Recipient

University Hospital Lewisham

First report 23 Aug 2013•Latest report 13 Jul 2021

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 5
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

13 Jul2021
Inner South London
Concerns raised3
1. Inadequate care planning for monitoring and observations after clinical deterioration
2. Failure to ensure adequate monitoring and observations for patients with severe pancreatitis
3. Failure to ensure that ITU admission criteria are not driven by capacity constraints
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

Abiodun Adisa ORITOGUN · 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

Mr Abiodun Adisa Oritogun was admitted with severe acute pancreatitis, deteriorated on the ward, and died after collapsing while self-discharging; the inquest concluded that he died from complications of pancreatitis and ileus. Concerns included inadequate monitoring and escalation after his condition worsened, and uncertainty about whether patients with severe pancreatitis received an appropriate level of care and ITU referral.

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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Inadequate care planning for monitoring and observations after clinical deterioration
Wider context from the report
“The coroner found that there were two concerns about medical care, namely 1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning. 2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year. Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level 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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure adequate monitoring and observations for patients with severe pancreatitis
Wider context from the report
“The coroner found that there were two concerns about medical care, namely 1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning. 2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year. Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level 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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure that ITU admission criteria are not driven by capacity constraints
Wider context from the report
“The coroner found that there were two concerns about medical care, namely 1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning. 2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year. Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level of care. ”
Open source report
16 Apr2021
Inner South London
Concerns raised2
1. Failure to initiate antibiotic treatment promptly for suspected fatal infection
2. Failure to confirm and record timely administration of Amikacin
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

Mr Yusuf Seyit · 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

Mr Yusuf Seyit had been in hospital since January and, after developing suspected urinary and chest infections, deteriorated into septic shock. He died on 3 July 2019. The concerns were uncertainty about whether there was a plan for timely antibiotic treatment, and uncertainty about when Amikacin was administered despite evidence that it was needed within an hour in septic shock.

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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Failure to initiate antibiotic treatment promptly for suspected fatal infection
Wider context from the report
“1. He was known to be at high risk of fatal infection and had developed symptoms 2 days before death and definitive proof of infection by the late afternoon of 2nd July, but it was not clear whether there was a plan for antibiotic intervention and no treatment was begun that 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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Failure to confirm and record timely administration of Amikacin
Wider context from the report
“2. When in septic shock in the early hours of 3rd, three antibiotics were prescribed and our initial death report indicated treatment had begun before he died. But the medical records available to the inquest did not confirm when Amikacin was actually administered. Evidence of a consultant physician was that it needed to be within an hour. ”
Open source report
24 Sep2019
Inner South London
Concerns raised2
1. Lack of a patient information leaflet for this type of surgery
2. Failure to provide adequate post-operative discharge advice about warning symptoms
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

Mr Francis Hodge · 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

Mr Francis Hodge died on 16 November 2018 at University Hospital Lewisham from a perforated colon, seven days after elective laparoscopic repair of multiple incisional hernias. Concerns were raised that he received inadequate discharge advice and was not told to seek help for breathlessness or persistent pain. It was also reported that no patient information leaflet existed for this type of surgery.

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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Lack of a patient information leaflet for this type of surgery
Wider context from the report
“(4) I was also told that no patient information leaflet existed for this type of surgery as it was not a common type of procedure. ”
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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide adequate post-operative discharge advice about warning symptoms
Wider context from the report
“(1) At inquest I was told that on discharge Mr Hodge was given inadequate discharge advice. He was advised to rest as much as possible and that if he were to remain in severe pain in a week's time he should return. (2) The consultant who undertook the surgery explained that such discharge advice was not what should have been provided to a patient following this surgery. The patient should have been told to be concerned about and to look out for: breathlessness, pus or redness, and / or pain which would not settle. (3) Mr Hodge was suffering breathless the night before his collapse and pain which would not settle. He however, did not want to seek medical advice. I am told, because he was following what he had been told to do on discharge. ”
Open source report
14 Aug2014
Inner South London
Concerns raised5
1. Lack of regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment
2. Failure to secure complete employment histories, references and fitness to practise information for long-term locum doctors
3. Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers
1. Failure to place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete
2. Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors
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

Thomas Warren · 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

Thomas Warren, a child with cerebral palsy, died after receiving a 25 microgram fentanyl patch for pain and subsequently developing symptoms before suffering a cardiac arrest. The report identified concerns about prescribing an opiate to an opiate-naïve child without hospital admission, missed opportunities to stop dispensing the drug and provide parents with adequate monitoring information, and gaps in checks on the fitness to practise of a locum doctor.

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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Lack of regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment
Wider context from the report
“(4) There did not appear to be any regulatory mechanism for monitoring or reviewing cases where the doctor no longer works for the Trust where a remediation referral was made and NCAS (or other body) assessment is not completed, before subsequent locum employment. Revalidation requirements might not be an effective mechanism for employment of short notice locum vacancies. ”
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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Failure to secure complete employment histories, references and fitness to practise information for long-term locum doctors
Wider context from the report
“(2) There are particular difficulties with securing a complete sequence of employment and the associated references and confirmation about concerns for fitness to practice of long term locum doctors who may have gaps between jobs or worked abroad. Thus serious concerns about practice may have existed but not come to notice of the Agency or prospective employing NHS Trust. ”
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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers
Wider context from the report
“(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance. ”
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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Failure to place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete
Wider context from the report
“(3) Crucial information was held by the GMC about concerns about this doctor’s fitness to practice, including his referral to NCAS. This information was not available to those enquiring about his fitness to practice at a subsequent time. Nor was any provisional condition placed on his registration, having learnt that he was leaving the NHS so that the NCAS assessment was at risk of being in abeyance. ”
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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors
Wider context from the report
“(1) There does not appear to be clarity as to who or which organization should enquire into previous fitness to practice concerns and referrals to NCAS (or successor organization) which have not led to restrictions or conditions of registration by the GMC when locum doctors are being recruited by an Agency at short notice by prospective NHS Trusts. In this case it appears that neither the Recruitment Agency nor Trust nor consultant asked the doctor before his employment began. ”
Open source report
23 Aug2013
Inner South London
Concerns raised1
1. Insufficient out-of-hours obstetric theatre capacity
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

Luna Lesko · 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

Baby Luna Lesko died after being found collapsed with no respirations following an airway occlusion, inadequate required observations and a prolonged period of hypoxia, despite resuscitation and intensive care. The report raised concerns about delays in cardiotocograph monitoring and delivery by caesarean section, including insufficient out-of-hours theatre capacity and a potential risk to future babies.

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 Hospital Lewisham; that does not assign responsibility.
PFD Monitor interpretation
Insufficient out-of-hours obstetric theatre capacity
Wider context from the report
“(2) LSCS was required for the baby, due to lack of progression despite augmentation, adverse position and prolonged rupture of membranes with meconium. The decision was taken at 20.00 hours, but delivery was not possible until 21.40 hours, as theatres were busy. This delay of 1 hour 40 minutes for a category 2 section was 40 minutes outside the Trust’s own guidelines. (3) The consultant obstetrician reported that this delay, which occurred out of hours, in a unit with over 4000 births per year was unacceptable. It worsens the potential impact, carrying a higher risk of brain damage or death of babies, if there were several emergencies at one time. Staff were reluctant to use the second out of hours (non obstetric) theatre as they cannot then respond to a category 1 emergency. My expert obstetric witness, ████████ of Kings College Hospital, gave an opinion that the out of hours theatre access created a real risk of preventable death, especially with the increasing rate of performing LSCS. He advised me that I should be concerned and bring the matter to the attention of the Trust. (4) Whilst the Head of Midwifery reported management changes and compliance with CNST assessment, she did not provide assurance that the theatre capacity had been increased out of hours. Furthermore it was reported that the Trust is shortly to be disbanded and a new Trust is being formed by merger with another. This may lead to service configuration changes. She reported that the future obstetric services were under review. (5) I concluded that a real risk existed that I should report to the Trust and the commissioning body, to ensure that it was fully appreciated and given appropriate priority in the service reconfiguration planning. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Inadequate care planning for monitoring and observations after clinical deterioration

Failure to ensure adequate monitoring and observations for patients with severe pancreatitis

Failure to ensure that ITU admission criteria are not driven by capacity constraints

Concerns raised2

Failure to initiate antibiotic treatment promptly for suspected fatal infection

Failure to confirm and record timely administration of Amikacin

Concerns raised2

Lack of a patient information leaflet for this type of surgery

Failure to provide adequate post-operative discharge advice about warning symptoms

Concerns raised5

Lack of regulatory monitoring and review of incomplete remediation referrals before subsequent locum employment

Failure to secure complete employment histories, references and fitness to practise information for long-term locum doctors

Unavailability of GMC-held fitness to practise and NCAS referral information to subsequent enquirers

Failure to place provisional registration conditions when an NCAS assessment is at risk of remaining incomplete

Lack of clarity over responsibility for enquiring into previous fitness to practise concerns and NCAS referrals when recruiting short-notice locum doctors

Concerns raised1

Insufficient out-of-hours obstetric theatre capacity