Concerns raised 1 Failure to notify GPs of hospital admissions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
John Christopher Lloyd · 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 Christopher Lloyd died at UHW on 27 February 2015 following a second accidental morphine overdose. He had chronic pain after a serious foot injury and had previously been admitted after an overdose. The principal concern was that notification of his first hospital admission was not sent to his GP, and that failures in notifying GPs occurred frequently, potentially affecting continuity of treatment.
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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to notify GPs of hospital admissions
Wider context from the report “For Mr Adam Cairns, Chief Executive, UHW
(1) The notification that should have been sent to the GP after the first admission to UHW on 29th January 2015 was not sent. I heard evidence from ████████ that this was not an isolated incident but arose quite often particularly in times of stress .
(2) ████████ told me that an electronic system of notification had been introduced in mid-2014. This electronic system should therefore have been in place for Mr Lloyd but was not apparently utilised.
Had this information been available to the GP then it may have caused more questions to be asked at his consultation on the 16th February 2015 and may have led to a different course of treatment and outcome. The Coroner is concerned that UHW should employ systems to ensure the notification of admission to GPs in future cases to aid with the continuity of treatment. The Coroner is particularly concerned that failures in notification of admission occur quite frequently.
” Open source report
20 Feb 2015 Lexie Louise Harrison · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 9 Lack of local policy and/or guidelines for paediatric endoscopic banding of oesophageal varices View source Failure to standardise Consultant practice for paediatric endoscopic banding of oesophageal varices View source Lack of defined Consultant competency and supervision criteria for the procedure View source Lack of standardised post-endoscopy care requirements View source Lack of a defined pre-procedure assessment process for banding programme patients View source Lack of defined patient suitability criteria for banding programmes View source Lack of defined criteria for which varices should undergo banding View source Lack of defined assessment and management steps for variceal bleeding View source Lack of precise definitions of oesophageal varix grades 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
Lexie Louise Harrison · 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
Lexie Louise Harrison, who had Infantile Refsum Disease, underwent an unsuccessful attempt to band an oesophageal varix on 30 May 2013, which caused trauma and extensive bleeding. Her condition deteriorated and she died at home on 18 June 2013; the medical cause of death was recorded as liver failure and Infantile Refsum Disease. The concerns included the absence of relevant policies or guidelines at two trusts and a lack of standardisation in practice, including decisions about banding, assessment, post-endoscopy care, management of bleeding, and consultant competence.
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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of local policy and/or guidelines for paediatric endoscopic banding of oesophageal varices
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to standardise Consultant practice for paediatric endoscopic banding of oesophageal varices
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure , by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of defined Consultant competency and supervision criteria for the procedure
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of standardised post-endoscopy care requirements
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined pre-procedure assessment process for banding programme patients
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of defined patient suitability criteria for banding programmes
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of defined criteria for which varices should undergo banding
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of defined assessment and management steps for variceal bleeding
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of precise definitions of oesophageal varix grades
Wider context from the report “(1) Birmingham Children’s Hospital NHS Foundation Trust has a policy in place and/or guidelines dealing with paediatric endoscopy procedures for the banding of an oesophageal varix/oesophageal varices (“the procedure”). Neither Sheffield Children’s NHS Foundation Trust nor Leeds Teaching Hospitals NHS Trust has such a policy and/or guidelines. Both of the latter Trusts have undertaken the said procedure for many years.
(2) There is no standardisation of practises (either locally or nationally) adopted by Consultants when undertaking the said procedure, by reason predominantly of there being no national policy and/or guidelines in relation thereto. Such a national policy and/or guidelines should address the following:-
(a) Precise definitions of the grades of oesophageal varices;
(b) Which grades of varices should be subject to banding and which should not;
(c) Those patients who are to be deemed suitable for placing on a banding programme and those who are not;
(d) Once a patient is placed on a banding programme, the assessment process to be adopted prior to the said patient undergoing each procedure;
(e) Post endoscopy care, for example, the administration of sucralfate, frequency of basic observations;
(f) The steps to be taken to properly assess for and manage variceal bleeding, for example, the immediate use of antibiotics;
(g) The circumstances in which a Consultant is deemed to be competent to undertake the procedure alone or with supervision.
” Open source report
Concerns raised 9 Failure to record first lumbar puncture test results in the core donor data form View source Failure of systems to ensure capture and transmission of relevant donor information View source Failure of accepting consultants or centres to view the EOS system before organ acceptance decisions View source Lack of SN-OD certification of transmitted donor information when required View source Failure to transmit relevant medical microbiology information to the accepting transplant centre View source Absence of team-based decision-making about prophylactic anti-viral therapy View source Use of an inadequate standard consent form for transplant operations View source Incomplete capture of donor lumbar test information View source Absence of team-based transplant acceptance decision-making 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
Robert James Stuart and Darren Llewellyn Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert James Stuart and Darren Llewellyn Hughes developed meningoencephalitis after receiving kidney transplants from the same donor and died on 17 and 19 December 2013 respectively. The infection was caused by a Halicephalobus nematode in the transplanted kidneys. Concerns included incomplete transmission of donor information, inadequate use of the EOS system and the need for a more multidisciplinary organ-acceptance process.
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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to record first lumbar puncture test results in the core donor data form
Wider context from the report “(1) The core donor data form could have contained more information as to the second lumbar test performed on the donor and could have given the results of the first lumbar puncture test .
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of systems to ensure capture and transmission of relevant donor information
Wider context from the report “Had this information been available to the accepting consultant ████████ then it may have caused more questions to be asked and aided in the acceptance process. The Coroner is concerned that NHSBT should employ systems to ensure the capture and transmission of all relevant information to the accepting transplant centre , and that SN-ODs should be in a position if required to certify that all relevant and available information has been transmitted.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of accepting consultants or centres to view the EOS system before organ acceptance decisions
Wider context from the report “(1) The Kidneys were accepted by the transplant centre following a telephone conversation between the consultant and the transplant coordinator. The Coroner heard that all consultants have access to the EOS system but that the consultant did not use it on this occasion . The Coroner is concerned that a viewing of the EOS system should be standard practice by all accepting consultants/centres before a decision is made , as the information on EOS is much fuller than anything that can be conveyed over the telephone.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of SN-OD certification of transmitted donor information when required
Wider context from the report “Had this information been available to the accepting consultant ████████ then it may have caused more questions to be asked and aided in the acceptance process. The Coroner is concerned that NHSBT should employ systems to ensure the capture and transmission of all relevant information to the accepting transplant centre, and that SN-ODs should be in a position if required to certify that all relevant and available information has been transmitted .
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit relevant medical microbiology information to the accepting transplant centre
Wider context from the report “(2) There was information available on the medical microbiology report which was not passed on to the accepting transplant centre.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Absence of team-based decision-making about prophylactic anti-viral therapy
Wider context from the report “(2) The kidneys were accepted by the consultant acting alone. The Coroner heard evidence that in many centres the acceptance process is conducted on a “team” basis, with the consultant accepting advice from microbiologists and even other on call consultant surgeons. The Coroner is concerned that a team approach offers the most informed method of decision making, not only over the decision to accept organs but also over the nature and duration of prophylactic anti-viral therapy . The Coroner is concerned to hear about any action that is being taken over this in the transplant centre.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Use of an inadequate standard consent form for transplant operations
Wider context from the report “(3) The Coroner heard that a standard consent form is used for all operations , and heard evidence that this has proved unsatisfactory for transplant operations where issues have to be covered that are not catered for by the standard form
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Incomplete capture of donor lumbar test information
Wider context from the report “(1) The core donor data form could have contained more information as to the second lumbar test performed on the donor and could have given the results of the first lumbar puncture test.
” 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 of Wales; that does not assign responsibility.
PFD Monitor interpretation Absence of team-based transplant acceptance decision-making
Wider context from the report “(2) The kidneys were accepted by the consultant acting alone . The Coroner heard evidence that in many centres the acceptance process is conducted on a “team” basis , with the consultant accepting advice from microbiologists and even other on call consultant surgeons. The Coroner is concerned that a team approach offers the most informed method of decision making , not only over the decision to accept organs but also over the nature and duration of prophylactic anti-viral therapy. The Coroner is concerned to hear about any action that is being taken over this in the transplant centre.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations