Concerns raised 2 Failure to ensure a formal referral to MHLT View source Failure to provide accurate information about MHLT availability 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
Alex Alfred ROBINSON · 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
Alex Alfred Robinson was admitted to Royal Shrewsbury Hospital on 8 September 2025 and was later found unresponsive at Church Lane, Little Wenlock, Telford, on 10 September 2025 after ligaturing himself; he was declared deceased at the scene. The principal concern was conflicting information about whether the Mental Health Liaison Team was available and whether a formal referral had been made, representing a possible lost opportunity for him to receive appropriate care, although this could not be known to have prevented 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure a formal referral to MHLT
Wider context from the report “That consultant has made a statement and in paragraph 12 sets out his plan including “arrange review by mental health liaison team (MHLT). Following discussion, MHLT provided advice and a leaflet to be given to the patient as they are available on site out of hours to review the patient physically”.
In a later statement (in paragraph 3) the consultant further states “I was not present at that moment when the resident doctor discussed with MHLT service, but she informed me that MHLT informed her they will not be available to see Mr Robinson at that time”.
Subsequent inquiry with MHLT stated clearly that Midlands Partnership Foundation Trust (MPFT) Mental Health Liaison Team at RSH is a 24/7 service, they had the usual night cover of cover of two staff on the 8/9 September 2025 and that no formal referral was ever received .
This conflicting information represents a lost opportunity for Alex to have received appropriate care from MPFT which may have prevented Alex from killing himself on the 10 September 2025, but this cannot be known.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about MHLT availability
Wider context from the report “That consultant has made a statement and in paragraph 12 sets out his plan including “arrange review by mental health liaison team (MHLT). Following discussion, MHLT provided advice and a leaflet to be given to the patient as they are available on site out of hours to review the patient physically”.
In a later statement (in paragraph 3) the consultant further states “I was not present at that moment when the resident doctor discussed with MHLT service, but she informed me that MHLT informed her they will not be available to see Mr Robinson at that time ”.
Subsequent inquiry with MHLT stated clearly that Midlands Partnership Foundation Trust (MPFT) Mental Health Liaison Team at RSH is a 24/7 service , they had the usual night cover of cover of two staff on the 8/9 September 2025 and that no formal referral was ever received.
This conflicting information represents a lost opportunity for Alex to have received appropriate care from MPFT which may have prevented Alex from killing himself on the 10 September 2025, but this cannot be known.
” Open source report
Concerns raised 4 Failure to establish routine practice of setting upper alarms on bedside oxygen meters View source Uncertainty over whether bedside oxygen meters can be set with an upper alarm View source Failure to reflect relevant written responses in consultant evidence View source Failure to set an upper alarm on bedside oxygen meters View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Elizabeth GRIMSLEY · 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 Elizabeth Grimsley was admitted to hospital after a fall at home and died there on 22 January 2025 following an infection during the last 24 to 48 hours of her life. Concerns included the apparent absence or use of an upper alarm setting on a bedside oxygen meter, inconsistencies in evidence about a response to her daughter, and uncertainty about whether an upper alarm could be set or was routinely used.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish routine practice of setting upper alarms on bedside oxygen meters
Wider context from the report “(3) It is not clear whether an upper alarm can be set and/or whether it is practice to do so .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty over whether bedside oxygen meters can be set with an upper alarm
Wider context from the report “(3) It is not clear whether an upper alarm can be set and/or whether it is practice to do so.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reflect relevant written responses in consultant evidence
Wider context from the report “(2) The evidence of a Consultant Respiratory Physician did not reflect the response from SaTH in a letter to the deceased daughter of the 30 May 2024 at page 10.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to set an upper alarm on bedside oxygen meters
Wider context from the report “(1) The apparent absence of or use of an upper alarm setting on a bedside oxygen meter . The evidence indicated that a lower scale alarm was set, but not an upper alarm which required manual observations and when a nurse or healthcare assistant was carrying out observations. The risk is that over-oxygenation could take place without medical attention being sought .
” Open source report
×
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 Upper oxygen alarms are not used because lower alarms with regular monitoring better address the greater risk of low oxygen levels.
Verbatim wording from the response “The upper alarm is not used as the greatest risk to the patient is low blood oxygen levels. Using the lower alarm in patients with severe lung disease to keep oxygen levels within the required tight range is extremely challenging, and will often require frequent adjustment by the nursing staff to keep the oxygen levels high enough. When considering the poor correlation between oxygen saturations and actual blood levels as well as the higher risk of low oxygen levels, the focus on the ward is the lower alarms with regular monitoring to minimise higher results.” Source location Response from Shewsbury and Telford Hospital Trust
Open published response
Concerns raised 4 Failure of document exchange and communication between gastroenterology and cardiology teams View source Failure to obtain cardiology review of discharge appropriateness View source Failure to arrange cardiology follow-up after discharge View source Failure to investigate what went wrong and why between treating and administration teams View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lynn SILCOCK · 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
Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of document exchange and communication between gastroenterology and cardiology teams
Wider context from the report “(3) There was no document exchange or communication between the gastroenterology team and the cardiology team meaning that Ms Silcock was then forgotten about.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain cardiology review of discharge appropriateness
Wider context from the report “(1) Discharged by the gastroenterology team without referral to the cardiology team as to whether the discharge was appropriate .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange cardiology follow-up after discharge
Wider context from the report “(2) Discharged without a cardiology clinic appointment or plan to be later referred .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate what went wrong and why between treating and administration teams
Wider context from the report “(4) No investigation by Shrewsbury and Telford NHS Trust as to what went wrong and why between the treating teams and their respective administration teams .
” Open source report
×
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 Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Verbatim wording from the response “A project feasibility request has already been raised to assess the need for a digital solution to support referral management. This is the route whereby needs are reviewed and scoped to develop proposals and business cases to place the need on the Trusts ‘digital roadmap’ (the overall programme of work to mature the Trusts digital systems).” Source location Response from Shrewsbury and Telford Hospital
Open published response
×
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 a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Verbatim wording from the response “The case of Mrs Silcock has been raised as a Patient Safety Investigation (PSII) under the Patient Safety Incident Response framework and some of the initial work of that investigation has been used to inform the response outlined in this letter.” Source location Response from Shrewsbury and Telford Hospital
Open published response
×
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 Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
Verbatim wording from the response “In the short to medium term the Trust’s Medical Director and Deputy Medical Director are tasking the leadership teams of our clinical divisions to ensure each inpatient specialty has a clear standard operating procedure (SOP) for inpatient to outpatient referrals. This will be documented and shared across the team with clear direction on process, roles, and responsibilities in ensuring referrals are made and a system of safety netting is in place to ensure decisions to refer to other specialties are followed through and actioned.” Source location Response from Shrewsbury and Telford Hospital
Open published response
×
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 Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
Verbatim wording from the response “There will be a single referral email for each specialty for referral for outpatient follow-up, the referrals within the team will then be managed in the standard way all referrals are with appropriate triage. This process will be developed over the next 3 months with SOPs developed and appropriate communications cascaded.” Source location Response from Shrewsbury and Telford Hospital
Open published response
×
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 Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Verbatim wording from the response “The possibility of bleeding or malignancy led to the endoscopy investigations being prioritised with cardiology advising these should be completed first then cardiology would continue the process to investigate the aortic stenosis. On review it is clear there was no expectation that the gastroenterology team would be responsible for following up the referral to cardiology once Ms Silcock’s endoscopy investigations were completed.” Source location Response from Shrewsbury and Telford Hospital
Open published response
Concerns raised 2 Failure to record prescribed-drug counselling and safety advice View source Lack of provision to record actions when patients lack capacity to understand medication explanations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Stephen GREEN · 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 Stephen Green was admitted to hospital after a seizure and was prescribed Lamotrigine. He was later readmitted with a collapse and rash, developed Stevens-Johnson Syndrome, and died on 9 July 2023 from toxic epidermal necrolysis secondary to Lamotrigine, with alcohol dependent disease contributing to his death. The concerns were that patients were not given or recorded as receiving counselling about drug side effects and complications, and that there was no provision to record what should happen when a patient lacked capacity to understand such an explanation.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record prescribed-drug counselling and safety advice
Wider context from the report “(1) Once any patient at The Royal Shrewsbury Hospital is initiated on a new prescribed drug during an admission, no written record is ever made anywhere by anyone including pharmacy; nurses; doctors or consultants explaining or counselling the patient upon the possible side-effects or complications as a result of taking a specific prescribed drug; nor is there any written record on what to look out for and what to do in such circumstances and where they can get assistance .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of provision to record actions when patients lack capacity to understand medication explanations
Wider context from the report “(2) No provision seems to be in place to record what should happen when the patient lacks capacity to understand such an explanation even when it is offered .
” Open source report
×
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 Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.
Verbatim wording from the response “Informed consent/counselling when prescribing a new medication:
Treating clinicians have a duty and responsibility to ensure patients are aware of any material risk associated with planned treatment, this includes significant side effects of medication.” Source location Response from Shrewsbury and Telford NHS Trust
Open published response
×
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 Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.
Verbatim wording from the response “Record of counselling
The counselling of a patient in hospital should be undertaken by the medical staff on prescribing the medication, by the nursing staff and pharmacy staff in preparation for discharge. All professions have a role in drug counselling, our pharmacists are the specialists in medication and counselling and have access to additional resources and referral services.
Pharmacy led counselling/documentation:” Source location Response from Shrewsbury and Telford NHS Trust
Open published response
Concerns raised 5 Tele-tracking system failing to support clear transport communication View source Lack of clear porter responsibilities when nursing staff are unavailable View source Failure to provide clear allocation and communication of transport assessment responsibilities View source Failure to ensure that transport preferences are based on sufficient information View source Failure to ensure porters know patients’ falls risk View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Arthur John SIMONS · 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 Arthur John SIMONS died following two falls while receiving treatment at Royal Shrewsbury Hospital, with the second fall identified as more significant and preventable. Concerns included confusion and communication failures in the Tele-tracking transport system, unclear responsibilities when nursing staff were unavailable to assist a patient, and inadequate awareness of the patient's falls risk.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Tele-tracking system failing to support clear transport communication
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly.
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear porter responsibilities when nursing staff are unavailable
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly.
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear allocation and communication of transport assessment responsibilities
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly .
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that transport preferences are based on sufficient information
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly.
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure porters know patients’ falls risk
Wider context from the report “(1) The Tele-tracking system
a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it.
b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly.
c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame.
(2) Assistance.
It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available.
(3) Risk awareness.
The porter did not know the patient’s level of risk of falls.
” Open source report
×
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 transport roles and responsibilities in the wider Hospital Transfer Policy through the Trust ratification process.
Verbatim wording from the response “• The process, including roles and responsibilities, will be included in a new wider Hospital Transfer Policy. This has been drafted and is currently going through the Trust’s ratification process.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
×
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 Deliver falls-awareness training to Portering staff, including recognition of visual fall-risk alerts, with induction and three-yearly refresher delivery.
Verbatim wording from the response “Falls awareness training is currently being delivered by the Falls Practitioner to all Portering staff. This training includes making Porters aware of visual alerts that patients at risk of falls have in place, for example yellow wrist bands and icons both at their bed space and on the patient safety screens near the nurses’ station. The expectations around undertaking falls awareness training for Porters will be included in the Procedure for Managing Inpatient Falls. This training will now be delivered to Portering staff on induction and 3 yearly as part of statutory mandatory training for Porters. The training, in combination with a clear briefing from the Registered Nurse to the Porter transferring the patient, should ensure the Porter is aware of the individual risk for the patient being transferred.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
×
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 mandatory falls-awareness training expectations for Porters in the Procedure for Managing Inpatient Falls.
Verbatim wording from the response “Falls awareness training is currently being delivered by the Falls Practitioner to all Portering staff. This training includes making Porters aware of visual alerts that patients at risk of falls have in place, for example yellow wrist bands and icons both at their bed space and on the patient safety screens near the nurses’ station. The expectations around undertaking falls awareness training for Porters will be included in the Procedure for Managing Inpatient Falls. This training will now be delivered to Portering staff on induction and 3 yearly as part of statutory mandatory training for Porters. The training, in combination with a clear briefing from the Registered Nurse to the Porter transferring the patient, should ensure the Porter is aware of the individual risk for the patient being transferred.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
×
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 radiology transfer form requiring registered-nurse assessment, documentation, and sign-off before transfer and on return.
Verbatim wording from the response “The mode of transport to the department for the investigation for an inpatient is specified on the form by the doctor making the request. This should be done in discussion with the nursing staff. However, the patient’s condition may change from the time of the request to the investigation being undertaken and so a further assessment should be made by the registered nurse (RN) caring for the patient at the time of transfer of the patient.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
×
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 the transfer form with key staff to ensure dynamic risk assessment and clear nursing documentation before patient transfer.
Verbatim wording from the response “• A review of the form has taken place with all key staff, to ensure this is a dynamic risk assessment, and there is clear documentation for the RN caring for the patient prior to the patient being transferred to and from an investigation/procedure.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
×
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 Put in place a radiology patient-transport Standard Operating Procedure incorporating the new transfer process.
Verbatim wording from the response “• A Standard Operating Procedure (SOP) for Transporting Patients to and from Radiology has been put in place and this new process has been included in that (enclosed).” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
×
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 Recommunicate the requirement that nursing staff assist Porters with patient transfers through a Trust safety alert, meetings, and written instructions to Porters.
Verbatim wording from the response “This was communicated as part of the SI and Porters DO NOT transfer patients from chair to wheelchair or bed without the assistance of a nurse when being transferred off or onto the ward.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
×
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 Wheelchair transport was appropriate because the patient mobilised with assistance and was comfortable sitting, although the assessment process was undocumented.
Verbatim wording from the response “The mode of transport to the department for the investigation for an inpatient is specified on the form by the doctor making the request. This should be done in discussion with the nursing staff. However, the patient’s condition may change from the time of the request to the investigation being undertaken and so a further assessment should be made by the registered nurse (RN) caring for the patient at the time of transfer of the patient.” Source location 2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
Open published response
Concerns raised 1 Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Edward SMITH · 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 Edward SMITH died on 4 March 2019 after relapsing on 20 February 2019. The report identified significant delay in the diagnosis and treatment of his adenocarcinoma, with tests, reports, appointments and discussions taking place consecutively so that surgery was no longer possible by the scheduled date.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions
Wider context from the report “1. There was significant delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma which contributed to his death on the 4th March 2019.
2. Time was of the essence, but tests, reports, appointments and discussions took place consecutively to the extent that by the time a final date for surgery was fixed it was no longer possible.
3. Had tests been conducted expeditiously and concurrently with predictable tests organised in advance it is likely that the surgery would have been able to take place significantly earlier than it did.
” Open source report
×
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 Streamline the lung cancer diagnostic pathway through direct-to-CT referral, urgent chest X-ray reporting, and coordinated diagnostic processes.
Verbatim wording from the response “From November 2019, the Trust has streamlined the diagnostic pathway (enclosed at Appendix 2) for patients being investigated for potential lung cancer which involved collaboration with Clinical Commissioning Group’s regarding ‘direct to CT’ pathways and to the urgent ‘hot-reporting’ of chest x-” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 and ratify diagnostic bundles specifying appropriate investigations for patient groups and pre-surgical risk assessment.
Verbatim wording from the response “Improvement work has been undertaken and evaluated with regards to developing diagnostic ‘bundles’ of tests to streamline investigations and agree which investigations are appropriate for specific patient groups, recognising that each investigation involves a potential delay, but that it is important to ensure that a patient is risk assessed appropriately prior to listing for surgical intervention.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 Standardize pre-operative assessment to minimize clinically unnecessary tests and associated delays.
Verbatim wording from the response “• The request of additional tests can result in further delays: the Trust’s new protocol has standardised the pre-operative assessment process to try and minimise clinically unnecessary tests, recognising that each additional test builds in a potential time delay.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 Allow PET scans to be requested before multidisciplinary discussion, requiring discussion after the PET-CT result.
Verbatim wording from the response “• Patient’s cases do not need to be discussed at an MDT meeting in order to facilitate the requesting of a PET scan, but only following receipt of the PET CT result.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 Update the standard operating procedure for referring suspected or confirmed lung cancer patients for surgical resection.
Verbatim wording from the response “The Trust and the teams involved recognise the delays in this case and have reviewed their pathways and processes. From November 2019, the Trust has updated their Standard Operating Procedure (SOP) which provides advice on the referral of patients for surgical resection of proven or suspected lung cancer to prevent delays. This covers the following areas:” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 quality improvement work towards compliance with the National Optimal Lung Cancer Pathway.
Verbatim wording from the response “All improvements have also supported the Trust in quality improvement to work towards compliance with the National Optimal Lung Cancer Pathway which is due to come into practice by April 2020.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 Flag concerning abnormal chest X-rays to the Lung Cancer Team daily.
Verbatim wording from the response “• Every chest x-ray with an abnormality which is concerning for a potential lung cancer is now flagged up to the Lung Cancer Team on a daily basis. Although, in the case of Mr Smith, his initial x-ray had been reported as normal as the changes were subtle.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 Triage CT results daily after abnormal chest X-rays raise possible lung cancer, alerting the Lung Cancer Team and responsible consultant.
Verbatim wording from the response “• There is daily triage of CT scan results performed following receipt of an abnormal chest x-ray where the potential for lung cancer has been raised by the reporting radiologist. It has been established that had this been the case for Mr Smith, this may have reduced the timescale between radiology reporting and receipt of that report by the requesting clinician by six days. This would also trigger the Lung Cancer Team and alert the patient’s Consultant.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 Increase surgical clinical capacity to prevent delays in clinic appointments.
Verbatim wording from the response “• There has been an increase in surgical clinical capacity, preventing delays for clinic appointments.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
×
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 Maintain coordinated lung cancer working arrangements with UHNM, including weekly thoracic surgical outpatient clinics and multidisciplinary team attendance.
Verbatim wording from the response “The Shrewsbury and Telford Hospital NHS Trust and UHNM continue to maintain close links and working closely together in the diagnosis and treatment of lung cancer patients. UHNM cardiothoracic surgeons attend SaTH weekly to operate surgical outpatient clinics and to attend weekly MDT meetings in person.” Source location 2020-0022-Response-from-Shrewsbury-and-Telford-NHS-Trust
Open published response
Concerns raised 6 Failure to refer patients to the Tissue Viability Nurse at indicated pressure-ulcer risk or severity points View source Lack of guidance on Tissue Viability Nurse referrals for patients with paraplegia or neurological deficit View source Lack of clear guidance on when and in what circumstances to refer patients to the Tissue Viability Nurse View source Lack of guidance linking Waterlow score determination to Tissue Viability Nurse referral View source Lack of guidance on Tissue Viability Nurse involvement in pressure-sore prevention plans for patients with additional risks View source Failure of the Pressure Ulcer Prevention and Treatment booklet to reference Tissue Viability Nurse referral before Category or Grade 3 pressure ulcers 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.
×
AI-generated summary
Peter SUDLOW · 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 SUDLOW developed a sacral pressure sore during a hospital admission following ischaemic myelopathy and paraplegia. The sore deteriorated, became infected, and he later died in a hospice on 8 April 2019. Concerns included failures to refer to the Tissue Viability Nurse at relevant stages and a lack of clear guidance on referrals, pressure sore prevention, and the relationship with Waterlow scores, particularly for patients with paraplegia or neurological deficits.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to the Tissue Viability Nurse at indicated pressure-ulcer risk or severity points
Wider context from the report “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time.
(2) There was no referral to the TVN when the sore was categorised as a grade 2.
(3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17.
(4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19.
(5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made.
(6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores.
(7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit.
(8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff.
(9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on Tissue Viability Nurse referrals for patients with paraplegia or neurological deficit
Wider context from the report “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time.
(2) There was no referral to the TVN when the sore was categorised as a grade 2.
(3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17.
(4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19.
(5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made.
(6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores.
(7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit.
(8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff.
(9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance on when and in what circumstances to refer patients to the Tissue Viability Nurse
Wider context from the report “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time.
(2) There was no referral to the TVN when the sore was categorised as a grade 2.
(3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17.
(4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19.
(5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made.
(6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores.
(7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit.
(8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff.
(9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance linking Waterlow score determination to Tissue Viability Nurse referral
Wider context from the report “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time.
(2) There was no referral to the TVN when the sore was categorised as a grade 2.
(3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17.
(4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19.
(5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made.
(6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores.
(7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit.
(8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff.
(9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on Tissue Viability Nurse involvement in pressure-sore prevention plans for patients with additional risks
Wider context from the report “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time.
(2) There was no referral to the TVN when the sore was categorised as a grade 2.
(3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17.
(4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19.
(5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made.
(6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores.
(7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit.
(8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff.
(9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Pressure Ulcer Prevention and Treatment booklet to reference Tissue Viability Nurse referral before Category or Grade 3 pressure ulcers
Wider context from the report “(1) During the period of time the deceased spent in hospital between 23/1/19 and 23/2/19 there was no referral to the Tissue Viability Nurse (TVN) at any time.
(2) There was no referral to the TVN when the sore was categorised as a grade 2.
(3) There was no referral to the TVN when the Waterlow score of the deceased increased to 17.
(4) There was no referral to the TVN when the deceased was readmitted to hospital on 16/3/19 and the pressure sore determined to be Grade 4 until 22/3/19.
(5) There was no clear guidance as to when and in what circumstances a referral to the TVN should be made.
(6) The deceased presented with additional risks as determined by the Waterlow score with paraplegia and there was no clear guidance as to when a TVN referral should be made for those patients with additional risks such as paraplegia or neurological deficit for the purpose of seeking advice as to the prevention of pressure sores.
(7) There was no clear guidance as to the involvement of the TVN in developing a plan to prevent pressure sores in those patients presenting with additional risks such as paraplegia or a neurological deficit.
(8) There was no clear guidance as to the relationship between the determination of the Waterlow score and referral to the TVN to assist nursing staff.
(9) The new Pressure Ulcer Prevention and Treatment 2 week booklet (PUPT) makes no reference to a TVN referral until a pressure ulcer has reached Category or Grade 3.
” Open source report
Concerns raised 12 Intermittent systems errors delaying D-Dimer results View source Absence of alerts for requested tests to the final decision maker View source Unclear telephone-reporting arrangements for A&E patients View source Operational pressure from the A&E four-hour deadline View source Failure to repeat observations before discharge View source Failure to record and communicate relevant presenting symptoms and prior clinical advice View source Failure to record a differential diagnosis of DVT View source Insufficient clinical documentation to resolve staff discrepancies View source Failure to complete a body map View source Failure to record blood-test requests, reasons and outstanding results View source Failure to check administration of Oramorph and account for symptom masking View source Inadequate system access for agency nurses and locum doctors View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Richard HINTON · 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
Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Intermittent systems errors delaying D-Dimer results
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine . It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of alerts for requested tests to the final decision maker
Wider context from the report “(2) System failures.
a) The system did not require or mandate the person who requested blood tests, specifically in this case a D-Dimer test, to record that request or the reason for it. There was no alert system which would have alerted the final decision maker of that request . At that time a health care assistant, staff nurse or doctor could have requested the tests. Only a doctor may do so now.
b) The evidence indicated that agency nurses and locum doctors did not have access to the hospital systems in particular the “review” system for requesting and reporting on tests. It appears to have been common practice for those who could not do so to log on using a permanent member of staff’s pin number or access code, with or without their permission. The blood tests had been requested on nurse C’s ‘review’ account who denied doing so.
c) If none of the witnesses who gave evidence requested the D-Dimer test it meant that another person did and could do so without any entry or note made in the A&E records.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear telephone-reporting arrangements for A&E patients
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E . The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Operational pressure from the A&E four-hour deadline
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to repeat observations before discharge
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and communicate relevant presenting symptoms and prior clinical advice
Wider context from the report “(1) The information chain.
a) When Mark (as the family wish him to be referred to) attended A&E he informed the triage nurse (nurse A) that he had contacted 111 who advised to go to A&E due to possible ‘clot’. That information was not recorded or passed on to others . Recorded examination of Mark included pain and obvious swelling to right calf.
b) The Staff Nurse (nurse B) who then carried out observations on Mark came to the view that he ‘could probably do with a D-Dimer’. That nurse states she passed that information to the next (third) nurse (nurse C).
c) Nurse C states that information was not passed to her . She was unaware that Mark had pain in his calf and therefore had no reason to request bloods, particularly a D-Dimer test, and had no knowledge of them being requested.
d) At or around 19:33 hours it appears that bloods, including a D-Dimer test were requested. However there is no record of these (8) test being recorded or who ordered them or why.
e) When the attending doctor first saw Mark at 21:06 hours he saw the results of 7 blood tests none of which indicated to him the presence of a possible DVT. The 8th blood test (i.e. the D-Dimer test) was not shown and as there was no record of it having been requested he did not know it was outstanding and nor in his opinion, was it required. Upon the information before that doctor he medically discharged Mark from hospital. Following Marks’ discharge from hospital the result of the D-Dimer test became available which would have led to Mark being admitted with treatment which probably would have saved his life.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record a differential diagnosis of DVT
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded .
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinical documentation to resolve staff discrepancies
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a body map
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain.
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record blood-test requests, reasons and outstanding results
Wider context from the report “(1) The information chain.
a) When Mark (as the family wish him to be referred to) attended A&E he informed the triage nurse (nurse A) that he had contacted 111 who advised to go to A&E due to possible ‘clot’. That information was not recorded or passed on to others. Recorded examination of Mark included pain and obvious swelling to right calf.
b) The Staff Nurse (nurse B) who then carried out observations on Mark came to the view that he ‘could probably do with a D-Dimer’. That nurse states she passed that information to the next (third) nurse (nurse C).
c) Nurse C states that information was not passed to her. She was unaware that Mark had pain in his calf and therefore had no reason to request bloods, particularly a D-Dimer test, and had no knowledge of them being requested.
d) At or around 19:33 hours it appears that bloods, including a D-Dimer test were requested. However there is no record of these (8) test being recorded or who ordered them or why .
e) When the attending doctor first saw Mark at 21:06 hours he saw the results of 7 blood tests none of which indicated to him the presence of a possible DVT. The 8th blood test (i.e. the D-Dimer test) was not shown and as there was no record of it having been requested he did not know it was outstanding and nor in his opinion, was it required. Upon the information before that doctor he medically discharged Mark from hospital. Following Marks’ discharge from hospital the result of the D-Dimer test became available which would have led to Mark being admitted with treatment which probably would have saved his life.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check administration of Oramorph and account for symptom masking
Wider context from the report “(3) Other matters arising.
a) A second set of observations should have been made before Mark was discharged. This did not happen.
b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review.
c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?
d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded.
e) A body map had not been completed at any time.
f) Oramorph was recorded as having been given but not checked . Also it may the mask symptoms of pain .
g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.
h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff.
i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate system access for agency nurses and locum doctors
Wider context from the report “(2) System failures.
a) The system did not require or mandate the person who requested blood tests, specifically in this case a D-Dimer test, to record that request or the reason for it. There was no alert system which would have alerted the final decision maker of that request. At that time a health care assistant, staff nurse or doctor could have requested the tests. Only a doctor may do so now.
b) The evidence indicated that agency nurses and locum doctors did not have access to the hospital systems in particular the “review” system for requesting and reporting on tests . It appears to have been common practice for those who could not do so to log on using a permanent member of staff’s pin number or access code, with or without their permission . The blood tests had been requested on nurse C’s ‘review’ account who denied doing so.
c) If none of the witnesses who gave evidence requested the D-Dimer test it meant that another person did and could do so without any entry or note made in the A&E records.
” Open source report
×
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 ED staff compliance with documentation requirements and repeat the audit monthly.
Verbatim wording from the response “Agreed. The Trust relies on the integrity of individuals to maintain professional standards of completing documentation. There are clear guidelines issued by both the NMC and the GMC which should be adhered to. An action from the RCA was to audit whether the ED staff were compliant in completing documentation. The initial audit results showed poor compliance and the plan is for the audit to be repeated monthly. The results have been discussed by the senior ED management team who are tasked with bringing improvement.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
×
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 alert facility existed; failure to complete it was attributed to human factors rather than a system failure.
Verbatim wording from the response “a. The system did not require or mandate the person who requested blood tests, specifically in this case a D-Dimer test, to record that request or the reason for it. There was no alert system which would have alerted the final decision maker of that request. At that time a health care assistant, staff nurse or doctor could have requested the tests. Only a doctor may do so now.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
×
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 Because ED patients are classified as in-patients, pathology does not telephone D-Dimer results; the requester must check the system.
Verbatim wording from the response “c. Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category?” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
×
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 Body maps apply to significant skin conditions and majors patients, not patients classified as minors.
Verbatim wording from the response “e. A body map had not been completed at any time.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
×
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 Information-security policy, login lockouts and no generic PINs were relied on to control staff access to hospital systems.
Verbatim wording from the response “b. The evidence indicated that agency nurses and locum doctors did not have access to the hospital systems, in particular the “review” system for requesting and reporting on tests. It appears to have been common practice for those who could not do so to log on using a permanent member of staff’s pin number or access code, with or without their permission. The blood tests had been requested on nurse C’s ‘review’ account who denied doing so.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
×
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 was unaware of the suspected clot, and a painful leg alone was not necessarily indicative of a clot.
Verbatim wording from the response “g. Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
×
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 There is no pharmaceutical requirement for Oramorph to be double-checked.
Verbatim wording from the response “f. Oramorph was recorded as having been given but not checked. Also it may mask symptoms of pain.” Source location 2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
Open published response
Concerns raised 8 Failure to provide Shropdoc personnel with access to referring patients’ GP records View source Failure to remove leg bandages for full top-to-toe examination View source Lack of a programme to replace unavailable A&E Doctors View source Failure to follow Sepsis Six care bundles in accordance with guidelines View source Unavailability of prescribed drugs in the A&E department View source Failure to identify red flag signs of sepsis View source Insufficient A&E Doctor staffing to cover patient needs View source Failure to consider suitable alternative drugs when the prescribed drug is unavailable 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.
×
AI-generated summary
Patricia Violet PALIN · 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
Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide Shropdoc personnel with access to referring patients’ GP records
Wider context from the report “1. Shropdoc personnel, be that Doctors or Urgent Care Practitioners are not able to access the referring patients GP records . This meant that they did not have the full picture of Patricia’s past medical history before administering any advice or treatment. This is not a one off isolated incident and applies to every case that is referred to Shropdoc . Evidence was given at the inquest from the Shropdoc Urgent Care Practitioners that it would have assisted them.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to remove leg bandages for full top-to-toe examination
Wider context from the report “4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence;
a. Red flag signs of sepsis were missed.
b. Leg bandages were not removed to allow full top to toe examination .
c. Sepsis six care bundles were not followed in accordance with 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a programme to replace unavailable A&E Doctors
Wider context from the report “2. During the evening of the 1st October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow Sepsis Six care bundles in accordance with guidelines
Wider context from the report “4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence;
a. Red flag signs of sepsis were missed.
b. Leg bandages were not removed to allow full top to toe examination.
c. Sepsis six care bundles were not followed in accordance with 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of prescribed drugs in the A&E department
Wider context from the report “3. I heard evidence that a prescribed drug Ertapenem was not in stock within the A&E department and that led to a delay of some two hours and twenty five minutes until administration. Other suitable alternative drugs were available but not considered.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify red flag signs of sepsis
Wider context from the report “4. Whilst there was a general awareness of the dangers of sepsis from the Shropdoc and Hospital witness evidence;
a. Red flag signs of sepsis were missed .
b. Leg bandages were not removed to allow full top to toe examination.
c. Sepsis six care bundles were not followed in accordance with 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient A&E Doctor staffing to cover patient needs
Wider context from the report “2. During the evening of the 1st October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider suitable alternative drugs when the prescribed drug is unavailable
Wider context from the report “3. I heard evidence that a prescribed drug Ertapenem was not in stock within the A&E department and that led to a delay of some two hours and twenty five minutes until administration. Other suitable alternative drugs were available but not considered .
” Open source report
Concerns raised 5 Failure to request obstetric review after 1 hour of active pushing View source Failure to confirm CTG assessment using the agreed assessment tool View source Failure to request obstetric review for maternal tachycardia View source Failure to ensure support and supervision for inexperienced midwives performing episiotomy View source Failure to accurately monitor the foetal heart rate during the second stage of labour 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
Ivy Rebecca Morris · 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
Ivy Rebecca Morris was born with severe perinatal hypoxic ischaemic brain damage and died at home on 3 May 2016 after becoming unresponsive during a feed. The report identified concerns about foetal heart monitoring, failures to follow midwifery guidelines, and potential delays relating to episiotomy support. The inquest concluded that appropriate monitoring during the second stage of labour would have prevented her death, according to the supplied text.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request obstetric review after 1 hour of active pushing
Wider context from the report “(2) Failure to follow midwifery guidelines.
a. To confirm assessment of the CTG using the agreed assessment tool.
b. The need to request an obstetric review after 1 hour of active pushing.
c. The need to request an obstetric review for maternal tachycardia.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm CTG assessment using the agreed assessment tool
Wider context from the report “(2) Failure to follow midwifery guidelines.
a. To confirm assessment of the CTG using the agreed assessment tool.
b. The need to request an obstetric review after 1 hour of active pushing.
c. The need to request an obstetric review for maternal tachycardia.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request obstetric review for maternal tachycardia
Wider context from the report “(2) Failure to follow midwifery guidelines.
a. To confirm assessment of the CTG using the agreed assessment tool.
b. The need to request an obstetric review after 1 hour of active pushing.
c. The need to request an obstetric review for maternal tachycardia.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure support and supervision for inexperienced midwives performing episiotomy
Wider context from the report “(3) Episiotomy.
Infiltration took place which could have led to an episiotomy and delivery within 10 minutes. There was unresolved evidence as to whether an episiotomy was a planned event or a contingency which did not arise. There was though evidence that the midwife who performed the infiltration had not performed an episiotomy since qualification and wished to have support and supervision should one become necessary . Whilst such support and supervision may have been available in this case, in other this could lead to delay .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately monitor the foetal heart rate during the second stage of labour
Wider context from the report “(1) Foetal heart monitoring.
Ivy's foetal heart rate ought to have been monitored and was not monitored. In the second stage of labour the maternal heart rate was recorded on the external CTG machine for the majority of (if not all) the time when the intent was to monitor the foetal heart rate . The confounding factor was the similarity of the heart rates at the commencement of the second stage. There were opportunities and methodologies available to resolve this issue that were not taken. There was evidence of potential error of this kind in the interpretation of CTG traces being a known phenomenon.
” Open source report
Concerns raised 4 Failure to send discharge summaries to patients’ GPs View source Failure to act on available radiological reports View source Failure to ensure that abdominal x-ray reports are available to doctors before diagnosis View source Failure to provide prescribed medication at hospital discharge 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
Martin Rowland HILL · 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
Martin Rowland HILL died on 24 April 2014 after an abdominal x-ray taken during an A&E attendance showed small bowel obstruction, but the report was not seen by subsequent doctors and he was treated for constipation. The concerns included the failure to act on the radiology report, which might have led to surgical review and readmission, as well as medication not being provided on discharge and no discharge summary being sent to his GP.
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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to send discharge summaries to patients’ GPs
Wider context from the report “(6) For completeness, and it is an issue which arose in an earlier Inquest, no discharge summary was sent to the patient’s GP . This appears to have been an exception to normal practice and an indication was given at the Inquest that this issue has already been addressed. Confirmation of this is sought.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on available radiological reports
Wider context from the report “(4) On the 20th April there was radiological evidence of small bowel obstruction, according to the independent pathologist, most likely episodic. Over the next 4 days it became progressively worse, described by the pathologist at PM as hugely distended. The prospects of successful intervention declined over the subsequent 4/5 days. The report, when available, was not acted upon.
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that abdominal x-ray reports are available to doctors before diagnosis
Wider context from the report “(1) The abdominal x-ray report was not seen by any doctor and all subsequent diagnoses were made without knowledge of its content .
” 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 Shrewsbury and Telford Hospital NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prescribed medication at hospital discharge
Wider context from the report “(5) An additional concern arose separate to this. Mr Hill, when he was discharged on the 20th April, had been prescribed medication. Mr Hill should have left the hospital with that medication but none was provided to him. It is unlikely that its absence had any material effect in this case but it could in others .
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations