risk assessment had been carried out with regard to Mrs Wells being placed in this particular room .
” 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