6 Dec 2024 Michael John THOMPSON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 3 Failure to record key aspects of surgery View source Failure to learn from deaths View source Failure of investigations to address relevant clinical issues 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
Michael John THOMPSON · 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
Michael John THOMPSON underwent hindquarter amputation for chondrosarcoma and later collapsed after vomiting; post-mortem examination found an internal hernia through a peritoneal defect, leading to aspiration. Concerns were raised that the peritoneal defect and repair were not recorded in the operation note, and that the Trust’s investigation did not address this issue or adequately support learning from the death.
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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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record key aspects of surgery
Wider context from the report “1. During the surgery on 08/04/24 a defect was made in the peritoneum whilst dissecting this away from the tumour and the defect was repaired with sutures. The operation note did not record this complication and other staff were unaware of it . This raises a concern about the adequacy of record keeping in the Trust as a key aspect of the patient’s surgery was not recorded .
” 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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from deaths
Wider context from the report “2. Under the PSIRF process a PSII investigation was undertaken however this only dealt with resuscitation efforts and did not address the peritoneal defect and its repair which was the root cause of Mr Thompson’s death. This raises a concern about the adequacy of investigations being undertaken by the Trust and their ability to learn from deaths .
” 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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to address relevant clinical issues
Wider context from the report “2. Under the PSIRF process a PSII investigation was undertaken however this only dealt with resuscitation efforts and did not address the peritoneal defect and its repair which was the root cause of Mr Thompson’s death. This raises a concern about the adequacy of investigations being undertaken by the Trust and their ability to learn from deaths.
” Open source report
1 Dec 2015 Bryan Arnold CATANACH · Prevention of Future Deaths report Worcestershire
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Concerns raised 5 Failure of communication during inter-hospital transfers View source Unsafe CT scanning of patients in traction without releasing traction weights View source Failure to provide adequate protection and supervision for patients with unstable neck fractures View source Unavailability and poor identification of required traction equipment View source Failure to carry out Consultants' instructions and communicate when they cannot be carried out View source See 2 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
Bryan Arnold CATANACH · 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
Bryan Arnold Catanach sustained a fractured odontoid peg and cervical injury after a fall, and died in hospital on 8 February 2015 after his condition deteriorated. The report identified concerns about communication and delays in transfer and senior review, inpatient falls prevention, and the availability and use of appropriate traction equipment.
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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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication during inter-hospital transfers
Wider context from the report “(1) There were a number of difficulties with communication between the various clinicians and hospital Trusts. This led to a delay in the initial transfer of the patient, a delay in his subsequent review by a senior clinician and confusion on the part of nursing staff as to whether Mr Catanach was to be kept nil by mouth and/or given his prescribed medication. While it is a matter for you it may be that the Trust will want to reflect on whether there is a need to standardize its inter-hospital transfer process so that nursing as well as medical staff are fully engaged with the process.
” 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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe CT scanning of patients in traction without releasing traction weights
Wider context from the report “(5) I heard evidence at the inquest that there was no safe and effective way of a patient in traction to have a CT scan without the traction weights being released . While I was told that only a small number of patients will require both traction and a CT scan it may be that the Trust considers that this is something that should be considered further.
” 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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate protection and supervision for patients with unstable neck fractures
Wider context from the report “(3) Almost immediately after his admission into the Royal Orthopaedic Hospital with a fracture dislocation of the neck Mr Catanach fell out of this hospital bed. This was probably due to him attempting to get up to use the toilet. Mr Catanach's fall took place even though two members of the nursing staff had expressly told Mr Catanach not to move and provided him with a buzzer through which to seek nursing assistance if required.
Mr Newton-Ede, having reflected upon the matter, felt that similar patients in the future may be better protected by a transfer into the HDU rather than a standard ward .
The Trust may wish to reflect on whether this is a realistic alternative. If implemented this change will need to be audited to see whether there are sufficient resources available within HDU. If not, an alternative course of action considered at inquest was that for the small number of patients admitted with an unstable neck fracture it may be appropriate immediately to arrange one to one nursing care pending operative fixation of the fracture .
” 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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability and poor identification of required traction equipment
Wider context from the report “(4) Traction equipment - Mr Catanach had a halo crown fitted in an attempt to reduce the fracture he had suffered. At the time this was undertaken Mr Newton-Ede did not have available to him the required Balkan beam traction equipment and a Swan neck device was used instead. This was plainly inferior and indeed a pulley wheel was found to have jammed the following morning rendering the traction ineffective and causing the fracture to slip back.
It took 48 hours for the correct traction equipment to be found . It was likely that the equipment was available the whole time but that either staff did not know where it was kept, or those sent to find it did not know for what they were looking .
It is a matter for the Trust to reflect on how to remedy this situation. It would seem that training of relevant staff would be a sensible first step.
” 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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out Consultants' instructions and communicate when they cannot be carried out
Wider context from the report “(2) Additional concerns over communication were identified with clear instructions from Consultants not being carried out . In particular, an instruction to have the deceased transferred to the Royal Orthopaedic Hospital before 08:00 hours on 5th February 2015 was cancelled (on the wrong basis that no spare bed was available) and the cancellation of the transfer was not communicated back to the consultant . Additionally, an instruction by the consultant to a junior doctor directing his Registrar to review Mr Catanach was only partly acted upon . This led to a delay in the senior review of Mr Catanach which, when it took place 9 hours after admission, recognised a deterioration in his condition.
It is a matter for the Trust to reflect on how best to ensure that Consultants' instructions are fully acted upon and where, for whatever reason, that proves impossible, the situation is communicated back to the Consultant concerned.
” 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 Enhance the internal equipment register to identify traction equipment held elsewhere.
Verbatim wording from the response “Traction Equipment
Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation.” Source location Bryan-Catanach-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 Conduct CT examinations involving traction equipment under a refreshed standard operating policy.
Verbatim wording from the response “CT Scan under Traction
The final point of concern raised with your Regulation 28 letter related to the technical inability of the Trust to undertake a CT diagnostic scan with a patient’s traction weights in-situ. Due to the nature of equipment this is an issue that would exist at every site operating a CT scanner. Current technology does not allow for such examinations with weight equipment. Whilst I am unable to assure you as to any regularised mitigation for such examination; each case being considered on its” Source location Bryan-Catanach-Response
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 pictorial traction-equipment guidance and respond to related staff training and orientation needs.
Verbatim wording from the response “Traction Equipment
Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation.” Source location Bryan-Catanach-Response
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 on-site spinal equipment and establish a central store for traction apparatus.
Verbatim wording from the response “Traction Equipment
Your own investigations correctly identified the challenges that had occurred in both identifying and securing the timely use of appropriate traction equipment. Since this incident, the Trust has expanded the range of spinal equipment held on site in the Trust and has created a central store for all traction apparatus. The Trust has also enhanced its internal register of equipment and in so doing, highlighted other sites around the hospital and beyond that hold similar equipment beyond that within our store. Finally, an enhanced pictorial training folder has been developed to allow staff, who may infrequently request spinal equipment, to recognise all of its contingent parts once delivered. The spinal services team have also responded to the issues around equipment training and orientation.” Source location Bryan-Catanach-Response
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 and simplify proforma-based documentation for nursing and medical multidisciplinary teams.
Verbatim wording from the response “Additional concerns over communications
Following apparent communication and messaging issues identified in this case, Mr Newton-Ede has led a piece of work to refresh and simplify proforma based documentation. Both nursing and medical members of the multi-disciplinary team have been involved in delivering this change. There is a clearly held view from clinical colleagues that these developments have already been seen to be positively impacting on improved communication flow and necessary escalation.” Source location Bryan-Catanach-Response
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 and reaffirm emergency patient receiving and first-line management processes, including a ring-fenced spinal emergency bed and HDU escalation route.
Verbatim wording from the response “Difficulties with communication between various clinicians and hospital Trusts.
The Trust has looked to progress improved communication routes and systems in preparedness for the receipt of an emergency/unscheduled patient. As was explained within your Court, ROH acts as a regional centre for a range of spinal emergencies. Broadly speaking two to three spinal emergencies are transferred into the ROH each week for emergency elective care. Following this court hearing, the Trust has refreshed and reaffirmed its receiving and first line management processes in preparedness for the arrival of such patients. The Trust robustly pursues the ring fencing of a single spinal emergency bed and this provides a guaranteed safe point of arrival for any inbound emergency patient.” Source location Bryan-Catanach-Response
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 The Trust will not introduce a HDU-only arrival model because the strengthened spinal emergency bed and HDU escalation process is considered sufficient.
Verbatim wording from the response “Future patients protected from fall by transfer to HDU at point of arrival
As noted earlier within my letter rather than moving forward with Mr Newton-Ede’s personal suggestion regarding potential direct admission to HDU, the Trust considered it both more clinically appropriate and an easier structure to maintain a position of standardised practice and quality to strengthen and reaffirm the use of the spinal emergency bed or HDU escalation bed. Working with a wider group of clinical colleagues the Trust has therefore consciously decided not to introduce a HDU only arrival model. I would however note no new concerns have been identified since the strengthening of this process.” Source location Bryan-Catanach-Response
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 Current technology prevents CT scanning with traction weights in situ, so regularised mitigation cannot be assured.
Verbatim wording from the response “CT Scan under Traction
The final point of concern raised with your Regulation 28 letter related to the technical inability of the Trust to undertake a CT diagnostic scan with a patient’s traction weights in-situ. Due to the nature of equipment this is an issue that would exist at every site operating a CT scanner. Current technology does not allow for such examinations with weight equipment. Whilst I am unable to assure you as to any regularised mitigation for such examination; each case being considered on its” Source location Bryan-Catanach-Response
Open published response
9 Mar 2015 Leonardus Adrianus VRIES · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to audit and track the use of non-controlled medication 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
Leonardus Adrianus VRIES · 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
Leonardus Adrianus Vries apparently obtained medical-grade drugs from his workplace and injected himself at his family home, where he died; the inquest concluded that his death was accidental, involving respiratory depression and combined toxicity of bupivacaine, morphine and diamorphine. The principal concern was inadequate documentation and auditing of medication, particularly non-controlled medication, at the Royal Orthopaedic Hospital, creating an opportunity for abuse or theft.
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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 Royal Orthopaedic Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to audit and track the use of non-controlled medication
Wider context from the report “Whilst the control of controlled medications appears to have been addressed by way of training and increased scrutiny and audit procedures ████████ confirms that there is still no audit of non-controlled medication . Specifically he said that when stocks of non-controlled medication are delivered to wards and departments there is no check as to who uses the medication or for what purpose .
It appears to me therefore that there is a significant opportunity for the abuse or theft of non-controlled medication.
” 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 Continue monitoring drug-usage trends across all Trust areas to identify potential diversion risks.
Verbatim wording from the response “this risk the Chief Pharmacist will continue to monitor trends in usage of drugs in all areas of the Trust.” Source location 2015-0088-Response-by-Royal-Orthopaedic-Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct unannounced spot audits of theatre drug storage and documentation.
Verbatim wording from the response “Since February 2015 a weekly audit of Controlled Drug documentation is carried out by theatres management. Since March 2015 the Chief Pharmacist has carried out unannounced spot audits (normally two per week) on drug storage (all drugs) and documentation in theatres. No concerns regarding diversion or theft of medicines have been identified through this audit cycle and all documentation is correctly completed.” Source location 2015-0088-Response-by-Royal-Orthopaedic-Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review controls governing controlled and non-controlled medicines.
Verbatim wording from the response “In summary, the controls around both Controlled Drugs and “non-controlled” drugs have been reviewed. Standard Operating Procedures for Controlled Drugs have been updated and audits conducted by the Chief Pharmacist have shown compliance with the standards required. Controls around “non-controlled” medicines have been reviewed and found to be compliant with or indeed exceed all national guidance. There remains a small risk that these medicines could be diverted as is the case in all hospitals. This is mitigated by the professional responsibilities of all staff regarding the use of medicines. To further mitigate” Source location 2015-0088-Response-by-Royal-Orthopaedic-Hospital
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing controls and professional responsibilities are considered sufficient to mitigate the small residual risk of medicine diversion.
Verbatim wording from the response “In summary, the controls around both Controlled Drugs and “non-controlled” drugs have been reviewed. Standard Operating Procedures for Controlled Drugs have been updated and audits conducted by the Chief Pharmacist have shown compliance with the standards required. Controls around “non-controlled” medicines have been reviewed and found to be compliant with or indeed exceed all national guidance. There remains a small risk that these medicines could be diverted as is the case in all hospitals. This is mitigated by the professional responsibilities of all staff regarding the use of medicines. To further mitigate” Source location 2015-0088-Response-by-Royal-Orthopaedic-Hospital
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations