Concerns raised 6 Inconsistent coordination between specialist and non-specialist hospitals View source Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred View source Lack of consistent understanding of appropriate specialist contacts and engagement timing View source Failure to clearly define patient information for specialist renal hospitals View source Lack of consistent awareness of and access to kidney transplant care guidelines and protocols View source Lack of consistent understanding of responsibility for initiating patient transfers 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
John Frederick Doyle · 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
John Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.
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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Inconsistent coordination between specialist and non-specialist hospitals
Wider context from the report “Concern 6: Coordination Between Specialist and Non-Specialist Hospitals
There may be variation in how specialist renal hospitals engage with non-specialist hospitals that rely on their expertise , impacting collaborative efforts in patient care. Currently, there is no clear guidance on how specialist and non-specialist teams should work together effectively to ensure consistent, high-quality care for these 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred
Wider context from the report “Concern 5: Decision-Making for Patient Location
Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ , potentially affecting consistency in care approaches.
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of appropriate specialist contacts and engagement timing
Wider context from the report “Concern 1: Contacting Specialist Centres
Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal hospitals .
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly define patient information for specialist renal hospitals
Wider context from the report “Concern 2: Information Sharing with Specialist Centres
The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined .
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent awareness of and access to kidney transplant care guidelines and protocols
Wider context from the report “Concern 3: Accessibility to Renal Care Guidelines
Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients . This could lead to a misunderstanding of the significance and urgency of the actions recommended by specialist renal hospitals.
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of responsibility for initiating patient transfers
Wider context from the report “Concern 4: Transfer Responsibility
There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers .
” Open source report
Concerns raised 3 Lack of national guidelines for central venous catheter removal View source Electronic clinical notes permitting alteration of author times View source Failure to provide constant visual observation after central venous catheter removal 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
John Waite · 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
John Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.
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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for central venous catheter removal
Wider context from the report “iv. There are no national guidelines in relation to the removal of central venous catheters, particularly temporary central venous catheters for haemodialysis. The evidence at the Inquest confirmed that the Secretary of State, the Renal Association, the British Renal Society and the Intensive Care Society would be appropriate organisations to consider the issue of a national policy, protocol and guidance relating to the removal of central venous catheters.
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Electronic clinical notes permitting alteration of author times
Wider context from the report “4. I request the Salford Royal Hospital to review their information technology systems to prevent the changing of author times of notes on the electronic system because the author times can represent an important time in relation to the treatment and care given to a patient and may be relied upon by healthcare professionals who give treatment and care after the time of a note . The review should also consider whether both the time of the author of the report and the time that appropriate action is taken should be included in the note so that healthcare professionals would have to record both times when completing notes to ensure that there is unequivocal clarity as to the time the action was taken and the time the note was authored .
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Failure to provide constant visual observation after central venous catheter removal
Wider context from the report “ii. The Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters in existence within the Salford Royal NHS Foundation Trust at the time of the death included the fact that pressure should be applied for approximately 5 minutes after removal of the catheter or until bleeding has stopped and a patient should lie flat or supine for 30 minutes after removal of the catheter (if medically safe to do so). The guidelines did not state that a patient requires visual observation for a period of time following the removal of the catheter.
iii. Following the death of the Deceased the Salford Royal NHS Foundation Trust has taken action to address the concerns in relation to the Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters, together with the ongoing training of staff who undertake the removal of catheters and the management of rare complications.
A quick reference guide has been issued to staff by the Hospital in relation to the removal of catheters at the Hospital. The guide requires the patient to remain supine for 30 minutes post removal of the catheter with further bed rest for 2 hours post removal and a visual inspection of the dressing every 5 minutes during the period of 1 hour following the removal. However, the guide does not require constant visual observation for a period of time following the removal of the catheter.
The evidence at the Inquest was that, if there is haemorrhage following the removal of a catheter, blood loss could amount to 200mls every minute so that in the period of 5 minutes between each 5-minute inspection of the dressing, advised by the guidance, one litre of blood could be lost, which could lead to death.
The evidence at the Inquest was that a period of constant visual observation is required for a period of up to one hour following the removal of a catheter to reduce the risk of blood loss rather than simply monitoring by inspecting the dressing every 5 minutes for that period of time.
” Open source report
28 Jul 2017 Pamela Keech · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 3 Failure to include the risk of fatal fistula/graft-site haemorrhage in training requirements View source Lack of national guidance on predicting and managing graft/fistula haemorrhage View source Failure to escalate fistula/graft-site bleeds for renal or surgical review 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
Pamela Keech · 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
Pamela Keech, who had end-stage renal failure and received haemodialysis through a leg graft, experienced repeated bleeds from the graft site before being found unconscious with substantial blood loss on 7 July 2015. She died from a catastrophic haemorrhage from the graft site. Concerns included the lack of national guidance and training on predicting and managing fatal graft or fistula haemorrhage, and whether patients with such bleeds are escalated for renal or surgical review.
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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Failure to include the risk of fatal fistula/graft-site haemorrhage in training requirements
Wider context from the report “(2) I heard evidence that the risk of developing a fatal haemorrhage from a fistula/graft site is not part of the training requirement for A&E doctors/paramedic carers
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance on predicting and managing graft/fistula haemorrhage
Wider context from the report “(1) I heard evidence that there is no National Guidance on how to predict and manage a fatal graft/fistula haemorrhage
” 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 Renal Association; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate fistula/graft-site bleeds for renal or surgical review
Wider context from the report “(3) I am concerned that other patients presenting with bleeds from fistula/graft sites might not be escalated for renal/surgical review before a fatal bleed presents .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations