5 Oct 2023 Lilian Margaret BOARD · Prevention of Future Deaths report Lincolnshire
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Concerns raised 1 Failure to prevent duplicate medication prescriptions between hospital and GP View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Lilian Margaret BOARD · 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
Lilian Margaret BOARD, aged 91, died at Lincoln County Hospital on 1 February 2023 after intentionally ingesting tablets the previous day; a note of intent was left. The principal concern was that both her GP and the hospital had prescribed the same medication, raising a question about checks to prevent duplicate prescriptions.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent duplicate medication prescriptions between hospital and GP
Wider context from the report “The deceased was prescribed ████████ by her GP.
Following discharge from hospital on 18th January 2023 LCH also prescribed ████████.
The deceased therefore had two prescriptions of the same medication that she used to end her life.
Are there any checks in place to avoid duplicity of prescriptions between hospital and GP ?
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s 14-day discharge-supply policy and associated arrangements remain appropriate despite accepted overlapping prescriptions.
Verbatim wording from the response “It is important to point out that the policy of the Trust (Policy for Medicines Management Supply of Medicines), in agreement with Lincolnshire Primary Care colleagues including the Primary Care Networks, the Local Medical Committee and the Integrated Care Board, is that we supply patients with 14 days supply of medication as a default at the point of discharge, This is not unusual, as almost all acute provider Trusts within NHS England have similar policies to dispense medication supplies upon discharge, with these supply arrangements ranging anywhere between 7-28 days depending on policies of the specific NHS Trusts.” Source location Response from United Lincolnshire Hospitals NHS Trust
Open published response
6 Jul 2023 Elizabeth Oluwatofunmi AGBEJIMI · Prevention of Future Deaths report Lincolnshire
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Concerns raised 1 Failure to investigate a significantly abnormal respiratory acidosis blood gas result View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Elizabeth Oluwatofunmi AGBEJIMI · 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
Elizabeth Oluwatofunmi AGBEJIMI died on 27 June 2021 at Lincoln County Hospital following multiple falls identified by the pathologist as a direct cause of death. Concerns were raised that a venous blood gas sample showing significant respiratory abnormal acidosis was not further investigated, with the deceased dying two weeks later of a respiratory condition; the report questioned whether this involved training or communication.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate a significantly abnormal respiratory acidosis blood gas result
Wider context from the report “████████ gave evidence that following a venous blood gas sample undertaken on 12th June 2021 which showed a significant respiratory abnormal acidosis reading but no further investigation was undertaken . The deceased died 2 weeks later of a respiratory condition. Is this a training/communication issue?
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require ED clinicians acknowledging blood gas results to document abnormalities requiring management and the planned further management.
Verbatim wording from the response “1. Ensure better documentation of the identification of the abnormalities on the blood gas results” Source location Response from United Lincolnshire Hospitals NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have clinical audit teams in both ULHT departments audit blood gas results and documentation to assess whether the learning and actions are embedded.
Verbatim wording from the response “In order to assure that these processes have been embedded, the clinical audit team in both ULHT departments will undertake an audit of blood gas results and the documentation in them to review the learning and actions have been embedded.” Source location Response from United Lincolnshire Hospitals NHS Trust
Open published response
7 Sep 2022 Michael James Robert ROLFE · Prevention of Future Deaths report Lincolnshire
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Concerns raised 1 Prescribing Rivaroxaban despite liver impairment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Michael James Robert ROLFE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael James Robert ROLFE, a 72-year-old man, was admitted on 23 August 2019 with decreasing consciousness and a cerebellar haemorrhage with intraventricular extension, and died the following day after treatment was considered not possible. The report raises concern that prescribing Rivaroxaban in the context of liver impairment, low platelets and impaired renal function may have increased bleeding risk and may have contributed to the rectal bleeding and cerebral haemorrhage.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Prescribing Rivaroxaban despite liver impairment
Wider context from the report “With reference to cause of death at 1b.
The deceased had liver impairment due to cirrhosis. He was prescribed the anticoagulant Rivaroxaban for presumed deep vein thrombosis. Within 48 hours he developed rectal bleeding. During his admission to hospital his INR was 1.8 indicating blood was thin. Renal function impaired with a GFR of 39 - baseline 46. Rivaroxaban is contradicted in liver impairment, low platelets and severe renal impairment .(Documented in the product literature and British National Formulary). Consequently, it is represented that the deceased should not have been prescribed Rivaroxaban due to the bleeding risk. Administration of Rivaroxaban to someone with impaired clotting and low platelets would exaggerate the anticoagulant effect and be responsible for the rectal bleed and cerebral haemorrhage that resulted. If accepted the potential inappropriate administration may have led to the cause of death and this has important safety implications that are in the public interest. An action plan to prevent future deaths may be needed.
” Open source report
Concerns raised 1 Failure to implement the action plan in full View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Vilmantas Venskutonis · 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
Vilmantas Venskutonis was admitted to Pilgrim Hospital with chest pains, which intensified before he was transferred to Lincoln County Hospital, where he died. The report acknowledges 11 separate intervention opportunities that were missed at Pilgrim. The principal concern was whether a nine-point action plan intended to prevent further deaths had been fully implemented, and, if not, why each point had not been completed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the action plan in full
Wider context from the report “I refer to the action plan dated December 2019 that was attached to the SI report, Lead
Investigator, Dr ████████ (Cardiology). The commencement of the plan is January 2020.
There are nine points to this plan, I need to know if the plan has been implemented in full to prevent
further deaths with implementation dates for all 9 points.
If not implemented in full or in part please state reason why identifying each point.
” Open source report
23 Jan 2019 Gail Bailey · Prevention of Future Deaths report Lincolnshire
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Concerns raised 3 Failure to forewarn obstetric and gynaecology clinicians of emergency arrivals View source Failure to date and sign recorded emergency pre-alerts View source Failure of hospital clinicians to be prepared for emergency admissions 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
Gail Bailey · 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
Gail Bailey, who was nine weeks pregnant, developed abdominal discomfort while on holiday on 5 August 2017. An ambulance was called but arrived after a delay, and she was declared deceased at Boston Pilgrim Hospital later that evening. The report raised concerns about emergency communication and preparedness, including pre-alert calls that were not dated or signed and the apparent lack of advance warning to obstetric and gynaecology staff.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to forewarn obstetric and gynaecology clinicians of emergency arrivals
Wider context from the report “C) I received evidence from Mr Bailey that upon arrival at hospital the clinicians appeared not to be ready for his wife's arrival.
D) I received evidence from Mr ████████, consultant in the Accident and Emergency Unit at Boston Pilgrim Hospital, that ████████, a Specialty Doctor in Emergency medicine present at the time had noted in the medical records that he, together with other doctors had attempted to resuscitate Mrs Bailey who had presented to A & E in a collapsed state around 21.00 hours and had noted that "a cardiac arrest call-out had also been initiated in or around the time of the patients' arrival to Pilgrim."
E) I received evidence from the locum registrar for the labour ward, ████████ that "[My understanding at that time was that] no Obstetrician and gynaecologist was forewarned about this patients arrival to the A & E department. "
F) The ED records confirmed that two pre alert calls were recorded but not dated nor signed.
G) Whilst the severity of Mrs Bailey's condition meant that in the particular circumstances of this case the treatment Mrs Bailey received at hospital neither caused nor contributed to her death, the apparent breakdown in communication does raise an area of concern in relation to future emergency admissions.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to date and sign recorded emergency pre-alerts
Wider context from the report “C) I received evidence from Mr Bailey that upon arrival at hospital the clinicians appeared not to be ready for his wife's arrival.
D) I received evidence from Mr ████████, consultant in the Accident and Emergency Unit at Boston Pilgrim Hospital, that ████████, a Specialty Doctor in Emergency medicine present at the time had noted in the medical records that he, together with other doctors had attempted to resuscitate Mrs Bailey who had presented to A & E in a collapsed state around 21.00 hours and had noted that "a cardiac arrest call-out had also been initiated in or around the time of the patients' arrival to Pilgrim."
E) I received evidence from the locum registrar for the labour ward, ████████ that "[My understanding at that time was that] no Obstetrician and gynaecologist was forewarned about this patients arrival to the A & E department."
F) The ED records confirmed that two pre alert calls were recorded but not dated nor signed.
G) Whilst the severity of Mrs Bailey's condition meant that in the particular circumstances of this case the treatment Mrs Bailey received at hospital neither caused nor contributed to her death, the apparent breakdown in communication does raise an area of concern in relation to future emergency admissions.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of hospital clinicians to be prepared for emergency admissions
Wider context from the report “C) I received evidence from Mr Bailey that upon arrival at hospital the clinicians appeared not to be ready for his wife's arrival .
D) I received evidence from Mr ████████, consultant in the Accident and Emergency Unit at Boston Pilgrim Hospital, that ████████, a Specialty Doctor in Emergency medicine present at the time had noted in the medical records that he, together with other doctors had attempted to resuscitate Mrs Bailey who had presented to A & E in a collapsed state around 21.00 hours and had noted that "a cardiac arrest call-out had also been initiated in or around the time of the patients' arrival to Pilgrim. "
E) I received evidence from the locum registrar for the labour ward, ████████ that "[My understanding at that time was that] no Obstetrician and gynaecologist was forewarned about this patients arrival to the A & E department."
F) The ED records confirmed that two pre alert calls were recorded but not dated nor signed.
G) Whilst the severity of Mrs Bailey's condition meant that in the particular circumstances of this case the treatment Mrs Bailey received at hospital neither caused nor contributed to her death, the apparent breakdown in communication does raise an area of concern in relation to future emergency admissions.
” Open source report
14 Feb 2018 Elaine Bradbrook · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 11 Failure to record Glasgow Coma Scale observations after deterioration in consciousness View source Failure to provide clinical review before transfer View source Failure to discuss a significantly deteriorating patient with neurosurgeons before transfer View source Failure to provide a clinical escort during transfer View source Failure to provide representation or support at formal proceedings and conclusions View source Failure to provide clinical or nursing review after deterioration in consciousness View source Failure to protect the airway during transfer of a patient with severely reduced consciousness and vomiting risk View source Failure to send a requested clinical witness to a formal review View source Failure to contact the patient’s family in line with the duty of candour View source Failure to escalate and act on a deteriorating patient condition View source Failure to carry out an internal investigation after serious failures View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Elaine Bradbrook · 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
Elaine Bradbrook suffered a severe ischaemic stroke, deteriorated into a deep coma, underwent a craniectomy, and died at Queen’s Medical Centre on 27 April 2017. Concerns included failures to escalate and monitor her deterioration, reassess her condition before transfer, and reduce risks during transfer, including transfer with an unprotected airway and without clinical escort. The report also raised concerns about the trust’s failure to investigate the circumstances, fulfil its duty of candour, and support or properly represent witnesses during the inquest.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record Glasgow Coma Scale observations after deterioration in consciousness
Wider context from the report “b. There was a failure to record a single GCS after 14.00 , when her level of consciousness dropped. I found no evidence of any clinical or nursing review after this time.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinical review before transfer
Wider context from the report “d. There was a failure to reduce the risks during transfer – a patient with a GCS of 4 and a history of vomiting was handed over to ambulance staff with an unprotected airway and without clinical review , or escort.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discuss a significantly deteriorating patient with neurosurgeons before transfer
Wider context from the report “c. There was a failure to discuss Elaine’s condition with neurosurgeons in Nottingham again before she was transferred to Nottingham , when it was clear that her condition had deteriorated significantly.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clinical escort during transfer
Wider context from the report “d. There was a failure to reduce the risks during transfer – a patient with a GCS of 4 and a history of vomiting was handed over to ambulance staff with an unprotected airway and without clinical review, or escort .
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide representation or support at formal proceedings and conclusions
Wider context from the report “g. The trust legal services team did not send the witness (doctor) responsible for reviewing Elaine shortly before transfer, as requested. It sent no representative or supporter with ████████, despite the trust being an Interested Person. There was no representative in attendance to hear the conclusions which raised serious concerns.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clinical or nursing review after deterioration in consciousness
Wider context from the report “b. There was a failure to record a single GCS after 14.00, when her level of consciousness dropped. I found no evidence of any clinical or nursing review after this time .
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to protect the airway during transfer of a patient with severely reduced consciousness and vomiting risk
Wider context from the report “d. There was a failure to reduce the risks during transfer – a patient with a GCS of 4 and a history of vomiting was handed over to ambulance staff with an unprotected airway and without clinical review, or escort.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to send a requested clinical witness to a formal review
Wider context from the report “g. The trust legal services team did not send the witness (doctor) responsible for reviewing Elaine shortly before transfer, as requested . It sent no representative or supporter with ████████, despite the trust being an Interested Person. There was no representative in attendance to hear the conclusions which raised serious concerns.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the patient’s family in line with the duty of candour
Wider context from the report “e. The trust appears not to have appreciated the significance of these issues. It has not carried out any internal investigation, nor contacted Elaine’s family in line with its duty of candour . I am concerned that there has been no opportunity for learning within the trust, following these serious failures.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and act on a deteriorating patient condition
Wider context from the report “a. There was a failure to escalate and act on Elaine’s deteriorating condition from at least 14.00 on 22 April 2017, when her NEWS was 6, and her GCS is also likely to have dropped.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out an internal investigation after serious failures
Wider context from the report “e. The trust appears not to have appreciated the significance of these issues. It has not carried out any internal investigation , nor contacted Elaine’s family in line with its duty of candour. I am concerned that there has been no opportunity for learning within the trust, following these serious failures.
” 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 Commence a serious incident investigation to review the care provided.
Verbatim wording from the response “I agree that there are clear learning points from this case and I have asked the Risk Team to commence an SI investigation to review the care and submit an action plan, as necessary. I will of course share this with you and the family once complete.” Source location 2018-0044-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve the serious incident process, including Trust-wide investigation training and governance oversight.
Verbatim wording from the response “The Trust recognises that the SI process at that time was poor. However we have, in the last 12 months, made significant improvements to our SI process and this incorporates training across the Trust on undertaking SI investigations. This process is being overseen by me and the Director of Nursing and we currently have in post an Interim Director of Governance who is leading on this project. Our new Risk Manager also commenced in post in February 2018.” Source location 2018-0044-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an Interim Director of Governance role leading the serious incident process improvement project.
Verbatim wording from the response “The Trust recognises that the SI process at that time was poor. However we have, in the last 12 months, made significant improvements to our SI process and this incorporates training across the Trust on undertaking SI investigations. This process is being overseen by me and the Director of Nursing and we currently have in post an Interim Director of Governance who is leading on this project. Our new Risk Manager also commenced in post in February 2018.” Source location 2018-0044-Response-by-United-Lincolnshire-Hospitals-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 Establish the new Risk Manager post to support serious incident process improvement.
Verbatim wording from the response “The Trust recognises that the SI process at that time was poor. However we have, in the last 12 months, made significant improvements to our SI process and this incorporates training across the Trust on undertaking SI investigations. This process is being overseen by me and the Director of Nursing and we currently have in post an Interim Director of Governance who is leading on this project. Our new Risk Manager also commenced in post in February 2018.” Source location 2018-0044-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing Legal Services processes are considered sufficient to ensure timely handling of requests and adequate staff support when the Trust is notified.
Verbatim wording from the response “It is usual practice for the Legal Services Manager to ensure that staff are adequately supported through the inquest process either meeting her or with the Trust’s legal representatives, if instructed. Indeed, this is a large part of the role in the Department. I am sorry this did not happen in this particular case. I am confident that there are processes in place in the Legal Services Department to ensure requests are dealt with in a timely manner and staff are adequately supported, when notified.” Source location 2018-0044-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Open published response
4 Dec 2017 Dorothy Doreen BREISLIN · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 2 Failure to implement incident action plans View source Delays in receiving incident review reports View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Dorothy Doreen BREISLIN · 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
Dorothy Doreen BREISLIN was admitted to hospital after a fall at home and was initially treated for a pulmonary embolism. A later diagnosis identified a right eighth-rib fracture that led to massive bleeding and her death. Concerns included delays in receiving the Incident Review Report, uncertainty about an apology said to have been provided, and confirmation that the referenced Action Plan had not been implemented.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement incident action plans
Wider context from the report “3 ████████ confirmed on oath that none of the Action Plan referred to in the Appendices at 3 have been implemented . If not, in view of the Incident Date why not?
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in receiving incident review reports
Wider context from the report “1 The incident date was 27th January 2015. The Incident Review Report was not received in this office until 10th August 2017. Why the delay?
” 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 Clear the backlog of serious incident reports under oversight from the Medical Director and Director of Nursing.
Verbatim wording from the response “I can only apologise for the unacceptable delay in not only recognising that this was an SI but for the delay in forwarding the final report to you. The Trust recognises that the SI process at that time was poor. We are working hard to clear our backlog of SI reports, which is being overseen by myself and the Director of Nursing and we are also implementing a new SI process. This incorporates training across the Trust on undertaking SI investigations.” Source location 2017-0348-Response-United-Lincolnshire-Hospitals-NHS-Trust
Open published response
20 Oct 2017 Liam Oldsworth · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1 Delays in receipt of Serious Incident Analysis reports 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
Liam Oldsworth · 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
Liam Oldsworth, a child aged 22 months, was admitted with a high temperature and difficulty breathing and was treated for septicaemia and meningitis, but his condition deteriorated despite medical support. The report raises concern that a Serious Incident Analysis report dated 18/3/2015 was received by the office only within the last week, with recommendations and shared learning attached.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in receipt of Serious Incident Analysis reports
Wider context from the report “The Serious Incident Analysis report dated 18/3/2015 has only within the last week been received by this office .
Attached are recommendations and shared learning.
” Open source report
28 Mar 2017 Olive DAYNES · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 1 Failure to communicate hospital advice, medication changes and increased INR levels to the GP in time View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Olive DAYNES · 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
Olive Daynes, described as an 86-year-old lady, presented to hospital with an altered mental state and a suspected fall after earlier treatment for painful or sore legs and ulcers. The report identified concerns about Warfarin being prescribed with antibiotics, inadequate monitoring, communication between the hospital and GP surgery, and a subsequent INR increase to over 9 before she passed away.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate hospital advice, medication changes and increased INR levels to the GP in time
Wider context from the report “1. On 28/12/2015 Mrs. Daynes was admitted to Accident and Emergency at the Pilgrim Hospital, Fishtoft, and Boston following painful / sore legs/ulcers.
2. Her INR was recorded at 3.6, her medication changed and the matter was referred back to the GP.
3. A doctor from the GP's surgery saw Mrs Daynes the next day on 29th December 2015 but was unaware of the advice provided by the hospital, change in medication or increased IRN levels .
4. The hospital wrote to the surgery and the letter arrived on 4/2/2016 (date stamp verified by the Coroner).
5. In the intervening period the patients INR increased to over 9 and she passed away on 5/1/2016.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue and recirculate standards for communicating test results between secondary and primary care.
Verbatim wording from the response “7. In 2016 the Trust and the Lincolnshire Local Medical Committee issued a document setting the standards and principles by which test results should be communicated by secondary and primary care. I enclose a copy of this document which was sent to all clinicians within ULHT. This has been circulated again to remind colleagues of their responsibilities.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.
Verbatim wording from the response “9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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 Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.
Verbatim wording from the response “5. In order to prevent similar deaths in the future, the discharge letter is sent by electronic means to the appropriate GP email address of the appropriate GP surgery.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to the lead clinicians of all three Accident and Emergency departments about the concerns and required timely communication.
Verbatim wording from the response “8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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 Circulate an organisation-wide patient safety bulletin on antibiotic-related anticoagulation interactions and timely communication.
Verbatim wording from the response “8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
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 Electronic A&E-to-GP communication cannot yet be implemented because competing Trust-wide electronic systems and IT upgrades constrain progress.
Verbatim wording from the response “9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:” Source location Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Open published response
18 Jul 2016 Sidney Brian Alexander · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 1 Inadequate space or lack of addendum provision in biopsy reporting forms 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
Sidney Brian Alexander · 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
Sidney Brian Alexander, who had a cardiac transplant and other medical conditions, was admitted with several months of diarrhoea and treated for a suspected Crohn’s exacerbation. He later developed respiratory distress with diffuse right-sided infiltrates and died in hospital; a concern was raised that a biopsy report could not be fully completed because there was insufficient room on the form.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate space or lack of addendum provision in biopsy reporting forms
Wider context from the report “1 ████████ Consultant Gastroenterologist gave live evidence, During that evidence he conceded that he hadn't been able to fully complete a Biopsy report for Unilabs as there was insufficient room on it . Surely a form can be expanded or provision made for an addendum?
” Open source report
23 Mar 2015 Robert Spring · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 4 Failure of the Air Liquide notification system to transmit smoking-related risk information to LFRS View source Failure by LFRS to assess high-risk Home Oxygen users for safety equipment View source Lack of direct notification of heightened Home Oxygen and smoking risks to LFRS View source Lack of awareness among relevant agencies of available safety equipment for high-risk patients 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
Robert Spring · 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
Robert Spring, who had chronic obstructive pulmonary disease and used home oxygen while smoking, died in a fire at his home on 14 March 2014. The fire was attributed to either a cigarette lighter or a dropped cigarette. The principal concerns were that relevant agencies were not fully informed of his smoking-related risk, so he was not assessed for available fire-safety equipment, and that more extensive communication between agencies was needed.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the Air Liquide notification system to transmit smoking-related risk information to LFRS
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by LFRS to assess high-risk Home Oxygen users for safety equipment
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of direct notification of heightened Home Oxygen and smoking risks to LFRS
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known, and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among relevant agencies of available safety equipment for high-risk patients
Wider context from the report “(I) Mr Spring was identified at the initial hospital assessment as being at high risk by virtue of his use of Home Oxygen and also by virtue of his smoking habit. There was no mechanism in place whereby such risk could be notified directly to LFRS notwithstanding that Mr Spring had expressly consented to his personal information being shared with them. Such reporting was deferred to Air Liquide.
(II) The fact that Mr Spring, as a smoker, was considered to be high risk was confirmed by risk assessments undertaken by representatives of Air Liquide, the Home Oxygen supplier, upon the installation of the Home Oxygen on 27 March 2013 and upon subsequent service visits undertaken on 19 June 2013 and 8 January 2014.
(III) Although a mechanism existed for the communication of that increased risk to LFRS by Air Liquide, a facet of their system, designed to prevent duplicate notifications being delivered, operated to prevent notification of his status as a smoker and LFRS were notified only that Mr Spring was a user of Home Oxygen.
(IV) Evidence was given at Inquest that LFRS have available, free of charge, a variety of safety equipment for those most at risk of such incidents. Such equipment comprises both smoke and carbon monoxide alarms, flame retardant bedding and portable “misting systems”.
(V) The absence of full notification to LFRS meant that the extent of the risk to which Mr Spring was exposed was not identified. As a consequence, he was not assessed by LFRS for the provision of the safety equipment described above.
(VI) Whilst a number of Properly Interested Persons have already met to discuss the concerns raised by this death, and whilst Air Liquide have already taken steps to ensure that their internal systems are more robust, there remains a need to put in place more extensive lines of communication between all relevant agencies, to ensure that the heightened risks posed by such patients are drawn to the attention of LFRS at the earliest opportunity.
(VII) Evidence was also given at Inquest that the availability of such safety equipment is not well known , and that by increased publicity to the relevant agencies in relation to their availability, there may be a wider distribution of such material with a consequential saving of lives.
” 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 a process for sharing information with Lincolnshire Fire & Rescue and Air Liquide into Trust policy.
Verbatim wording from the response “1. ULHT have met with Lincolnshire Fire & Rescue (LF&R) and Air Liquide to agree a process for sharing information. This is described in a new document which has been incorporated into Trust policy (see Attachment A).” Source location 2015-0123-Response-by-United-Lincolnshire-Hospitals-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 Include a documented fire-risk assessment in the standard operating procedure to identify patients at increased risk.
Verbatim wording from the response “3. As part of our standard operating procedure we have included a documented risk assessment designed by LF&R to identify patients who are at increased risk of fire (see Appendix 1 within the above attachment). The standard operating procedure also outlines a clear and agreed communication process between all parties. This will provide LF&R an opportunity to conduct a home assessment, and install any required safety equipment.” Source location 2015-0123-Response-by-United-Lincolnshire-Hospitals-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 Define an agreed communication process between the relevant parties in the standard operating procedure.
Verbatim wording from the response “3. As part of our standard operating procedure we have included a documented risk assessment designed by LF&R to identify patients who are at increased risk of fire (see Appendix 1 within the above attachment). The standard operating procedure also outlines a clear and agreed communication process between all parties. This will provide LF&R an opportunity to conduct a home assessment, and install any required safety equipment.” Source location 2015-0123-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Open published response
6 Mar 2015 Thor Harrison Dalhaug · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 12 Failure to maintain independence between clinical responsibility and SUI investigation View source Failure to identify and address inadequacies in an operating surgeon's statement and SUI View source Failure of statements to disclose the lack of support for forceps use to disimpact the fetal head View source Failure of SUI reports to disclose the lack of support for forceps use to disimpact the fetal head View source Failure to identify and rectify missing full notes after a death View source Failure to discipline those responsible for producing an inadequate SUI View source Interference with candid disclosure of the circumstances of a death View source Failure to read source statements before signing off an SUI Report View source Failure to formalise changes to the policy for inducting new staff View source Failure to supervise an operating surgeon during a complex twin delivery View source Failure to discipline clinicians or limit their practice after adoption of an inappropriate delivery technique View source Failure to maintain full contemporaneous records of term neonatal deaths View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Audit the accuracy of medical-record information and remind medical and midwifery staff of their candour duties.
Stated plannedThe respondent said that this action was planned when they made their response on 6 March 2015. View source
Action
Deliver case-study learning and disseminate reminders to medical staff about complete contemporaneous clinical documentation.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2015. View source
Action
Strengthen serious-incident investigations through revised governance processes, independent investigator requirements, weekly senior oversight, external submission and Trust Board reporting.
Stated in progressThe respondent said that this action was in progress when they made their response on 6 March 2015. View source
Action
Conduct annual operative-note spot audits for three years following the annual changeover of middle-grade doctors.
Stated plannedThe respondent said that this action was planned when they made their response on 6 March 2015. View source
Action
Implement the comprehensive junior-doctor obstetrics and gynaecology induction programme, including orientation, competency assessments, guidance access, support contacts, follow-up and supernumerary work.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2015. View source
Action
Embed the duty of candour into complaints and serious-incident systems, with compliance reported to the Quality Governance Committee.
Stated completedThe respondent said that this action was complete when they made their response on 6 March 2015. View source See 3 more actions
×
AI-generated summary
Thor Harrison Dalhaug · 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
Thor Dalhaug was delivered by caesarean section on 23 September 2013 in poor condition after difficulties delivering his deeply engaged head, and died approximately one hour after birth. The report identified concerns including lack of supervision of the operating surgeon, use of an inappropriate forceps technique, inadequate contemporaneous records and shortcomings in the internal investigation and disclosure of the circumstances of 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain independence between clinical responsibility and SUI investigation
Wider context from the report “(V) The fact that the consultant ultimately responsible for Thor was also charged with undertaking the SUI Report into his death . Further, that the consultant signed off the original SUI Report without having read any of the statements referred to in that report.
Please disclose the policy or means by which it has been made clear that this should not happen 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address inadequacies in an operating surgeon's statement and SUI
Wider context from the report “(IX) The fact that there was a failure to recognise the inadequacy of the operating surgeon's original statement and SUI and that these inadequacies were not addressed until I directed the Trust to obtain a full statement and undertake a comprehensive SUI .
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of statements to disclose the lack of support for forceps use to disimpact the fetal head
Wider context from the report “(VIII) The fact that none of the statements served by the Trust disclosed that there was no support for the use of forceps to disimpact the fetal head .
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of SUI reports to disclose the lack of support for forceps use to disimpact the fetal head
Wider context from the report “(VI) The fact that the original SUI and the revised version completed after receipt of the post mortem failed to disclose that there was no support for the use of forceps to disimpact the fetal head .
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and rectify missing full notes after a death
Wider context from the report “(IV) The failure to identify in the immediate aftermath of Thor's death that the operating surgeons had neglected to make a full note of the circumstances in which he died and to obligate them to provide the same ; in particular ████████ was advised to amend the Caesarean pro forma, to include the fact that forceps were used in the interests of candour. He was then dissuaded from doing so by senior management as a result of their concerns as to how this would be perceived if the matter was investigated. This raises very serious concerns as to the degree of candour in disclosing the circumstances of this death. What steps have been taken to obviate a repetition of this behaviour 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discipline those responsible for producing an inadequate SUI
Wider context from the report “(VII) The fact that no steps have been taken to discipline those involved in the production of this wholly inadequate SUI .
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Interference with candid disclosure of the circumstances of a death
Wider context from the report “(IV) The failure to identify in the immediate aftermath of Thor's death that the operating surgeons had neglected to make a full note of the circumstances in which he died and to obligate them to provide the same; in particular ████████ was advised to amend the Caesarean pro forma, to include the fact that forceps were used in the interests of candour. He was then dissuaded from doing so by senior management as a result of their concerns as to how this would be perceived if the matter was investigated. This raises very serious concerns as to the degree of candour in disclosing the circumstances of this death . What steps have been taken to obviate a repetition of this behaviour 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to read source statements before signing off an SUI Report
Wider context from the report “(V) The fact that the consultant ultimately responsible for Thor was also charged with undertaking the SUI Report into his death. Further, that the consultant signed off the original SUI Report without having read any of the statements referred to in that report .
Please disclose the policy or means by which it has been made clear that this should not happen 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise changes to the policy for inducting new staff
Wider context from the report “(I) The failure to supervise the operating surgeon on her first day at work for this complex twin delivery. It was stated in evidence that the policy of inducting new staff had changed but that this had not been enshrined in any formal document . Such a document should be produced and a copy submitted to myself.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise an operating surgeon during a complex twin delivery
Wider context from the report “(I) The failure to supervise the operating surgeon on her first day at work for this complex twin delivery . It was stated in evidence that the policy of inducting new staff had changed but that this had not been enshrined in any formal document. Such a document should be produced and a copy submitted to myself.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to discipline clinicians or limit their practice after adoption of an inappropriate delivery technique
Wider context from the report “(II) The lack of any steps having been taken to discipline the clinicians involved or limit their practice given their decision to adopt a wholly inappropriate, unacceptable, and unorthodox technique in delivering Thor, resulting in his death.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain full contemporaneous records of term neonatal deaths
Wider context from the report “(III) The failure to ensure a full contemporaneous record was kept by doctors involved in a term neonatal death . Such failure has seriously hampered my investigation into the circumstances surrounding Thor's death and has resulted in serious difficulties to Thor's family who clearly struggled and suffered as a result of not being able to understand why their son died shortly after his birth.
” 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 the accuracy of medical-record information and remind medical and midwifery staff of their candour duties.
Verbatim wording from the response “The Trust fully accepts, however, that any inference that a later timed addendum should not be added to provide greater clarity to the records was not appropriate. By way of reassurance, whilst reminding staff of the need to complete full contemporaneous notes we will also be auditing the accuracy of information within medical records, the Clinical Director and Head of Midwifery have written to all medical and midwifery staff to remind them of their duties regarding candour.” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-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 Deliver case-study learning and disseminate reminders to medical staff about complete contemporaneous clinical documentation.
Verbatim wording from the response “It is accepted that contemporaneous recording of all events is important in healthcare practice. By way of reassurance, the doctors who join the Department are informed about the importance of ensuring a full contemporaneous record of any clinical interaction at their Trust and departmental induction. The Head of Service and the Consultant Labour Ward Lead undertake case study learning sessions. Lessons about, but not limited to, documentation problems from this case are included in the lessons learnt section.” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-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 Strengthen serious-incident investigations through revised governance processes, independent investigator requirements, weekly senior oversight, external submission and Trust Board reporting.
Verbatim wording from the response “This was not appropriate and should not have happened. Since 2014 the Trust has significantly reviewed and changed its processes relating to investigations (please see Appendix 2).” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-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 Conduct annual operative-note spot audits for three years following the annual changeover of middle-grade doctors.
Verbatim wording from the response “Whilst dissemination of learning is important, the Trust will also undertake spot audits of operative notes, once a year for the next 3 years. This will be done after annual change of middle grade doctors and facilitated by audit leads on both sites. Should there be any failures from the audit; appropriate action will be taken until the Trust is satisfied that there is a robust system of recording.” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-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 the comprehensive junior-doctor obstetrics and gynaecology induction programme, including orientation, competency assessments, guidance access, support contacts, follow-up and supernumerary work.
Verbatim wording from the response “As indicated in the evidence heard at inquest, the Trust has now taken various steps to significantly reduce the chance of such a situation occurring again. In particular, all junior doctors will now:-” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-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 Embed the duty of candour into complaints and serious-incident systems, with compliance reported to the Quality Governance Committee.
Verbatim wording from the response “The duty of candour has been incorporated into our complaints policy. It is also incorporated into our DATIX incident management system for moderate and severe harms. The compliance with the documentation of duty of candour is reported upward to the Quality Governance Committee – one of four sub-committees that report to the Trust Board.” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-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 did not consider it appropriate to single out or blame an individual, preferring wider analysis of working systems and processes.
Verbatim wording from the response “Matters relating to disciplinary proceedings are confidential between the employee and employer. The Trust would, however, like to offer you assurance that appropriate management action has been taken including liaison with the relevant regulatory authorities. The Trust would also like to make it clear that whilst it acknowledges that the forceps delivery should not have been attempted, it did not feel it appropriate to single out or blame any individual for the tragic events that occurred that day during delivery. The Trust wished to analyse the wider context” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-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 could not discuss disciplinary proceedings because they were confidential matters between employee and employer.
Verbatim wording from the response “As discussed at response 2 above the Trust is advised that it would not be appropriate to discuss any disciplinary proceedings.” Source location 2015-0063-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Open published response
26 Aug 2014 Iris May GRIMWOOD · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 3 Insufficient nursing staffing capacity View source Failure to use semi-automatic thermometers correctly for measuring body temperature View source Failure to administer topical medication to the correct body site 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
Iris May GRIMWOOD · 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
Iris May GRIMWOOD, aged 80, died at Pilgrim Hospital on 8 October 2013 as a result of progressive neurological disease. Concerns were raised about difficulties providing the nursing care she needed, including errors in using semi-automatic thermometers and an attempted application of an antifungal ointment prescribed for oral thrush to her genital region.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nursing staffing capacity
Wider context from the report “Evidence from medical staff at Pilgrim Hospital and members of Iris's family included expressions of concern that there were difficulties in providing the level of nursing care that Iris needed . Evidence was also given that mistakes were made in the use of semi-automatic thermometers for measuring body temperature and an episode was described where a nurse attempted to apply an antifungal ointment to Iris's genital region, this having been prescribed for the treatment of oral thrush, before being stopped by a family member. The medical staff attributed these problems to less than optimal numbers of nursing staff , compounded by difficulties in recruitment and retention of nursing staff as well as problems with funding training.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use semi-automatic thermometers correctly for measuring body temperature
Wider context from the report “Evidence from medical staff at Pilgrim Hospital and members of Iris's family included expressions of concern that there were difficulties in providing the level of nursing care that Iris needed. Evidence was also given that mistakes were made in the use of semi-automatic thermometers for measuring body temperature and an episode was described where a nurse attempted to apply an antifungal ointment to Iris's genital region, this having been prescribed for the treatment of oral thrush, before being stopped by a family member. The medical staff attributed these problems to less than optimal numbers of nursing staff, compounded by difficulties in recruitment and retention of nursing staff as well as problems with funding training.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer topical medication to the correct body site
Wider context from the report “Evidence from medical staff at Pilgrim Hospital and members of Iris's family included expressions of concern that there were difficulties in providing the level of nursing care that Iris needed. Evidence was also given that mistakes were made in the use of semi-automatic thermometers for measuring body temperature and an episode was described where a nurse attempted to apply an antifungal ointment to Iris's genital region, this having been prescribed for the treatment of oral thrush , before being stopped by a family member. The medical staff attributed these problems to less than optimal numbers of nursing staff, compounded by difficulties in recruitment and retention of nursing staff as well as problems with funding training.
” Open source report
14 Jan 2014 Craig Adam White · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 4 Failure to provide continuing patient education about Infliximab treatment risks View source Delays in initiating treatment when tuberculous meningitis is suspected View source Lack of protocols for pre-Infliximab tuberculosis screening View source Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment 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
Craig Adam White · 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
Craig Adam White was a 21-year-old student who developed disseminated tuberculosis, including tuberculosis leptomeningitis, while receiving immunosuppressive treatment for Crohn’s disease. He had recurrent chest infections and later deteriorated with neurological illness before tuberculosis was confirmed. The principal concerns were tuberculosis screening before Infliximab treatment, healthcare professionals’ awareness of the associated risk, continuing patient education, and prompt treatment when tuberculous meningitis is suspected.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuing patient education about Infliximab treatment risks
Wider context from the report “3 The need for continuing patient education about the risks of Infliximab treatment
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in initiating treatment when tuberculous meningitis is suspected
Wider context from the report “4 The need for prompt treatment to be initiated when tuberculous meningitis is suspected
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols for pre-Infliximab tuberculosis screening
Wider context from the report “1 Protocols for pre-Infliximab treatment screening for tuberculosis
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of healthcare professional awareness of the increased tuberculosis risk inherent in Infliximab treatment
Wider context from the report “2 Awareness of Health Care Professionals, in particular prescribers of the increased risk of TB inherent Infliximab treatment
” Open source report
4 Nov 2013 Susan Jill Hammond · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 3 Failure to ensure effective allergy information handover during transfers from A&E to EAU View source Failure to make patient allergies sufficiently prominent in hospital documentation View source Failure to clarify whether relevant professional referrals were being made 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
Susan Jill Hammond · 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
Susan Jill Hammond, who had a known penicillin allergy, was admitted to hospital after becoming ill and was administered intravenous Augmentin despite allergy warnings. She suffered a cardiac arrest and died on 3 July 2009. The principal concerns were that allergy warnings were not sufficiently noticed and that the handover between departments did not communicate her penicillin allergy.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective allergy information handover during transfers from A&E to EAU
Wider context from the report “(2) It appears that when Mrs Hammond transferred from the A&E unit to the EAU she was accompanied by a nurse who had little knowledge of Mrs Hammond's condition . As a consequence no discussion took place at the handover regarding the nature of Mrs Hammond's allergy to penicillin . It is felt that the nurse who had cared for Mrs Hammond in the A&E department had personally accompanied her to the EAU this would have enabled a more productive handover and would have given an opportunity for discussion regarding the allergy. Although I appreciate there may be practical difficulties I would suggest that in future when a patient is transferred care for the patient in A&E should always accompany the patient to the EAU department in order that constructive handover can take place .
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make patient allergies sufficiently prominent in hospital documentation
Wider context from the report “(1) Although there were written warnings of Mrs Hammond's allergy on hospital documentation they appear not to have been noticed by the nurse who administered augmentin . In an effort to highlight the fact that a patient has an allergy I feel that there needs to be a much clearer indication on the file that the patient has such an allergy . At the inquest, it was suggested that a different coloured file should be used for any patient who has an allergy. Alternatively, a large sticker on the front of the file warning of the allergy would assist.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify whether relevant professional referrals were being made
Wider context from the report “(3) Your representative at the inquest hearing was not clear as to whether the doctor involved in this case was going to be referred to the General Medical Council and the nurse who administered Augmentin was going to be referred to the Nursing & Midwifery Council it was agreed that he would inform me of this within 14 days of conclusion of the inquest.
” Open source report
30 Aug 2013 Jessica Florence Ashton-Pyatt · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 3 Unco-ordinated staff response to immediate care View source Lack of consultant leadership of immediate care View source Failure to maintain a ready-to-use defibrillator and defibrillation pads 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
Jessica Florence Ashton-Pyatt · 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
Jessica Florence Ashton-Pyatt became acutely unwell on 28 October 2012 and died after unsuccessful resuscitation following admission to hospital. Concerns included unco-ordinated care, initially absent consultant leadership, an uncharged defibrillator, and no defibrillation pads initially being available.
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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unco-ordinated staff response to immediate care
Wider context from the report “The response of the staff to Jessica's care on admission was unco-ordinated , with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant leadership of immediate care
Wider context from the report “The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available.
” 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 United Lincolnshire Teaching Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a ready-to-use defibrillator and defibrillation pads
Wider context from the report “The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations