Concerns raised 5 Failure to communicate relevant postoperative risks and complications to community carers View source Inadequate systematic assessment of physical symptoms View source Failure to measure and record community patients’ vital signs View source Failure of surgical teams to maintain ongoing oversight after discharge View source Lack of a discharge plan for possible pelvic infection View source See 2 more concerns
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AI-generated summary
Keith Fleming · 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
Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.
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 Trinity Medical Centre, South Shields; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant postoperative risks and complications to community carers
Wider context from the report “The General Practitioner and consequently the nursing staff were not aware of that the anastomosis of the bowel carried out during the original operation ( 2007) had dehised. Nor were they aware of an internal area of abscess adjacent to the repaired stoma site , only discovered on post mortem and together leading to a catastrophic infection within the deceased particularly and significantly in the area of his left buttock. The reality was the infection within the otherwise pelvic area had tracked through the pelvis into the area of the left buttock.
It was the presence of the swelling of this area of the buttock which was to alert the deceased’ wife several days after his discharge home to the growing crisis and resulted in her summoning her husband’s GP Dr.████████. The Doctor immediately recognized the symptoms, arranged for the deceased’ emergency admission to the South Tyneside District Hospital.
” 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 Trinity Medical Centre, South Shields; that does not assign responsibility.
PFD Monitor interpretation Inadequate systematic assessment of physical symptoms
Wider context from the report “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded.
Physical symptoms were noted but only on a generalized – impressionistic basis - tiredness, responsiveness to questions and discussion – level of activity and mobility – diet.
” 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 Trinity Medical Centre, South Shields; that does not assign responsibility.
PFD Monitor interpretation Failure to measure and record community patients’ vital signs
Wider context from the report “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded.
Physical symptoms were noted but only on a generalized – impressionistic basis - tiredness, responsiveness to questions and discussion – level of activity and mobility – diet.
” 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 Trinity Medical Centre, South Shields; that does not assign responsibility.
PFD Monitor interpretation Failure of surgical teams to maintain ongoing oversight after discharge
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” 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 Trinity Medical Centre, South Shields; that does not assign responsibility.
PFD Monitor interpretation Lack of a discharge plan for possible pelvic infection
Wider context from the report “Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears.
On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future.
” 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