The Whittington Hospital

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First report 22 Feb 2021•Latest report 22 Feb 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from The Whittington Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Cecilia EDWARDS · 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

    Cecilia Edwards was admitted to Whittington Hospital on 26 September 2020 with a severe right elbow infection and died there two weeks later. The report identified concerns that a category 3 pressure ulcer was not referred promptly to a tissue viability nurse, that many visiting nurses were agency staff without clear protocols, and that nursing visits were not routinely coordinated with carers, resulting in incomplete care on some occasions.

    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 Whittington Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear protocols integrating agency district nurses into the organisation

    Wider context from the report

    “2. 60% of the district nurses who visited Cecilia Edwards were agency nurses. This is obviously undesirable in itself, although I recognise that it may be very difficult to address. That notwithstanding, the district nurse team manager giving evidence in court agreed with Ms Edwards’ niece (herself a former district nurse and health visitor, and her auntie’s longstanding advocate) that clear protocols would raise standards, make mistakes less likely and bring the agency staff in as part of the organisation. Ultimately this would improve patient care. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Whittington Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    High proportion of district nursing care provided by agency nurses

    Wider context from the report

    “2. 60% of the district nurses who visited Cecilia Edwards were agency nurses. This is obviously undesirable in itself, although I recognise that it may be very difficult to address. That notwithstanding, the district nurse team manager giving evidence in court agreed with Ms Edwards’ niece (herself a former district nurse and health visitor, and her auntie’s longstanding advocate) that clear protocols would raise standards, make mistakes less likely and bring the agency staff in as part of the organisation. Ultimately this would improve patient care. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to The Whittington Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make immediate tissue viability referrals for category 3 pressure ulcers

    Wider context from the report

    “1. On 12 February 2020, a district nurse assessed Ms Edwards’ elbow as a category 3 pressure ulcer, which should have prompted an immediate referral to the tissue viability nurse. However, no such referral was made, either by the attending nurse; the district nurses who visited twice a week over the next seven months; the frequent care plan reviewers; or the shift co-ordinator until 22 September 2020. ”
    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 Whittington Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely coordinate district nurse and carer visits

    Wider context from the report

    “3. The district nurses who visited Cecilia Edwards needed the assistance of the two carers to turn her and attend to all her nursing needs, but sometimes when they visited there were no carers present and so the nursing care given was incomplete. The carers attended at set hours four times a day, and so it seems that the onus was on the nursing team to arrange the twice weekly visits appropriately. Sometimes, individual nurses would ring individual carers to make arrangements, but there was no organisational system to ensure that nurse and carer visits coincided as a matter of routine. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026