Concerns raised 1 Lack of clear explanation of the UCLH dietetic service’s scope and exclusion of eating-disorder treatment 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
Charlotte Louise WERNER · 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
Charlotte Louise Werner, aged 13, hanged herself at home and the inquest determined that she died by suicide. Her mother believed Charlotte was suffering from an eating disorder and that the referral to a UCLH dietitian was partly to explore this, but Charlotte had not been diagnosed with an eating disorder and the referral was solely to consider whether her nutritional status affected her height.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear explanation of the UCLH dietetic service’s scope and exclusion of eating-disorder treatment
Wider context from the report “Charlotte’s mother formed the view that Charlotte was suffering from an eating disorder and was under the impression that the referral to a UCLH dietitian was made, at least in part, in order to explore this .
In fact, Charlotte was never diagnosed with an eating disorder, did not meet the criteria for a referral on this basis and was referred solely for consideration of whether her nutritional status was having an impact on her height.
I found no evidence of any link between Charlotte’s eating and her death. However, that might be different for another child.
It seems from the evidence I heard that an explanation, perhaps on the website or in correspondence, that the UCLH dietetic service is not a mental health service and does not treat eating disorders, could be helpful .
” Open source report
30 Sep 2024 Sophie Ann Dean · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to provide complete information about treatment options before consent View source Failure to ensure that consultation notes fully record discussions and assessments View source Failure to obtain treatment consent without pressuring families View source Omissions from medical records 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
Sophie Ann Dean · 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
Sophie Ann Dean, who was aged 18, underwent surgery after free air was found in her abdomen and later required re-closure of her abdominal wound. She developed a chest infection and, after the second operation on 4 September 2023, suffered a cardiac arrest and died despite resuscitation efforts. The substantive concerns related to omissions and inadequacies in the medical records and whether the rationale and alternatives to surgery were sufficiently discussed with her parents before consent was given.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete information about treatment options before consent
Wider context from the report “3) The on-call surgeon used language such as having “pushed the family” into agreeing to surgery on 24 August 2023. There was also evidence that not all options/possibilities were discussed with Miss Dean’s parents prior to their consenting to surgery . The evidence was that Miss Dean’s parents may not have fully understood the rationale for surgery or the possibility of conservative management of the issue , prior to the laparotomy on 24 August 2023.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that consultation notes fully record discussions and assessments
Wider context from the report “1) Consultant’s undertaking ward rounds allowed very junior doctors to make the entry from these consultations in the patient records. While there is no concern about this per se, there were numerous key factors missing from these notes . I am concerned that the notes did not fully represent the discussions and assessments that took place , which creates risk.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain treatment consent without pressuring families
Wider context from the report “3) The on-call surgeon used language such as having “pushed the family” into agreeing to surgery on 24 August 2023. There was also evidence that not all options/possibilities were discussed with Miss Dean’s parents prior to their consenting to surgery. The evidence was that Miss Dean’s parents may not have fully understood the rationale for surgery or the possibility of conservative management of the issue, prior to the laparotomy on 24 August 2023.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omissions from medical records
Wider context from the report “2) There were other omissions from the medical records for Miss Dean’s admission.
” Open source report
Concerns raised 5 Failure to provide household infection-control safety advice after E coli diagnosis View source Failure to provide treating clinicians with public health investigation feedback and infection-control information View source Failure to obtain relevant exposure information from household contacts during E coli source investigation View source Failure to obtain a sufficiently complete exposure history during E coli source investigation View source Failure of public health authorities to provide an accessible route to meaningful information for bereaved relatives View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Laura Lesley FARMER · 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
Laura Farmer was admitted to hospital after a diarrhoeal illness and was diagnosed with HUS caused by Shiga toxin-producing E. coli. She suffered an unexpected stroke while thought to be recovering and died as a consequence. The report raises concerns about public-health investigation and communication, including limited information-gathering, lack of feedback to clinicians and family, and insufficient advice on infection-control and safety.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide household infection-control safety advice after E coli diagnosis
Wider context from the report “3. After his wife’s diagnosis, Mr Farmer was given no advice about how to keep himself and their child safe . He cleaned the bathroom in anticipation of his wife’s return home, but did not use any personal protective equipment.
When he later became unwell, he did not know whether he had put himself at risk. Having heard his description in court, I think it is not an exaggeration to say that he was then terrified that his own actions might leave his child an orphan.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide treating clinicians with public health investigation feedback and infection-control information
Wider context from the report “4. The clinicians treating Ms Farmer gave evidence at inquest that they did not know if the source of the infection that killed her had ever been identified.
Mr Farmer saw in the news that there was a local E coli outbreak in Waverley, Surrey. The clinicians at UCLH knew which strain of E coli had infected Ms Farmer, but not whether that strain had been discovered in Waverley or indeed elsewhere, because after reporting to the UKHSA they received no feedback , no advice on infection control and no information they could give Mr Farmer.
After a death from E coli, there seems to have been no closing of the loop of safety information that could have assisted those most closely involved.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain relevant exposure information from household contacts during E coli source investigation
Wider context from the report “2. The UKHSA did not at any stage ask ████████ for information to assist in attempting to determine the source of the E coli infection that ultimately killed his wife. If asked, Mr Farmer would have explained that on 6 April 2024, not only did he and his wife visit a local restaurant, they also had drinks at a nearby club, and they had recently eaten and drunk at local military establishments. None of that information appears to have been considered by the UKHSA .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain a sufficiently complete exposure history during E coli source investigation
Wider context from the report “1. Someone from what was described to me as public health (I assume the UKHSA) spoke to Laura Farmer the day before her death, asking for information. However, she was in intensive care at the time and not able to give a full, detailed picture . There was apparently no exploration of potential contact with animals or water sports and I was told that only scant details of a recent restaurant visit were obtained .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of public health authorities to provide an accessible route to meaningful information for bereaved relatives
Wider context from the report “5. Mr Farmer explained to me that he had spent some considerable time and effort since his wife’s death trying to obtain basic information from the public health authorities without success. He struck me as a person of significant drive, and yet he found it incredibly difficult to find the correct person to speak to and then incredibly difficult to gain any meaningful understanding of what had happened .
This cannot inspire public confidence and seems a very offhand way to treat a grieving relative.
I did not call anyone from the UKHSA to give evidence at inquest, because I had expected that UKHSA would have shared relevant information with both clinicians and family. It may be, therefore, that there are explanations for what seem to be surprising actions and inactions. If that is the case, then of course you will be able to explain as much in your response.
” Open source report
Concerns raised 9 Removal of the patient call buzzer and closure of the patient’s door at night View source Failure to maintain timely effective nasogastric tube decompression View source Failure to implement safety changes to policies, procedures and systems View source Failure to transfer care to the appropriate clinical specialty View source Failure to communicate and understand acute clinical information in consultant handover View source Inadequate pain relief provision View source Lack of a proper trust investigation after a patient death View source Delays and confusion in inter-hospital transfer coordination View source Failure to escalate unsuccessful nasogastric tube placement to appropriate medical expertise View source See 6 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
Sarah CHAPPELL · 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
Sarah Chappell was transferred to University College London Hospital on 31 May 2023 and died there on 23 June 2023. The report identified concerns about delays in transfer, failure of the appropriate clinical team to take charge, inadequate pain relief and poor communication. It also identified inappropriate management of her nasogastric tube; the inquest concluded that her care was suboptimal and that, if the tube had been managed appropriately, she would have survived this episode.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Removal of the patient call buzzer and closure of the patient’s door at night
Wider context from the report “4. Whilst at UCLH, the pain relief offered to Ms Chappell (principally simply paracetamol) was completely inadequate. At night, her buzzer was taken away from her and her door was shut .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain timely effective nasogastric tube decompression
Wider context from the report “5. The management of the nasogastric tube that was crucial in attempting to avoid a fatal aspiration was inappropriate . The tube in situ that was operating effectively was removed approximately ten days before her death . Her abdomen became extremely distended.
A further tube placement was not attempted until the day before she died . When this proved beyond the nurses’ skillset, a doctor was not called to assist until the following afternoon.
By then, two experienced doctors were unable to insert a tube and, as they were attending her (with her mother present), their patient suffered a massive aspiration and died shortly afterwards.
I was told at inquest that if the nasogastric tube had been passed at an earlier point, this would have been done successfully and the fatal cardiac arrest would have been avoided.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement safety changes to policies, procedures and systems
Wider context from the report “6. This death occurred almost six months ago, but no proper trust investigation has taken place, no changes in policies or procedures has been agreed , and the systems at UCLH remain largely what they were on the day that Sarah Chappell died .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer care to the appropriate clinical specialty
Wider context from the report “2. From at least 16 June 2023, the consultant urology surgeon in charge of Ms Chappell’s care was very firmly of the view that he was not the best clinician to fulfil this role . He had long since correctly determined that she had not sustained a ruptured bladder, and thus considered that her care belonged with the gastroenterologists or the general surgeons.
Despite the agreement on 16 June of the gastroenterology clinical director that Ms Chappell’s care should be led by the gastroenterologists, they had not taken over her care by the time of her death , and there had not even been a conversation between the gastroenterology and general surgery consultants about the transfer of care .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and understand acute clinical information in consultant handover
Wider context from the report “3. There was a frequent misunderstanding among the medical staff that Ms Chappell’s issues were all chronic . Her acute situation was often not properly handed over or understood by her consultants .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate pain relief provision
Wider context from the report “4. Whilst at UCLH, the pain relief offered to Ms Chappell (principally simply paracetamol) was completely inadequate . At night, her buzzer was taken away from her and her door was shut.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a proper trust investigation after a patient death
Wider context from the report “6. This death occurred almost six months ago, but no proper trust investigation has taken place , no changes in policies or procedures has been agreed, and the systems at UCLH remain largely what they were on the day that Sarah Chappell died.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and confusion in inter-hospital transfer coordination
Wider context from the report “1. There was a ten day delay in Ms Chappell’s transfer from the Princess Royal Hospital to UCLH . I was told that this might have been because of a lack of beds, but it might also have been because of confusion about which UCLH site was the accepting surgeon’s preferred destination , a confusion that was understood at the time by the Princess Royal to be a rejection of the transfer.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate unsuccessful nasogastric tube placement to appropriate medical expertise
Wider context from the report “5. The management of the nasogastric tube that was crucial in attempting to avoid a fatal aspiration was inappropriate. The tube in situ that was operating effectively was removed approximately ten days before her death. Her abdomen became extremely distended.
A further tube placement was not attempted until the day before she died. When this proved beyond the nurses’ skillset, a doctor was not called to assist until the following afternoon .
By then, two experienced doctors were unable to insert a tube and, as they were attending her (with her mother present), their patient suffered a massive aspiration and died shortly afterwards.
I was told at inquest that if the nasogastric tube had been passed at an earlier point, this would have been done successfully and the fatal cardiac arrest would have been avoided.
” 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 Review processes for allocating the named consultant, agreeing joint care, and escalating disagreements about care ownership.
Verbatim wording from the response “We completely recognise that clearer processes both around joint care and escalation of decisions on ownership of care if there are disagreements are required. We will review our processes for allocating the named consultant in charge, agreeing joint care and escalation processes when there is disagreement over the named consultant by May 2024.” Source location Response from University College London Hospitals
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 Establish mortality surveillance reviews for all UCLH patients with a learning disability who die.
Verbatim wording from the response “In January 2023 we instigated a process as part of our mortality surveillance group to review all patients with a learning disability who die at UCLH. This group is chaired by the corporate medical director and attended by multi-professional group including the learning disability team, quality & safety team and structured judgement review leads.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a mental health and enhanced-observations programme board to assure care for patients requiring enhanced care.
Verbatim wording from the response “Whilst we were responsive to Ms Chappell’s concern about her buzzer we recognise that vulnerable patient groups may require enhanced levels of care and observation to ensure easy access to communication aids. In January 2024 we convened a mental health and enhanced observations programme board, chaired by the chief nurse. This group provides assurance to the nursing & midwifery board and senior directors team that the assessment, delivery and evaluation of care meets the needs of people requiring enhanced care.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the bowel-obstruction flow chart to include escalation procedures and timelines.
Verbatim wording from the response “We will also update our bowel obstruction flow chart by March 2024 to ensure it includes escalation procedures and timelines.” Source location Response from University College London Hospitals
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 Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.
Verbatim wording from the response “Recognising that there was confusion between PRUH and UCLH relating to transfer we will develop a referral form for urology by May 2024 to improve documentation around the reason for transfer and agreed decisions to inform the plan of care. This will be led by the clinical lead for urology and will mirror some of our best practice referrals such as in the thoracic service.” Source location Response from University College London Hospitals
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 Complete a cardiac-arrest rapid review and produce a detailed after-action improvement plan.
Verbatim wording from the response “A 72 hour cardiac arrest rapid review was undertaken on 3rd July 2023. This culminated in an after-action review with a robust and detailed action plan. There was a delay to producing the action plan (October 2023) and we recognise this as a concern.” Source location Response from University College London Hospitals
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 Launch a nurse-in-charge dashboard incorporating live pain-review and quality-and-safety metrics.
Verbatim wording from the response “We have since launched a nurse-in-charge dashboard (in January 2024) which incorporates a pain review. This is a live dashboard which allows the nurse-in-charge to rapidly view quality and safety metrics, such as pain scores, for all patients.” Source location Response from University College London Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the nasogastric-tube policy to cover surgical drainage and escalation of difficult or unsuccessful tube placement.
Verbatim wording from the response “Ms Chappell was admitted to UCLH with a nasogastric (NG) tube from PRUH on 1st June 2023. The NG tube was removed on 10th June 2023 due to low drainage volume which is appropriate practice. A NG tube can be uncomfortable for patients and prolonged placement can cause inflammation of the oesophagus. We therefore remove them if they are not required. Following a scan on 22nd June there was a request for a new, larger NG to be inserted. Nasogastric tube insertion can be difficult and not predictable as to which in patients such insertion may succeed. However, we recognise there were multiple attempts to insert the larger NG tube and that there were failings in the escalation of a difficult NG tube insertion.” Source location Response from University College London Hospitals
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 Undertake and report a pain-team service review to identify response-time gaps and improvement processes.
Verbatim wording from the response “We also recognise there are improvements required around monitoring response times to pain team referrals and evaluating impact. We will undertake a service review of the pain team by May 2024, led by the head of nursing for Surgery and Cancer Board, to understand gaps in the service and to identify systems and processes for improvement. This review will report to the pain steering group by July 2024.” Source location Response from University College London Hospitals
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 UCLH states the NG tube was removed appropriately because drainage was low, and that subsequent insertion was inherently difficult and unpredictable.
Verbatim wording from the response “Ms Chappell was admitted to UCLH with a nasogastric (NG) tube from PRUH on 1st June 2023. The NG tube was removed on 10th June 2023 due to low drainage volume which is appropriate practice. A NG tube can be uncomfortable for patients and prolonged placement can cause inflammation of the oesophagus. We therefore remove them if they are not required. Following a scan on 22nd June there was a request for a new, larger NG to be inserted. Nasogastric tube insertion can be difficult and not predictable as to which in patients such insertion may succeed. However, we recognise there were multiple attempts to insert the larger NG tube and that there were failings in the escalation of a difficult NG tube insertion.” Source location Response from University College London Hospitals
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The transfer delay reflected unavailable UCLH beds and an unconfirmed referral by PRUH, although UCLH acknowledges confusion about the transfer arrangements.
Verbatim wording from the response “Ms Chappell was transferred to UCLH as an emergency referral from PRUH on 1st June 2023, as the team there believed she had suffered a perforation of her neobladder. She had been discussed by the PRUH team with a urology consultant on 22 May 2023 and accepted for transfer, however there were no available beds at the time at UCLH. PRUH appear to have organised Ms Chappell’s transfer to the UCLH Emergency Department without confirming with the Urology team at UCLH and Ms Chappell was subsequently admitted to a surgical ward (T14 north) when they had a bed available. Ms Chappell was then transferred to T14 Acute Surgical Unit on the evening of 1st June 2023.” Source location Response from University College London Hospitals
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 UCLH disputes that pain relief was limited to paracetamol, citing morphine, intravenous paracetamol, patient preference and one-to-one care.
Verbatim wording from the response “Ms Chappell was given morphine and regular intravenous paracetamol for pain relief. When administered intravenously (as opposed to orally), paracetamol can be as effective as intravenous morphine but without the side effects such as drowsiness, nausea and lowered respiratory rate. On 3rd June 2023, Ms Chappell’s respiratory rate and oxygen levels dropped following morphine administration for pain. This led to Ms Chappell requiring naloxone to reverse the effects of the morphine.” Source location Response from University College London Hospitals
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 UCLH disputes that gastroenterology had agreed to take over care, stating that specialist gastroenterology teams reviewed the patient instead.
Verbatim wording from the response “For clarification, the clinical director for gastroenterology was not involved in discussions relating to Ms Chappell’s care at UCLH: this was undertaken by the clinical lead for gastroenterology.” Source location Response from University College London Hospitals
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 UCLH disputes that the buzzer was removed or the door routinely kept shut, stating the buzzer was sometimes difficult to locate.
Verbatim wording from the response “4. At night, her buzzer was taken away from her and her door was shut.” Source location Response from University College London Hospitals
Open published response
27 Jan 2023 Toby Wilbur Barwick · Prevention of Future Deaths report East London
View report summary
Concerns raised 1 Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices 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
Toby Wilbur Barwick · 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
Toby Wilbur Barwick was born on 24 November 2020 and died in hospital on 12 February 2021 after being found unresponsive while sleeping in a fabric baby carrier. The inquest heard that his parents did not receive advice and documentation from UCLH about SIDS and recommended safe practices, and UCLH could not provide clear evidence that the factors leading to this omission had been remedied.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide maternity discharge advice and documentation on SIDS and recommended safe practices
Wider context from the report “1. The inquest heard that infants of low birth weight have a higher chance of dying in circumstances of Sudden Infant Death Syndrome (“SIDS”). Upon discharge from a maternity unit mother should receive advice and documentation upon a number of issues including (but not limited to) SIDS and recommended safe practices to reduce risk. Mr & Mrs Barwick did not receive this material at UCLH. UCLH could not provide clear evidence that the factors that led to this omission had been successfully remedied.
” Open source report
Concerns raised 9 Failure to consider documented pressure-ulcer risk when issuing care instructions View source Failure to adequately investigate safeguarding explanations and evidence View source Failure to implement system, training and partnership changes after safeguarding investigation View source Failure to involve district nursing team in discharge planning View source Failure to arrange pressure-relieving bed and mattress replacement before discharge View source Failure to provide required personal hygiene and catheter care during home visits View source Failure to issue and disseminate daily skin-integrity checking instructions to all carers View source Omission of daily skin-integrity checking instruction from discharge assessment form View source Failure to establish daily skin-integrity monitoring responsibility View source See 6 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. 15
Action
Contribute to developing the NCL tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Deliver pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Train registered nurses to add discharge-relevant nursing notes to Epic discharge summaries; training is complete for senior ward nurses.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
Stated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022. View source
Action
Review and improve local processes and staff education to prevent poor patient outcomes and support safe, holistic discharge and community care.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Contribute to development of the North Central London tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Stated completedThe respondent said that this action was complete when they made their response on 8 December 2022. View source
Action
Communicate to staff the referral-screening process requiring completion of skin and nursing sections before referrals reach community partners.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source
Action
Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
Stated plannedThe respondent said that this action was planned when they made their response on 8 December 2022. View source See 12 more actions
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AI-generated summary
Richard Thomas SHANNON · 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
Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider documented pressure-ulcer risk when issuing care instructions
Wider context from the report “5. The City of Westminster social worker considering the Discharge to Assess form did not consider any part of the form other than the specific instructions . She did not include in her thinking the record a little further down the same page that Professor Shannon had a grade 2 pressure ulcer and was at high risk of developing pressure ulcers.
She told me that she was a social worker and not medically trained to read the Discharge to Assess form. However, she accepted that the form clearly stated that Professor Shannon had a grade 2 pressure ulcer and was at high risk of pressure ulcers.
She said that she did not issue a specific instruction to Kapital to check skin integrity every day.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately investigate safeguarding explanations and evidence
Wider context from the report “7. The City of Westminster undertook a safeguarding investigation after Professor Shannon’s death.
In that investigation, intended to learn lessons for the benefit of others, the City of Westminster investigator accepted, as the social worker had at the time, the explanation given by Kapital that the towels had been brought to the property after the carer’s first visit that morning and therefore had not been available to the carer. The investigator did not interview the Kapital carer. He accepted at inquest that he should have done.
There was no evidence to support Kapital’s assertion and it was in fact completely inaccurate.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement system, training and partnership changes after safeguarding investigation
Wider context from the report “8. The safeguarding investigation was concluded by the social worker from Westminster at the end of June 2022, but I was told that there have been no changes made to systems or training in the intervening five months . The social worker has recently emailed partner agencies suggesting a meeting, but no such meeting has taken place .
Apparently, no lessons have been learnt.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve district nursing team in discharge planning
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting , it is much more likely that this measure would have been considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange pressure-relieving bed and mattress replacement before discharge
Wider context from the report “1. The discharge team at University College Hospital (UCH) did not seek a pressure relieving bed and mattress to replace Professor Shannon’s own before he was discharged on 5 January.
This was because his sacral pressure ulcer was almost fully healed and so they did not consider it necessary. However, he was at risk of further pressure ulcers and so it was a measure that should have been sought. The changing of a bed is more difficult to organise once the patient is home and sleeping in it.
If the Central London Community Healthcare district nursing team at Soho Centre for Health and Care (the district nurses) had been invited and had attended the UCH discharge planning meeting, it is much more likely that this measure would have been considered.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide required personal hygiene and catheter care during home visits
Wider context from the report “6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag .
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it.
In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to issue and disseminate daily skin-integrity checking instructions to all carers
Wider context from the report “3. The district nurses expected the carers employed by Kapital Care UK Limited (the Kapital carers) and commissioned by social services at the City of Westminster Council (social services) to check the skin integrity every day. However, there is no record that they issued such an instruction .
Even if individual district nurses had sought to issue such an instruction to Kapital carers, the district nurses only attended the home once a day and did not always meet the carers. When the nurses did meet the carers, they rarely saw the same carer twice.
Individual district nurses could not ensure that such an instruction was issued to all carers who attended Professor Shannon. This instruction had to be given at a higher level and passed on to each and every Kapital carer.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Omission of daily skin-integrity checking instruction from discharge assessment form
Wider context from the report “4. Upon discharge, a Discharge to Assess form was completed by therapists (I am unclear whether occupational or physiotherapists) at UCH and sent to social services at the City of Westminster. The form raised a number of concerns, but did not specifically instruct that carers should check skin integrity every day. That was an omission.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish daily skin-integrity monitoring responsibility
Wider context from the report “2. Upon discharge, UCH sent a referral to the district nurses. This included notification of a grade 2 pressure ulcer and a high risk of pressure ulcers in the future. Professor Shannon had three significant risk factors. He was immobile, he had diabetes, and he had already suffered a pressure ulcer.
The UCH nurses expected the district nurses to check the skin integrity every day. The district nurses did not intend to include this in their daily tasks when they attended the home to assist with insulin administration for diabetic control and with catheter care.
If the district nurses had been invited and had attended the UCH discharge planning meeting, this misunderstanding could easily have been identified and the true position understood by all.
” 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 Contribute to developing the NCL tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Verbatim wording from the response “• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.” Source location Response from University College London Hospitals
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 Communicate referral-screening requirements to staff so therapists and referrers complete skin and nursing sections before referrals reach community partners.
Verbatim wording from the response “• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will be further communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.” Source location Response from University College London Hospitals
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 Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
Verbatim wording from the response “• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.” Source location Response from University College London Hospitals
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 pressure-ulcer training to therapists on causes, risk factors, and clear skin-care instructions in discharge-to-assess forms, completing Trust-wide training by June 2023.
Verbatim wording from the response “• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).” Source location Response from University College London Hospitals
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 Train registered nurses to add discharge-relevant nursing notes to Epic discharge summaries; training is complete for senior ward nurses.
Verbatim wording from the response “• Registered nurses will be trained to add nursing notes (pertinent to discharge and continuity of care), on the discharge summaries on Epic . This has been completed for the senior staff nurses working in the ward (care of older people), where Professor Shannon was a patient. This training has been evaluated and will now be rolled out to specific wards across all hospital sites that link with community and social care partners. This will be review quarterly and reported quarterly through the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse). The Trust Patient Safety Committee (PSC) will also be updated on a quarterly basis.” Source location Response from University College London Hospitals
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 Document tissue viability reviews in Epic’s discharge-planning section to communicate skin risks and equipment, dressing, and skin-check requirements before discharge.
Verbatim wording from the response “• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.” Source location Response from University College London Hospitals
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 Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
Verbatim wording from the response “• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.” Source location Response from University College London Hospitals
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 Document tissue viability reviews in Epic’s discharge-planning section to capture skin risks and equipment, dressing and skin-check requirements.
Verbatim wording from the response “• The Tissue Viability (TV) team at UCLH now document their reviews on the discharge planning section of the patient’s electronic health record system (Epic). This was previously completed under another section of the patient’s notes. This change ensures that the discharge team has a holistic view of the patient’s need, including skin concerns / risks and requests for equipment/dressings/skin checks, prior to discharge. This in turn ensures improved communication of risk, from UCLH discharge team to our community and social care partners.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
Verbatim wording from the response “• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
Verbatim wording from the response “• UCLH has liaised with Central London Community Health (CLCH) to improve links with district nurses. The UCLH discharge team now has the phone number of the district nurses and know that between 2-4pm Monday-Friday, the team will be available to discuss any discharges.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver pressure-ulcer training to therapists, including risk factors and clear communication of skin-care instructions on discharge-to-assess forms.
Verbatim wording from the response “• Pressure ulcer training for therapists has commenced in the ward where Professor Shannon was a patient. This includes understanding of the causes and risk factors for pressure ulcers to ensure information/instructions in relation to skin care and risk is communicated clearly on the discharge to assess forms. Regular drop-in teaching sessions continue, as well as planned sessions to ensure all therapists in the trust have had this training by the end of June 2023. This training will be evaluated and reported via the Harm-free Care Committee and the Nursing and Midwifery Board (chaired by the Chief Nurse).” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve local processes and staff education to prevent poor patient outcomes and support safe, holistic discharge and community care.
Verbatim wording from the response “We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contribute to development of the North Central London tissue viability passport for consistent pressure-ulcer information at discharge and in community care.
Verbatim wording from the response “• North Central London (NCL) Integrated Care Board (ICB) has developed a NCL tissue viability passport which is designed to be a consistent tool for recording and communicating information about pressure ulcers at the point of discharge and within the community. UCLH discharge and tissue viability teams have contributed to the development of the tool. The tissue viability passport form will be used across NCL hospitals, when signed off by the NCL ICB senior management team. Once finalised, this form will be embedded into the UCLH’s Epic system for hospital use.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate to staff the referral-screening process requiring completion of skin and nursing sections before referrals reach community partners.
Verbatim wording from the response “• Following discussion with the Islington Transfer of Care Hub Clinical Screener, all referrals should be screened to ensure that the skin section and all nursing sections are completed by the therapist/referrer, prior to them being sent to the community partners. This is the expected process which will further be communicated to staff to ensure clinical information is highlighted and an appropriate care plan identified.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
Verbatim wording from the response “• We have set up monthly review meetings with CLCH to ensure the partnership working continues to develop and improve including, enhancing UCLH’s understanding of the district nurse role. This will also include joint education and training, to better understand roles and responsibilities and reduce silo working and gaps in care.” Source location Response from University College London Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Verbatim wording from the response “We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.” Source location Response from University College London Hospitals
Open published response
Concerns raised 9 Failure to escalate and respond to prolonged inadequate fluid intake View source Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine View source Failure to secure patients safely in wheelchairs View source Failure to provide adequate clothing for patients unable to dress themselves View source Failure to encourage patients to drink or eat when intake is inadequate View source Failure to provide consistent toileting and continence care View source Failure to consistently encourage sufficient drinking and eating View source Failure to monitor patients in communal areas View source Inaccurate recording of patients’ fluid intake View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Francis GREGORY · 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
John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and respond to prolonged inadequate fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am . The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this .
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff.
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to secure patients safely in wheelchairs
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests . He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate clothing for patients unable to dress themselves
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks . By then Mr Gregory was not capable of dressing himself .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to encourage patients to drink or eat when intake is inadequate
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent toileting and continence care
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff .
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet ; on more than one occasion his family found him in wet bedclothes ; and he was put to bed at 7.30pm to fit in with nursing routine.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently encourage sufficient drinking and eating
Wider context from the report “2. His oral fluid intake was considered by Evergreen Ward, and steps were taken to address this, but the intake recorded on his charts demonstrate that it remained too low .
Maintaining sufficient fluid intake was a challenge, but there is the possibility that not every member of staff encouraged him to drink and eat in the way the sister in charge did.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients in communal areas
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff .
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients’ fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him .
This demonstrates that the chart was inaccurate . It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” Open source report
27 Mar 2017 Michael Brennan · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of a system informing clinicians of current bed status across the Trust’s multiple sites View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Brennan · 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 Brennan developed bleeding during a bronchoscopy to investigate a suspected lung cancer, deteriorated after a transfer to a satellite hospital could not be arranged because no beds were available, and died after transfer to intensive care. The principal concern was that the backup transfer plan relied on bed availability that was not known to clinicians, creating a risk of similar future deaths without a system to provide current bed-status information across the Trust’s sites.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system informing clinicians of current bed status across the Trust’s multiple sites
Wider context from the report “I am concerned that this backup plan relied on the availability of a bed at a satellite hospital, which was ultimately not available when it was required. This raises the concern that the bed status for the Westmoreland Street hospital was not known to the clinicians when this plan was devised . It is possible that future deaths could occur in similar circumstances if there is not a system in place to inform clinicians of the current bed status for the Trust’s multiple sites .
” 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 Extensively review bed-status and referral policies in preparation for implementing the electronic coordination centre.
Verbatim wording from the response “If a referral is accepted they will inform the referring hospital who will arrange transport. WMS critical care unit use the same system as UCH critical care which is an electronic whiteboard which all site managers have access to – this will also be incorporated into the revised policy by the end of May 2017 so that practice is reflected in the written policy.” Source location 2017-0114-Response-by-University-College-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 Amend relevant policies to record twice-daily Westmoreland Street bed updates and the electronic critical-care bed-status whiteboard system.
Verbatim wording from the response “If a referral is accepted they will inform the referring hospital who will arrange transport. WMS critical care unit use the same system as UCH critical care which is an electronic whiteboard which all site managers have access to – this will also be incorporated into the revised policy by the end of May 2017 so that practice is reflected in the written policy.” Source location 2017-0114-Response-by-University-College-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 an electronic coordination centre with TeleTracking to provide real-time bed-capacity and patient-demand data across specified hospital sites.
Verbatim wording from the response “For future bed management UCLH is currently implementing an electronic coordination centre in conjunction with TeleTracking. This will provide real-time data on bed capacity and patient demand and allow better management of the flow of patients through University College Hospital, National Hospital of Neurology and Neurosurgery and Elizabeth Garrett Anderson Wing. This means we can reduce delays in patient care and prevent cancellations of procedures at short notice as a result of not being assured that there is a bed for the patient to” Source location 2017-0114-Response-by-University-College-Hospitals-NHS-Trust
Open published response
6 Feb 2017 Nuala Seddon · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Lack of appropriate monitoring for patients discharged from ITU View source Failure to ensure clinical staff make discharge decisions View source Failure to investigate patient safety events appropriately View source Lack of available telemetry monitoring for patients discharged from ITU View source Lack of documentation of significant discharge decisions View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nuala Seddon · 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
Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate monitoring for patients discharged from ITU
Wider context from the report “(2) The lack of both telemetry and direct nursing visualisation raises a concern that patients who are discharged from the highest level of clinical care on ITU are then exposed to significant risk of unrecognised deterioration, owing to a lack of appropriate monitoring . This potentially remains the case even though the Heart Hospital has now transferred to be part of Barts NHS Trust, as the hospital at Westmoreland Street still operates as part of UCLH.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinical staff make discharge decisions
Wider context from the report “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate patient safety events appropriately
Wider context from the report “(3) The ward nurse who was caring for Mrs Seddon at the point of her arrest was not involved in any debrief or significant event investigation . This raises a concern that there was a lack of appropriate investigation into Mrs Seddon’s arrest . Future deaths could occur if the hospital Trust is not able to identify and address patient safety issues because of this failure to investigate appropriately .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of available telemetry monitoring for patients discharged from ITU
Wider context from the report “(1) I heard evidence from the ward nurse that concerns regarding lack of available telemetry remain a current issue at the Heart Hospital (which is now part of Barts NHS Trust). This raises a concern that patients who are discharged from the highest level of clinical care on ITU are then exposed to significant risk of unrecognised deterioration, owing to a lack of appropriate monitoring .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of significant discharge decisions
Wider context from the report “(1) It seems clear that a decision was made to transfer Mrs Seddon from ITU on 27 November 2014. There remains the potential that this decision was made by non-clinical staff. The lack of documentation regarding this significant decision is concerning and leaves open the possibility that future discharges could be based on non-clinical need or inappropriate decision-making which is not subsequently able to be scrutinised because of a lack of documentation .
” Open source report
30 Jul 2014 Monique Susanna WHITBREAD · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Failure to select a safer bariatric procedure for patients with a hernia 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
Monique Susanna WHITBREAD · 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
Monique Susanna Whitbread died from pulmonary aspergillosis and sepsis following intra-abdominal complications related to bariatric procedures, including a gastric bypass performed for obesity. The report raised concern that freeing omental fat during the bypass may have allowed her hernia to strangulate, and noted that sleeve gastrectomy may be safer for patients with a hernia.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to select a safer bariatric procedure for patients with a hernia
Wider context from the report “You performed a gastric bypass on 9 January 2014. At operation, you freed a plug of omental fat to perform the bypass, but it seems that this later allowed Ms Whitbread’s hernia to strangulate , and she died ultimately from the consequences of this.
You indicated to me at inquest that, in future, you will perform a sleeve gastrectomy rather than a gastric bypass on those patients who have a hernia . Although the surgery is not necessarily quite as effective, you believe it to be safer in this situation .
” Open source report
Concerns raised 1 Failure of sodium valproate blood test reference ranges to clearly indicate the therapeutic range 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
Ralph Stephen Goslin · 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
Ralph Stephen Goslin, an inpatient detained under Section 3 of the Mental Health Act, was found unresponsive in a bath on 21 June 2014 and died later that day in hospital. A concern was raised that a junior doctor did not recognise his sodium valproate level as subtherapeutic because of the reference range shown, delaying recognition of his failure to take anti-epilepsy medication.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of sodium valproate blood test reference ranges to clearly indicate the therapeutic range
Wider context from the report “1. The junior doctor at St Pancras Hospital who first reviewed the UCH blood test result giving Mr Goslin’s sodium valproate level as less than 3, did not realise that this was sub therapeutic , because the reference range was given as less than 100, rather than 50-100 as it is in some other hospitals . This meant that Mr Goslin’s failure to take his anti epilepsy medication was not recognised as quickly as it could have been.
” Open source report
7 May 2014 Peter John BROOKES · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 3 Unavailability of doctors for non-emergency reviews during weekend shifts View source Failure to elucidate the causes of dispensing errors View source Failure to administer PD medication in accordance with patients’ usual regimens View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter John BROOKES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter John Brookes was admitted to hospital after complications following catheterisation and later experienced problems with the administration of his Parkinson’s disease medication. After an episode of agitation and rapid breathing was not reviewed by ward doctors, he suffered a respiratory arrest on 19 August 2013, was found to have had a heart attack, developed bronchopneumonia and died on 27 August 2013. The concerns identified included inconsistent administration of Parkinson’s medication, limited availability of doctors for non-emergency weekend reviews, and an unexplained hospital pharmacy dispensing error.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of doctors for non-emergency reviews during weekend shifts
Wider context from the report “(2) The risks posed by the unavailability of doctors for non-emergency reviews, during weekend shifts , raises concern that future deaths could occur as a consequence .
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to elucidate the causes of dispensing errors
Wider context from the report “(3) The cause of the dispensing error , that resulted in the wrong medication being put in a box labelled as ‘Amantadine’, was not elucidated during the inquest and raises concern that future similar errors could recur , with potential for future deaths resulting.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer PD medication in accordance with patients’ usual regimens
Wider context from the report “(1) I heard evidence that the administration of PD medication in hospital routinely does not follow patients’ usual regimens and that this, in itself, could cause physiological stress and contribute to early death. It was not possible conclude that, on the balance of probabilities, this was the case in Mr Brookes death but it was clear that this was a continuing risk, which could result in future deaths .
” 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 Disseminate reminders about timely Parkinson’s medication through the Quality and Safety newsletter, linked resources, video, and the Clinical Practice Facilitators forum.
Verbatim wording from the response “The Trust recognises the importance of ensuring medications, particularly those relating to PD and other time sensitive medication are taken in accordance with the patient’s usual medication schedule. A key approach to this in the Trust’s specialist PD area is through promoting and encouraging self medication where appropriate.” Source location 2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-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 Raise awareness across the Trust of medical escalation processes through the Quality and Safety newsletter.
Verbatim wording from the response “The SHO is usually contacted via the hospital bleep system. However, if the nursing staff are unable to make contact via the bleep system for whatever reason (which was the situation which arose with Mr Brookes) they are advised to contact the medical staff via their mobile phones. A staff directory provided to the wards on a quarterly basis (most recently circulated in June 2014) contains numbers for clinical and managerial staff in the Urology specialty. If the SHO cannot be contacted nursing staff are instructed to escalate through the medical cover system to senior registrar and consultant level if necessary this would be supported by the ward sister or charge nurse for this area. At weekends the same escalation system would apply but with site practitioner available to support nurses escalating based in the operations centre rather than ward sister.” Source location 2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-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 Operate the dedicated Urology Specialist Registrar of the Week rota for ward and emergency cover, reducing handovers.
Verbatim wording from the response “The system of cover was further strengthened in November 2013 by the introduction of an ‘SpR of the week’ on call rota rather than a 12 hourly rotation. The Urology SpR of the week is dedicated entirely to on call duties and is available for both ward and A&E patients at both weekends and during the week (8am – 8pm). This has reduced the number of handovers which is where there is the possibility of actions being missed.” Source location 2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-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 Investigate dispensing and checking errors leaving pharmacy and review pharmacy incidents through clinical governance with action-plan monitoring.
Verbatim wording from the response “• Any dispensing/checking errors that leave the pharmacy department are thoroughly investigated.” Source location 2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-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 the weekend medical escalation process in nursing staff local induction and provide access to staff contact directories.
Verbatim wording from the response “The SHO is usually contacted via the hospital bleep system. However, if the nursing staff are unable to make contact via the bleep system for whatever reason (which was the situation which arose with Mr Brookes) they are advised to contact the medical staff via their mobile phones. A staff directory provided to the wards on a quarterly basis (most recently circulated in June 2014) contains numbers for clinical and managerial staff in the Urology specialty. If the SHO cannot be contacted nursing staff are instructed to escalate through the medical cover system to senior registrar and consultant level if necessary this would be supported by the ward sister or charge nurse for this area. At weekends the same escalation system would apply but with site practitioner available to support nurses escalating based in the operations centre rather than ward sister.” Source location 2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-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 Require staff involved in errors leaving pharmacy to complete reflective statements, lessons learned, and competency logs.
Verbatim wording from the response “• Staff (both dispensers and checkers) involved in any errors that leave the department are required to complete reflective statements as to why they felt the error occurred and include self-reflection on lessons learnt to try and prevent a re-occurrence. They are also required to complete checking/dispensing logs to assess competency.” Source location 2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-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 Existing weekend medical cover and escalation systems address risks from unavailable doctors for non-emergency reviews.
Verbatim wording from the response “The Trust has systems in place for the provision of urgent and non urgent medical cover over the weekend period. For Urology in particular there is:” Source location 2014-0205-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust
Open published response
4 Apr 2014 Eric Laser Matthews · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Insufficient research and restricted knowledge of positional asphyxia risks from baby slings View source Failure to publicise baby sling positional asphyxia risks to parents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Eric Laser Matthews · 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
Eric Laser Matthews, born on 26 November 2013, was placed in a baby sling on 24 December 2013 and was later found not to be breathing. He suffered a significant hypoxic brain injury and died on 1 January 2014; the reported concern was that positional asphyxia associated with baby slings may be insufficiently known and publicised to parents.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient research and restricted knowledge of positional asphyxia risks from baby slings
Wider context from the report “(1) There appears to be a body of evidence that positional asphyxia can occur through use of baby slings. However, knowledge of this risk appears to be limited at present to academic circles and has not been widely researched .
(2) If there is currently sufficient evidence to raise this risk to parents, I am concerned that this information has not been publicised more widely.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to publicise baby sling positional asphyxia risks to parents
Wider context from the report “(1) There appears to be a body of evidence that positional asphyxia can occur through use of baby slings. However, knowledge of this risk appears to be limited at present to academic circles and has not been widely researched.
(2) If there is currently sufficient evidence to raise this risk to parents, I am concerned that this information has not been publicised more widely .
” 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 Investigated the feasibility of surveying infant deaths in unusual scenarios such as slings and car seats.
Verbatim wording from the response “Although a couple of years ago I did investigate the possibility of doing a survey of ‘cot deaths’ in unusual scenarios such as slings and car seats, it did not prove feasible due to data protection and consent issues.” Source location 2014-0151-Response-by-University-Hospital-London-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 A study cannot be run from one centre, and undertaking one was outside the respondent’s professional interests and experience.
Verbatim wording from the response “Since the ‘back to sleep’ campaign, a subset of SUDI have been considered very likely to have been asphyxial – more investigation revealed that these are often associated with additional risk factors (e.g. sharing a sofa with a parent). What a review of deaths in slings and car seats might do is identify possible additional risk factors, such as the age of the baby or the design of the sling. Being so rare, no useful conclusions could be reached from the experience of one centre, even a very large one.” Source location 2014-0151-Response-by-University-Hospital-London-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 Further progress would require coroners to liaise with sudden infant death clinicians and release available child death review data.
Verbatim wording from the response “The way forward may be for the coroners to liaise with clinicians who are working on sudden infant death (ideally via FSIDS), and release whatever data is available from existing child death reviews.” Source location 2014-0151-Response-by-University-Hospital-London-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 Data protection, consent, rarity and locally held uncollated records prevent a useful survey or prospective study from being undertaken.
Verbatim wording from the response “Although a couple of years ago I did investigate the possibility of doing a survey of ‘cot deaths’ in unusual scenarios such as slings and car seats, it did not prove feasible due to data protection and consent issues.” Source location 2014-0151-Response-by-University-Hospital-London-NHS-Trust
Open published response
12 Feb 2014 Georgina Violet SWINDELLS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure to elucidate the cause of image transfer delays View source Failure to clarify the cause of erroneous scan reports and steps to address them View source Lack of available data required to investigate image transfer issues View source Failure to implement the image transfer backup system View source Lack of an image transfer backup process View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Georgina Violet SWINDELLS · 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
Georgina Violet Swindells underwent a right hemicolectomy for colon cancer and subsequently developed persistent hypotension and haemorrhage, dying on 18 September 2013. Concerns included delayed and failed transfer of CT images, the absence of an effective backup process, apparently erroneous reporting of the scan, and insufficient investigation data and incident reporting.
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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to elucidate the cause of image transfer delays
Wider context from the report “(1) The cause of the image transfer delay has not been elucidated ; I am concerned that a similar incident could recur as a consequence;
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify the cause of erroneous scan reports and steps to address them
Wider context from the report “(5) The cause of the apparently erroneous scan report and steps taken to address this issue were not sufficiently clarified on the available evidence . This raises concerns that mis-reporting could happen again.
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of available data required to investigate image transfer issues
Wider context from the report “(2) The lack of available data, required to investigate this issue , is also a cause for concern. This has not been addressed ;
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement the image transfer backup system
Wider context from the report “(4) The backup system in place (i.e. an on-call radiologist who can attend the hospital) appears not to have been implemented on this occasion . Again, the cause for this is unclear and I have concerns that the systems in place are not sufficiently robust;
” 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an image transfer backup process
Wider context from the report “(3) There is no image transfer back-up process in place which could obviate against failure of the primary system;
” Open source report
27 Jan 2014 Umul Kelsum Anna AUDU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of transport heater availability for patient transfers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Umul Kelsum Anna AUDU · 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
Umul Kelsum Anna Audu developed Toxic Epidermal Necrolysis after admission to hospital with headache and back pain, and died from its effects on 20 October 2013. A concern was raised that the lack of an available transport heater could cause future patients to become hypothermic during transfers, potentially resulting in 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 University College London Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of transport heater availability for patient transfers
Wider context from the report “(1) The lack of transport heater availability was not explained in the written evidence presented by the Trust. I did not judge it appropriate to adjourn the inquest in order to obtain further written or live evidence on this point, as sufficient information was available in order to conclude matters on 24 January 2014. However, it remains a concern that, in similar circumstances, the lack of transport heater could result in future patients becoming hypothermic on transfer , which might result in their death. As such, I am making this report in order that the Trust can respond to this concern.
” 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 Keep the transport-heater policy under review for patient-transfer safety.
Verbatim wording from the response “We will however be keeping the position under review. It is a complex issue and at present we do not believe simply introducing transport heaters is appropriate and, for the reason stated, based on our investigations we do not believe that a lack of transport heater availability in itself could give rise to a risk of future deaths.” Source location 2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-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 Transport heaters cannot be introduced for all investigations because warming devices containing metallic elements are contraindicated in MRI environments.
Verbatim wording from the response “More specifically, MRI scanning (the investigation that the patient in question underwent) is even more problematic. Transport heater devices such as warming blankets contain metallic elements, which are absolutely contraindicated for use in the MRI environment, and indeed there are reports in the literature of patients being burnt in MRI scanners when such devices have been used.” Source location 2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-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 lack of transport heater availability is not considered, in itself, to create a risk of future deaths.
Verbatim wording from the response “We will however be keeping the position under review. It is a complex issue and at present we do not believe simply introducing transport heaters is appropriate and, for the reason stated, based on our investigations we do not believe that a lack of transport heater availability in itself could give rise to a risk of future deaths.” Source location 2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-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 Standard measures during patient transfer are considered sufficient to prevent significant hypothermia-related harm, so transport heaters will not be introduced.
Verbatim wording from the response “Our considered position based on these enquiries and the views of my colleagues is that at present we would not propose to change our policy and introduce transport heaters for the reason set out above. That is:” Source location 2014-0038-Response-by-University-College-London-Hospitals-NHS-Foundation-Trust
Open published response
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Addressed to University College London Hospitals NHS Trust, now represented here by University College London Hospitals NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations