Concerns raised 9 Failure to record lying and standing blood pressure on admission View source Failure to complete a Datix report following an inpatient fall View source Failure to record an inpatient fall on the discharge letter View source Failure to complete a falls assessment within six hours of transfer View source Failure to time the request for medical review View source Failure to put falls prevention measures in place following the first falls assessment View source Failure to communicate CT findings and intracranial bleeding to the patient's family View source Delays in medical review following an inpatient fall View source Failure to document falls prevention measures at the first falls assessment View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hazel Gambles · 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
Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.
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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record lying and standing blood pressure on admission
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a Datix report following an inpatient fall
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record an inpatient fall on the discharge letter
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a falls assessment within six hours of transfer
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward , by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to time the request for medical review
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to put falls prevention measures in place following the first falls assessment
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate CT findings and intracranial bleeding to the patient's family
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical review following an inpatient fall
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document falls prevention measures at the first falls assessment
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” 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 Review national inpatient-falls audit data and share findings and improvement actions for qualifying injured inpatients.
Verbatim wording from the response “We have reviewed the national audit of inpatient falls (NAIF) data which demonstrates that the Trust is routinely completing accurate assessments for patients who fell in hospital and sustained an injury. The data confirm that the medical review for these patients is now taking place within 30 minutes.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand resident-doctor induction content on responding to deteriorating patients and prioritise overnight reviews for clinically deteriorating patients.
Verbatim wording from the response “The induction of resident doctors includes sessions on resuscitation and more details are now included on the response to a deteriorating patient. The clinical teams (resident doctors and the acute response team) will prioritise deteriorating patients who need to be reviewed overnight (elevated NEWS2 scores or abnormal neurological signs). The Trust is moving towards employing two medical registrars on call overnight.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standardised safety-huddle log with falls-prevention prompts and measure compliance and effectiveness during implementation.
Verbatim wording from the response “The Trust has also now implemented a standardised safety huddle log. Please find this attached at Exhibit 2. Within this, there is a section in relation to falls and specific prompts to ask:” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a real-time Meditech dashboard showing outstanding and completed risk assessments for nurse-in-charge oversight.
Verbatim wording from the response “Since Mrs Gambles’ admission, we have now implemented an overview dashboard within the Meditech system (the Trust’s medical records system). This is an electronic dashboard and shows in real time which risk assessments have been completed and which are still outstanding for each patient. The use of this board throughout the nurse in charge shift means that they now direct staff when assessments haven't been completed and it is much clearer to identify when risk assessments are overdue or have not taken place.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include falls prevention within the Exemplar Accreditation programme and continuously measure ward performance.
Verbatim wording from the response “within the Trust’s Exemplar Accreditation programme which is designed around the CQC key lines of enquiry to ensure the quality of care delivered to patients within a ward environment. Each area is measured continuously.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move towards employing two medical registrars on call overnight.
Verbatim wording from the response “The induction of resident doctors includes sessions on resuscitation and more details are now included on the response to a deteriorating patient. The clinical teams (resident doctors and the acute response team) will prioritise deteriorating patients who need to be reviewed overnight (elevated NEWS2 scores or abnormal neurological signs). The Trust is moving towards employing two medical registrars on call overnight.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign a falls champion to each ward to educate staff and check completion of required lying and standing blood pressures.
Verbatim wording from the response “Lying and standing blood pressure is part of the falls risk assessment and should be completed each time the risk assessment is re-done. To mitigate the risk of this being missed, there is now a falls champion on each ward and part of their responsibility is to educate the team around the importance of risk assessments. The falls champions are also tasked with completing checks to ensure that lying and standing blood pressures have been completed for those who need it.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add a mandatory discharge-summary question covering inpatient falls and other safety incidents, and monitor it during implementation.
Verbatim wording from the response “As a Trust, we have now added a mandatory question to the inpatient discharge summary to ask whether the patient has had a fall, VTE (Venous Thromboembolism), pressure ulcer or any other incident. This will prompt clinicians to consider whether any of these have occurred and if so, it will be clear on the discharge summary. This will be monitored throughout the implementation stage, to ensure effectiveness.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Refresh risk assessments on transfer to a new ward so staff complete them from the patient’s current presentation.
Verbatim wording from the response “Risk assessments also now refresh on transfer to a new ward so that there is less risk of a staff member copying the previous ward assessments. On transfer to a new ward, the staff member will be presented with a completely blank risk assessment which will prompt them to fill in the assessment from scratch based on the patient’s current presentation.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add incident-reporting prompts to the nurse-in-charge checklist to identify and escalate outstanding Datix reports.
Verbatim wording from the response “The nurse in charge checklist now asks the question “has there been any incidents? Have these been recorded via Datix?”. This gives an opportunity for the senior team to consider whether there are any outstanding incident reports and if so, ensure that these are reported at the earliest opportunity.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop board rounds before medical ward rounds and change consultant job plans to provide dedicated family-communication time.
Verbatim wording from the response “There are daily ward rounds on all medical wards and the Trust is working to ensure that “board rounds” take place prior to the ward round to ensure that all relevant information is captured and that all patients have a senior review on a daily basis. Some consultants already have time in their job plans for a consultant communication with families after the ward round, via telephone call. We are now changing job plans to ensure that all medical consultants have dedicated time to do this.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign a healthcare assistant on every shift to ensure required lying and standing blood pressures are completed.
Verbatim wording from the response “There is also now a healthcare assistant assigned on every shift and part of their role is to ensure that those patients who require a lying and standing blood pressure, have had this undertaken.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete Ward B4’s initial Exemplar Accreditation assessment, including handover and falls-assessment review, in October 2025.
Verbatim wording from the response “Ward B4 was initially set up as a winter pressures ward, but now has a substantive leadership team. As it is a new ward, it is in its baseline data gathering year and has not had an initial accreditation (using the Exemplar Accreditation Programme), however this will happen in October 2025 once there is a year’s worth of data. This will include handover and falls assessments and any non-compliance will lead to clear improvement actions.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit and commence a falls lead practitioner to drive Trust-wide falls-prevention improvements, audit clinical effectiveness and identify further quality-improvement work.
Verbatim wording from the response “In relation to falls, the Trust has also successfully recruited a falls lead practitioner. This practitioner is due to commence next month (September 2025). The falls lead will have a responsibility to drive improvements in the prevention and treatment of all falls within the Trust. Part of their role will be looking at clinical effectiveness and to look at anything which may fall outside of the falls audit. They will also be reviewing the national falls audit and considering where further improvements need to be made.” Source location Response from Rotherham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make falls-prevention documentation mandatory in risk assessments and audit compliance through Tendable.
Verbatim wording from the response “At the time of Mrs Gambles’ admission, the falls prevention measures part of the risk assessment was not a mandatory field and so there was a risk that this would be missed. Since Mrs Gambles’ death, this has now been changed to a mandatory field within the risk assessment. This means that nursing staff are unable to progress with documentation until they have completed the entry, and so it should be clear as to what falls prevention measures are required for each individual patient. Compliance with this is audited as part of the Tendable audit. The Tendable falls inspection overall outcome score from February 2025 to August 2025 shows that overall compliance has risen from 78% in February 2025 to 98% in August 2025.” Source location Response from Rotherham NHS Foundation Trust
Open published response
Concerns raised 2 Lack of communication between services for wound management View source Lack of automatic cardiology referral for in-patients with known cardiac failure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anne HAWKES · 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
Anne HAWKES was admitted to Rotherham Hospital after a fall and hip fracture, and later developed fluid overload associated with poorly managed cardiac failure. Her surgical wound broke down, with delayed tissue viability referral and an incohesive approach to wound management; she died on 15 July 2023 from multi-organ dysfunction due to an infected hip joint. The stated concerns were delayed cardiology referral and poor communication between surgery, cardiology and tissue viability services.
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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between services for wound management
Wider context from the report “(2) The lack of communication between services within the Trust (surgery, cardiology and tissue viability) led to a delayed and incohesive approach to the wound management .
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic cardiology referral for in-patients with known cardiac failure
Wider context from the report “(1) The delayed cardiology referral whilst Mrs Hawkes was on an orthopaedic ward led to sub-optimal management of her cardiac failure which in turn is implicated in her death. There is no procedure in place at the Trust for Clinicians to automatically refer in-patients with known cardiac failure to cardiology for expert management.
” 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 Communicate Tissue Viability Nurse referral criteria and raise awareness of the service across the Trust through collaborative Quality Governance work.
Verbatim wording from the response “On this occasion, it was recognised at the Inquest that the communication between orthopaedics, cardiology and our Tissue Viability Nurse services (TVN) could have been improved upon. However, this is not a reflection on the overall communication with the TVN service. Tracey Green, Tissue Viability Nurse, gave evidence that there exists a good working relationship between the surgical teams and the TVN service. It was acknowledged that TVN could have been contacted earlier when Mrs Hawkes was on Ward A1 when her wound started to break down and for this we reiterate our apology.” Source location Response from The Rotherham
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Automatic referral is not adopted because it would place disproportionate additional pressure on the service without benefiting patients.
Verbatim wording from the response “I acknowledge that you have highlighted there is no automatic referral for in-patients with known cardiac failure. It should be acknowledged that not all patients with known heart failure mandate a referral to the Heart Failure Service, unless there are signs of decompensation (including shortness of breath, decreasing oxygen saturations and tachycardia) and/or fluid overload (visible oedema and/or changes in body weight). We have carefully considered this and concluded that automatic referral would place a disproportionate amount of additional pressure on the service which ultimately would not prove beneficial for patients.” Source location Response from The Rotherham
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Not all inpatients with known heart failure require automatic referral; referral is indicated when decompensation or fluid overload signs occur.
Verbatim wording from the response “The aforementioned process is in addition to clinicians recognising other signs and symptoms of heart failure which also prompt referral to cardiology/heart failure service. Furthermore, orthopaedic inpatients are also reviewed by an orthogeriatrician during the Friday ward round where specialist input and guidance can be sought as to the medical management of the patient.” Source location Response from The Rotherham
Open published response
Concerns raised 8 Lack of effective communication between mental health professionals at differing levels View source Failure to identify changes in presentation and level of risk View source Failure to seek doctors' input when presentation or level of risk changes View source Lack of updated risk assessments after key events or significant deterioration in presentation View source Failure to manage patients under the care of departing staff View source Lack of effective communication between mental health professionals, patients and patients' families View source Difficulty in consultant psychiatrists accessing Home Treatment Team Services when needed View source Absence of an effective system to identify patients under the care of departing staff View source See 5 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 Atkinson · 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 Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team services.
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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication between mental health professionals at differing levels
Wider context from the report “(4) Lack of effective communication between mental health professionals at differing levels and also between those professionals and the patient and the patient’s family.
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify changes in presentation and level of risk
Wider context from the report “(2) Failure of the care co-ordinator to identify changes in presentation and level of risk and to seek a doctors input.
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek doctors' input when presentation or level of risk changes
Wider context from the report “(2) Failure of the care co-ordinator to identify changes in presentation and level of risk and to seek a doctors input .
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of updated risk assessments after key events or significant deterioration in presentation
Wider context from the report “(1) Lack of updated Risk Assessments when key events occurred or there was a significant deterioration in presentation .
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage patients under the care of departing staff
Wider context from the report “(3) Absence of an effective and robust system to identify and then manage patients under the care of departing staff (for example care co-ordinator).
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of effective communication between mental health professionals, patients and patients' families
Wider context from the report “(4) Lack of effective communication between mental health professionals at differing levels and also between those professionals and the patient and the patient’s family .
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulty in consultant psychiatrists accessing Home Treatment Team Services when needed
Wider context from the report “(5) Difficulty in consultant psychiatrists accessing Home Treatment Team Services when they considered a need (since a change in emphasis in interpreting the guidelines from the end of 2014).
” 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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an effective system to identify patients under the care of departing staff
Wider context from the report “(3) Absence of an effective and robust system to identify and then manage patients under the care of departing staff (for example care co-ordinator).
” Open source report
Concerns raised 1 Failure to adjust paracetamol dosage for extremely low body weight View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Hayley Christine Clark · 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
Hayley Christine Clark, aged 36, was admitted to Rotherham General Hospital with electrolyte imbalance and received an unadjusted standard adult dose of paracetamol despite her extremely low body weight. Her condition deteriorated and she died on 24 May 2015; the inquest recorded severe multifactorial malnutrition among the causes of death. The substantive concern was that staff failed to recognise the need to reduce the paracetamol dosage for her low body weight.
Read the report on judiciary.uk
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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 Rotherham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adjust paracetamol dosage for extremely low body weight
Wider context from the report “(1) There was a failure, on the part of the staff who prescribed and administered the Paracetamol to Ms Clark, to recognise the need to adjust the dosage (in evidence the required reduction was said to be 50%) to reflect Ms Clark’s extremely low body weight .
” 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 Audit documentation of patient weights in clinical, nursing, and prescription records and present the results to the Patient Safety Group.
Verbatim wording from the response “2.3 Review of documentation to ensure accurate recording of patients weight in the clinical records, nursing records and prescription charts” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop prescription-chart stickers to raise awareness of oral and intravenous paracetamol dose-reduction guidance.
Verbatim wording from the response “1.3 Development of stickers to be used on the Trust’s prescription charts to raise awareness and compliance with the dose reduction guidance of oral (and IV) paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide and record required staff training on paracetamol dose reduction, including training during induction.
Verbatim wording from the response “2.2 A record of all staff who require and have received appropriate training - on dosage reduction; will be collated to ensure all appropriate nursing and medical colleagues have received this in the required timescale” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop information for nursing and medical staff on adjusting paracetamol dosage for adult patients with extremely low body weight.
Verbatim wording from the response “2. Ensure all nursing and medical colleagues identify adult patients with extremely low body weight who may need adjustment in the dosage of oral paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Medicines Management Policy and develop local guidance, a standard operating procedure, or directive covering dose reduction for extremely low body weight.
Verbatim wording from the response “1. Ensure the Trust’s Medicines Management Policy includes the safe prescribing and administration of medication for patients with extremely low body weight.” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce and disseminate pharmacy and junior-medical-staff information on reducing oral paracetamol doses for patients under 50 kilograms or with relevant risk conditions.
Verbatim wording from the response “1.2 A pharmacy medications information leaflet to be produced on reducing the dose of oral paracetamol for patients who weigh less than 50kgs and/or with medical conditions which may require consideration of dose reduction – malnutrition/anorexia or high alcohol consumption all of which are known indications for considering a dose reduction of oral paracetamol” Source location 2016-0143-Response-by-The-Rotherham-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a learning event discussing the specific case as part of the September safety programme.
Verbatim wording from the response “2.5 A learning event to be held to discuss the details of this specific case” Source location 2016-0143-Response-by-The-Rotherham-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 Body weight alone is not considered a marker of increased risk of oral paracetamol toxicity, although associated conditions may warrant dose reduction.
Verbatim wording from the response “What timescale has been set and agreed?
As the British National Formulary (BNF) does not currently provide dosage reduction recommendations the Trust’s Chief Pharmacist has sought advice from the Medicines and Healthcare products Regulatory Agency (MHRA) who have recently reviewed the publication of a paper from Birmingham Trust; whilst body weight alone is not considered a marker for an increased risk of oral paracetamol toxicity, an adult weighing less than 50kgs is more likely to have conditions that predispose them to liver damage from the paracetamol. A dose reduction to 2-3g total daily dose may be warranted. The MHRA are not currently recommending a change to the licences of oral paracetamol products, or a change to the packaging of the paracetamol products for the public to buy.” Source location 2016-0143-Response-by-The-Rotherham-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