Concerns raised 1 Lack of awareness of the importance of checking the back of the throat in patients with a history of epistaxis or facial fractures View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Graham TAYLOR · 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 Graham Taylor suffered significant facial fractures and a subdural haematoma after a fall, developed epistaxis, then deteriorated and died at Southampton General Hospital on 5 June 2021. The concern was that bleeding following epistaxis or facial fractures may continue in the back of the throat and that the importance of checking this was not widely known in the Emergency Department and Trauma Admission Unit.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the importance of checking the back of the throat in patients with a history of epistaxis or facial fractures
Wider context from the report “The deceased suffered facial fractures and had episodes of epistaxis. I heard evidence that when a clot forms within the nose the bleeding can continue and is only visible if the back of the patient's throat is looked at. I heard evidence that, in the Emergency Department and Trauma Admission Unit, the importance of checking the back of the throat of a patient with a history of epistaxis or facial fractures was not widely known .
” 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 Add guidance to surgical senior house officer induction sessions on checking the oropharynx for ongoing posterior bleeding in facial trauma and epistaxis cases.
Verbatim wording from the response “The case was discussed at the ENT M&M meeting on 10th November 2022. The department were content that the management by the SHO was clinically appropriate. It was clearly documented that the posterior bleeding, once identified, stopped after the was pack inserted. It was agreed to raise awareness of epistaxis in facial trauma in OMFS and ED teams managing them. Specific guidance to check the oropharynx in these situations has been added to the surgical SHO induction sessions.” Source location Response from University Hospital Southampton NHS Foundation 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 Disseminate learning to ENT, OMFS and cross-covering senior house officers on recognising continuing anterior or posterior epistaxis after facial trauma and nasal packing.
Verbatim wording from the response “The actions that I support coming out of my discussion with the team is that the clinicians treating such patients would build into their education programme that patients should be explicitly asked to report an unpleasant taste or sensation. Following the meeting I chaired, the following was disseminated to all ENT, OMFS (oral-maxilla facial surgeons) and the cross covering senior house officers.” Source location Response from University Hospital Southampton 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 The Trust disputes that routine oropharyngeal inspection after traumatic epistaxis is clinically valuable or supported by national guidance.
Verbatim wording from the response “We reviewed the national guidance available for the management of epistaxis, currently the only guidance is from NICE (https://cks.nice.org.uk/topics/epistaxis-nosebleeds/management/acute-epistaxis/) this is for when epistaxis have started spontaneously and is not applicable for Traumatic injury such as the case of Mr Taylor. This highlights that there are no national guidelines that suggest the review of the back of a patient throat is advised.” Source location Response from University Hospital Southampton NHS Foundation Trust
Open published response
Concerns raised 3 Failure to maintain awareness of revised National Institute for Health and Care Excellence guidance on head-injury scanning View source Failure of the head-injury policy to include patients receiving low-dose anticoagulants within the 8-hour computerised tomography scan criterion View source Failure of the head-injury policy to reflect revised National Institute for Health and Care Excellence guidance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert James GOODMAN · 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 GOODMAN died at Southampton General Hospital on 30 March 2020 after an unwitnessed fall the previous day caused a head injury and subdural haematoma. The principal concern was that his CT scan occurred 30 hours after the injury because the Trust policy did not reflect revised guidance for patients receiving any anticoagulant treatment.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain awareness of revised National Institute for Health and Care Excellence guidance on head-injury scanning
Wider context from the report “When found on the floor the deceased stated that he had a head injury. The Trust has a policy for the assessment and early management of head injuries. The policy was, on the evidence, drafted in 2016. The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries.
The deceased was receiving the anticoagulant enoxaparine whilst in hospital.
The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment.
The evidence suggests that enoxaparine is a “low dose anticoagulant” which did not place the deceased within the Trust policy where a computerised tomography scan should be provided within 8 hours of a head injury.
The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury.
The Trust’s policy does not presently reflect the National Institute for Health and Care Excellence revised guidance, in place since September 2019.
It was accepted in evidence that the deceased would have had a computerised tomography scan within 8 hours of a head injury if the revised National Institute for Health and Care Excellence guidance had been applied and reflected in the Trust policy.
The deceased’s computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury.
” 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 Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the head-injury policy to include patients receiving low-dose anticoagulants within the 8-hour computerised tomography scan criterion
Wider context from the report “When found on the floor the deceased stated that he had a head injury. The Trust has a policy for the assessment and early management of head injuries. The policy was, on the evidence, drafted in 2016. The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries.
The deceased was receiving the anticoagulant enoxaparine whilst in hospital.
The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment.
The evidence suggests that enoxaparine is a “low dose anticoagulant” which did not place the deceased within the Trust policy where a computerised tomography scan should be provided within 8 hours of a head injury .
The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury.
The Trust’s policy does not presently reflect the National Institute for Health and Care Excellence revised guidance, in place since September 2019.
It was accepted in evidence that the deceased would have had a computerised tomography scan within 8 hours of a head injury if the revised National Institute for Health and Care Excellence guidance had been applied and reflected in the Trust policy.
The deceased’s computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury.
” 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 Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the head-injury policy to reflect revised National Institute for Health and Care Excellence guidance
Wider context from the report “When found on the floor the deceased stated that he had a head injury. The Trust has a policy for the assessment and early management of head injuries. The policy was, on the evidence, drafted in 2016. The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries.
The deceased was receiving the anticoagulant enoxaparine whilst in hospital.
The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment.
The evidence suggests that enoxaparine is a “low dose anticoagulant” which did not place the deceased within the Trust policy where a computerised tomography scan should be provided within 8 hours of a head injury.
The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury.
The Trust’s policy does not presently reflect the National Institute for Health and Care Excellence revised guidance, in place since September 2019 .
It was accepted in evidence that the deceased would have had a computerised tomography scan within 8 hours of a head injury if the revised National Institute for Health and Care Excellence guidance had been applied and reflected in the Trust policy.
The deceased’s computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury.
” 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 Continue ensuring CT scanning within eight hours for patients receiving prophylactic enoxaparin who develop clinical signs or symptoms after a fall, and for patients receiving therapeutic anticoagulants.
Verbatim wording from the response “Finally, I would like to assure you that, whilst further guidance from NICE is awaited, the Trust will continue to ensure that all patients receiving a prophylactic dose of Enoxaparin, who develop clinical signs and symptoms following a fall, will undergo a CT scan within 8 hours of a suspected head injury in addition to all those patients who have received a therapeutic dose of DOAC’s, Warfarin etc.” Source location 2020-0285-Response-from-Southampton-General-Hospital-Redacted
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 and launch the head-injury policy to require CT scanning within eight hours for patients receiving therapeutic anticoagulants, including DOACs.
Verbatim wording from the response “In respect of NICE Clinical Guideline [CG176], I can confirm that the Trust’s policy has now been amended so that it is clear that patients receiving therapeutic anticoagulant treatment including Direct Oral Anticoagulants (DOACs) should undergo a CT scan within 8 hours of a suspected head injury.” Source location 2020-0285-Response-from-Southampton-General-Hospital-Redacted
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 Disseminate the updated head-injury policy and key NICE changes to clinical teams and publish it on the staff intranet.
Verbatim wording from the response “The Trust launched the updated policy on the 26th January 2021, our head of patient safety emailed out to the clinical teams (including consultants, nursing, pharmacy and therapy staff) to notify them of the updated policy and highlight the key changes including the NICE guidance. We also included the updated policy on the clinical updates section on our staff intranet.” Source location 2020-0285-Response-from-Southampton-General-Hospital-Redacted
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 Patients receiving prophylactic enoxaparin are not routinely scanned after falls without clinical signs suggesting bleeding.
Verbatim wording from the response “On the basis of the current medical literature on the subject, patients who are receiving a prophylactic dose of Enoxaparin are not routinely given a CT scan following a fall unless they are exhibiting clinical signs that are suggestive of a bleed.” Source location 2020-0285-Response-from-Southampton-General-Hospital-Redacted
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 Universal CT scanning for patients receiving prophylactic enoxaparin could overwhelm scanning capacity and delay scans for patients who require them.
Verbatim wording from the response “The consensus opinion among Medicine for Older People colleagues is that providing a CT scan for all patients on a prophylactic dose of enoxaparin, without other clinical signs and symptoms being evident, would not influence the outcomes for those patients. However, it could overwhelm a hospital’s scanning capacity, meaning that there is a risk that other patients, who do require a CT scan, may face a delay in obtaining this to the potential detriment of their health.” Source location 2020-0285-Response-from-Southampton-General-Hospital-Redacted
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 NICE is expected to clarify whether prophylactic anticoagulants should trigger the same scanning requirements as therapeutic anticoagulants.
Verbatim wording from the response “Unfortunately, NICE’s Clinical Guideline [CG176] fails to provide specific guidance on this point. We, therefore, contacted the National Falls Lead at NHSE/I who confirmed that “we are aware that concordance with the guidelines by acute providers is problematic”. We understand that there is to be a full review of the evidence, undertaken by NICE, in order to clarify whether prophylactic anticoagulants should trigger the same requirements as therapeutic doses of DOACs and Warfarin.” Source location 2020-0285-Response-from-Southampton-General-Hospital-Redacted
Open published response
Concerns raised 4 Failure to record who made significant clinical decisions and why View source Lack of agreed use of beds with weight-indicating scales to support accurate medication dosing View source Failure to disseminate and implement weight-estimation learning and training for clinical staff treating high-risk patients View source Failure to accurately record or obtain patient weight for weight-dependent anticoagulant dosing 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.
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AI-generated summary
Scott Douglas Hooper · 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
Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospital Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record who made significant clinical decisions and why
Wider context from the report “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight.
2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision . This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why .
In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held.
In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning.
Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms.
I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category.
The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication.
” 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 Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed use of beds with weight-indicating scales to support accurate medication dosing
Wider context from the report “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight.
2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why.
In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held.
In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning.
Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms.
I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category.
The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication .
” 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 Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate and implement weight-estimation learning and training for clinical staff treating high-risk patients
Wider context from the report “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight.
2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why.
In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held.
In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning.
Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms.
I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category .
The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication.
” 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 Southampton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record or obtain patient weight for weight-dependent anticoagulant dosing
Wider context from the report “1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight .
2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why.
In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held.
In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning.
Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms.
I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category.
The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication.
” 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