1 May 2026 John McKinlay · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to investigate falls and implement adequate learning actions View source Failure to provide appropriate observation in accordance with falls risk assessments and care plans View source
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AI-generated summary
John McKinlay · 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 McKinlay died at Beech Hill Grange nursing home on 19 November 2025 after receiving end-of-life care. His death involved natural causes alongside a subdural haematoma and fractured neck of femur associated with a series of falls, including inpatient falls at Good Hope Hospital, Birmingham Heartlands Hospital and Queen Elizabeth Hospital. The principal concern was that some falls may have occurred without the observation required by his falls risk assessment and care plan, and that evidence was not provided of investigations into falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital.
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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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate falls and implement adequate learning actions
Wider context from the report “The evidence from witnesses was that Mr McKinlay had a total of 4 falls whilst an inpatient at the University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025 at Queen Elizabeth Hospital. Some, potentially all, of the falls occurred when Mr McKinlay was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan. He sustained a femur fracture requiring operative fixation from the fall on the 11th September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September. He did not have any investigations into the November falls as he was already receiving end of life care and there was no clinical evidence of injury. There has been a mortality review of the events at Good Hope Hospital, including the fall on the 11th September. However, evidence has not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital . It therefore cannot be determined that appropriate lessons have been learnt and adequate action taken creating a risk the situation has not improved.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate observation in accordance with falls risk assessments and care plans
Wider context from the report “The evidence from witnesses was that Mr McKinlay had a total of 4 falls whilst an inpatient at the University Hospitals of Birmingham: on the 11th September 2025 at Good Hope Hospital, 28th September 2025 at Birmingham Heartlands Hospital and on the 10th and 12th November 2025 at Queen Elizabeth Hospital. Some, potentially all, of the falls occurred when Mr McKinlay was not receiving the appropriate level of observation in accordance with his falls risk assessment and care plan. He sustained a femur fracture requiring operative fixation from the fall on the 11th September and an acute bleed of a pre-existing subdural haemorrhage on the 28th September. He did not have any investigations into the November falls as he was already receiving end of life care and there was no clinical evidence of injury. There has been a mortality review of the events at Good Hope Hospital, including the fall on the 11th September. However, evidence has not been provided of investigations into the falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital. It therefore cannot be determined that appropriate lessons have been learnt and adequate action taken creating a risk the situation has not improved.
” 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 Provide falls training covering the learning identified from the incidents, with staff attendance completed or being arranged.
Verbatim wording from the response “On 17 November 2025 the ward manager completed their local investigation into the incident and completed a Listen Learn Share form highlighting the non-adherence to the falls procedure and reminding staff of the importance of ensuring that relevant assessments were completed and a recommendation that they all re-familiarise themselves with the Trust falls procedure. The specific learning identified included; that staff must familiarise themselves with the post fall retrieval procedure to ensure that they are retrieving patients from the floor using the correct methods, to ensure that documentation is thorough in order to record specifics about a patient fall including what footwear the patient was wearing, what exactly was discussed with the patient’s next of kin, and also ensuring post fall observations are completed as per the Trust standards.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review every reported patient fall through local and central falls-team processes, identify learning, and implement appropriate corrective actions.
Verbatim wording from the response “All patient falls within our organisation are reviewed locally and also centrally by our governance and falls teams. We have a dedicated falls team and part of their role is to review every reported incident where a patient has suffered a fall. The service runs Monday to Friday. Each of Mr McKinley’s falls were incident reported and reviewed by a member of the falls team in a timely manner prior to the incident being closed.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate fall-related learning and required actions to ward staff through Listen Learn Share forms and electronic RADAR alerts.
Verbatim wording from the response “A Listen Learn Share form was also completed with the learning identified and actions required and this was circulated to all staff to read.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Escalate staffing and patient-dependency pressures daily while reviewing ward establishment levels to address increased dependency.
Verbatim wording from the response “The situation was escalated to the senior nursing team and contact was made with an external Trust to request a registered mental health nurse to support the ward. Cover was provided on this date. We are aware of an increase in dependency of patients on this ward and a review is being undertaken by the Matron of the establishment level with a view to changes in this to meet the changes in patient cohort.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce ward handovers remaining inside patient bays through daily safety-huddle reminders and stay-in-the-bay armbands, with compliance monitoring.
Verbatim wording from the response “As set out within the Senior Sister’s statement shared with the Coroner’s office on 16 December, she spoke to staff to ascertain how the fall occurred. In response, staff reflected that they had undertaken a handover outside of the bay instead of inside the bay which ultimately led to Mr McKinlay being able to get up unaided. The whole team were reminded of the importance of staying in bays during subsequent daily safety huddles. Stay in the bay arm bands were also introduced in order to reinforce this further. The Senior Sister continues to monitor compliance with this and the falls team have confirmed they have received no further incidents from this ward in relation to falls occurring when staff are leaving their designated area to handover.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing local and corporate falls reviews, learning, and actions were considered sufficient; no further action was proposed.
Verbatim wording from the response “A summary of the incident and findings from the scoping were also presented at a weekly Patient Safety Incident Review Group meeting on 8 January 2026. This meeting is chaired by a Deputy Chief Medical Officer and attended by specialty medical directors, senior nursing teams and governance leads. After considering the incident, the group concluded that there was no requirement for a formal investigation as the incident had already been thoroughly reviewed locally and the team had already reflected on the incident and put appropriate actions in place to prevent a similar incident occurring.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The falls team considered no further investigation necessary from its perspective, leaving further investigation to the ward team’s local process.
Verbatim wording from the response “The falls team reviewed the incident on Monday 29 September 2025 and the incident was deemed to be low harm in light of the NORSe neurosurgery review above, therefore, no further investigation was deemed to be required by the falls team and this remained for local investigation by the ward team.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action was considered necessary for the November fall because the patient was receiving end-of-life care under the medical team’s plan.
Verbatim wording from the response “On the morning of 10 November 2025 the falls team contacted the ward team confirming that they had reviewed the incident and downgraded the severity of the fall from moderate to low harm as there were no significant injuries noted following medical reviews. Again, the falls team reviewed the RADAR form, the clinical noting, observations recorded and assessments completed as well as reading the notes to understand the course of events and management plan going forward. At this stage it was recorded that Mr McKinlay continued on the end-of-life pathway and no further action was deemed necessary as per the medical team plan. It is noted that Mr McKinlay’s daughter was made aware of the fall at 13.35 hours.” Source location Response from University Hospitals of Birmingham NHS Foundation Trust
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23 Apr 2026 Stephanie Anne Barkley Link · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure to establish an agreed, documented care pathway for patients with complex acute pancreatitis that is accessible to and understood by clinicians across hospital sites View source
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AI-generated summary
Stephanie Anne Barkley Link · 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
Stephanie Anne Barkley Link attended hospital with acute pancreatitis, later developing malnutrition, sepsis, acute liver injury, aspiration and multi-organ failure. She died in intensive care after a cardiac arrest on 30 June 2024. The principal concern was the absence of an effective multidisciplinary approach and an agreed, documented care pathway for complex acute pancreatitis across hospital sites, alongside missed opportunities for specialist transfer and continued paracetamol despite deteriorating liver biochemistry.
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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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish an agreed, documented care pathway for patients with complex acute pancreatitis that is accessible to and understood by clinicians across hospital sites
Wider context from the report “3. However, I heard evidence from one of the Trust’s clinical delivery group medical directors that, as at the date of the inquest, whilst meetings had taken place between the specialisms at the different hospital sites regarding the proposed care pathway/MDT arrangements and a draft document setting these out had been discussed, this is still to be finalised and shared with all relevant staff .
4. In this case, I was satisfied that the absence of an effective MDT approach to the management of Stephanie’s condition had a more than minimal contribution to her death. I am therefore concerned that there remains a risk of future deaths until such time as there is an agreed, documented care pathway for patients with complex acute pancreatitis that is accessible to and understood by clinicians across the different UHB hospital 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 Formalise and implement a standard operating procedure defining the complex pancreatitis referral and multidisciplinary care pathway across hospital sites.
Verbatim wording from the response “Following conclusion of the Inquest cross site teams have developed a multidisciplinary team (MDT) for complex patients in this category. This has been formalised into a SOP which has been shared.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish annual auditing of the pancreatitis pathway to ensure it remains suitable.
Verbatim wording from the response “It is also proposed that an audit will be undertaken annually to ensure the pathway remains suitable.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the pancreatitis pathway SOP on the electronic clinical guidelines site and cascade it to relevant clinical leads and medical directors.
Verbatim wording from the response “The SOP document is available to all staff on our electronic clinical guidelines site and it has also been cascaded to all Clinical Service Leads, CDG Medical Directors and Hospital Medical Directors via email.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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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 weekly pancreatitis multidisciplinary team to review complex cases and support continuity of care.
Verbatim wording from the response “A weekly Pancreatitis MDT has also been established and will discuss the following patients to ensure continuity of care:” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The completed pancreatitis pathway and annual audit are considered sufficient to address the risk of future deaths.
Verbatim wording from the response “We are satisfied that the action that remained outstanding at the time of the Inquest is now complete and that an appropriate audit is in place.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
8 Dec 2025 Syeda Meerab FATIMA · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 4 Failure to eradicate persistent bullying and harassment in the maternity department View source Bullying culture within the maternity department View source Failure to maintain an inclusive workplace culture in which staff can express views and participate in urgent decision-making View source Failure to fully adopt and effectively implement a safe learning and working environment in the maternity department View source See 1 more concern
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Syeda Meerab FATIMA · 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 Syeda was born prematurely by a difficult footling breech vaginal delivery after delays in preparing for and carrying out an emergency Caesarean section. She was born in a poor condition, required resuscitation, and died a few hours later. The principal concern was a wider, systemic bullying and hierarchical workplace culture in the maternity department at Good Hope Hospital, which was identified as contributing to delays in the emergency response.
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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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to eradicate persistent bullying and harassment in the maternity department
Wider context from the report “8. What makes the Welfare Culture Report more shocking is that the Trust committed to addressing culture in 2023 following an independent review. The Trust’s Response to the 2023 culture review set out a plan and a roadmap to addressing cultural issues within the Trust. At the inquest into Syeda’s death, I heard evidence that the Trust has worked hard since 2023 to address culture, and that three monitoring criteria as stipulated by the CQC had been reduced from three to one. That is commendable. However, despite all of that work, it is clear that a culture of bullying and harassment has been allowed to persist and fester within the maternity department of Good Hope Hospital , undermining all of that hard work.
9. The PSII report was completed on 30/10/25 with the Workplace Culture report following thereafter. Under those reports, the Maternity department was tasked to explore NHS England’s Safe Learning Environment Charter (SLEC) to help to support a positive learning and working environment and for representatives from each MDT team to complete a self-assessment to identify areas of improvement. That Charter is available online (https://www.england.nhs.uk/mat-transformation/safe-learning-environment-charter/). In evidence, I was advised that the Safe Learning Charter has been widely adopted throughout the Trust, which is concerning in itself as it is clear that it was not fully adopted within the maternity department at Good Hope Hospital before this tragic incident. Having considered the Charter however, and the evidence of witnesses at the inquest, I am not confident that this will be the “silver bullet” to the problem, particularly as two years’ work by the Trust has failed to address and eradicate the problem already.
10. It is recognised that tackling issues of workplace cultural is not a “sprint to the finish line” as there will never be a proverbial “finish line” - it is an ongoing process and which requires the input and buy-in of all employees to ensure that the workplace is a safe place for all. However, it is clear that more must be done to address this issue so that both staff and patients’ lives are not at 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Bullying culture within the maternity department
Wider context from the report “5. The culture is described in the Workplace Culture Report as being “hierarchical” both between the obstetrics and midwifery teams, as well as being within those teams as well. The report indicates that lower banding staff and non-maternity staff cannot offer opinions or views; band 7 midwives make any staff below that banding feel unwelcome to set foot in the office; the band 7 midwives are reported to be “cliquey” and some have suggested that the culture stems from those band 7s and is top-down.
6. The department is described as “cold and unwelcoming” to new starters and outside staff members and has a “bullying culture” which is not felt or seen at other hospitals within the Trust.
7. The Delivery Suite/Labour ward is described as being the midwives’ “territory” with staff encountering considerable anxiety when urgent decision making is concerned. This is particularly shocking – patients’ lives should not be put at risk because of workplace culture.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an inclusive workplace culture in which staff can express views and participate in urgent decision-making
Wider context from the report “5. The culture is described in the Workplace Culture Report as being “hierarchical” both between the obstetrics and midwifery teams, as well as being within those teams as well. The report indicates that lower banding staff and non-maternity staff cannot offer opinions or views; band 7 midwives make any staff below that banding feel unwelcome to set foot in the office; the band 7 midwives are reported to be “cliquey” and some have suggested that the culture stems from those band 7s and is top-down.
6. The department is described as “cold and unwelcoming” to new starters and outside staff members and has a “bullying culture” which is not felt or seen at other hospitals within the Trust.
7. The Delivery Suite/Labour ward is described as being the midwives’ “territory” with staff encountering considerable anxiety when urgent decision making is concerned . This is particularly shocking – patients’ lives should not be put at risk because of workplace culture.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to fully adopt and effectively implement a safe learning and working environment in the maternity department
Wider context from the report “8. What makes the Welfare Culture Report more shocking is that the Trust committed to addressing culture in 2023 following an independent review. The Trust’s Response to the 2023 culture review set out a plan and a roadmap to addressing cultural issues within the Trust. At the inquest into Syeda’s death, I heard evidence that the Trust has worked hard since 2023 to address culture, and that three monitoring criteria as stipulated by the CQC had been reduced from three to one. That is commendable. However, despite all of that work, it is clear that a culture of bullying and harassment has been allowed to persist and fester within the maternity department of Good Hope Hospital, undermining all of that hard work.
9. The PSII report was completed on 30/10/25 with the Workplace Culture report following thereafter. Under those reports, the Maternity department was tasked to explore NHS England’s Safe Learning Environment Charter (SLEC) to help to support a positive learning and working environment and for representatives from each MDT team to complete a self-assessment to identify areas of improvement. That Charter is available online (https://www.england.nhs.uk/mat-transformation/safe-learning-environment-charter/). In evidence, I was advised that the Safe Learning Charter has been widely adopted throughout the Trust, which is concerning in itself as it is clear that it was not fully adopted within the maternity department at Good Hope Hospital before this tragic incident . Having considered the Charter however, and the evidence of witnesses at the inquest, I am not confident that this will be the “silver bullet” to the problem, particularly as two years’ work by the Trust has failed to address and eradicate the problem already .
10. It is recognised that tackling issues of workplace cultural is not a “sprint to the finish line” as there will never be a proverbial “finish line” - it is an ongoing process and which requires the input and buy-in of all employees to ensure that the workplace is a safe place for all. However, it is clear that more must be done to address this issue so that both staff and patients’ lives are not at risk.
” 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 Introduce twice-daily multidisciplinary Team of the Shift huddles to strengthen communication and escalation.
Verbatim wording from the response “Key initiatives we will be undertaking include:” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct Safety Champion walkarounds and Cappuccini checks to reinforce senior visibility, escalation routes and respectful communication.
Verbatim wording from the response “Key initiatives we will be undertaking include:” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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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 comprehensive review of the issues identified in the Regulation 28 notice.
Verbatim wording from the response “Whilst a significant amount of work has been undertaken, we are aware that further work is required. We have undertaken a comprehensive review of the issues identified within the Regulation 28 notice and have aligned our response with the ongoing Maternity and Neonatal Improvement Programme (MNIP) under the NHS England Maternity Safety Support Programme (MSSP). This programme focuses on leadership, culture, inclusion, communication, and governance to ensure sustainable improvement.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver enhanced multiprofessional leadership development, civility, active bystander and cultural humility training.
Verbatim wording from the response “Key initiatives we will be undertaking include:” Source location Response from University Hospitals Birmingham 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 Complete the Safe Learning Environment Charter maturity matrix across all maternity areas.
Verbatim wording from the response “Key initiatives we will be undertaking include:” Source location Response from University Hospitals Birmingham 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 Deliver structured simulation and PROMPT training to embed shared mental models during emergencies.
Verbatim wording from the response “Key initiatives we will be undertaking include:” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
20 Oct 2025 John Christopher RUST · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to ensure mandatory adequate training for clinical staff using automated CSF drainage equipment View source Failure to embed sustainable ongoing training for current and future staff using automated CSF drainage equipment View source
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AI-generated summary
John Christopher RUST · 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 RUST underwent elective thoracic aortic replacement surgery and subsequently suffered uncontrolled cerebrospinal fluid loss after his drain became disconnected, causing a catastrophic and unsurvivable brain injury. He died on 29 March 2025. The principal concern was that staff training on automated CSF drainage systems was not mandatory or embedded sustainably, creating a risk of future deaths.
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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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure mandatory adequate training for clinical staff using automated CSF drainage equipment
Wider context from the report “1. In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that "All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use..."
2. The evidence at inquest was that this training was not mandatory at present, and that at the time of the inquest, approximately 55% of the relevant staff have received the training. This has been slowed down somewhat due to a representative of the company being off sick, but further training sessions have been planned.
3. However, the evidence of ████████ (author of the PSII report and consultant neurosurgeon) indicated it was his view that the training should be mandatory, and that consideration must be given to ensuring this was rolled out in a "sustainable" way to staff - both current and future - as opposed to a "knee-jerk reaction" where training is only given to a limited number of staff following an incident.
4. There was no evidence before the court that there was any plan to embed this training and ensure that it is carried out in a "sustainable" way, with a particular focus on ensuring that future staff are adequately and properly trained. This was particularly concerning given the apparent high rotation and through-put of staff in the ITU department. It became apparent to me that the training being offered was the type of "knee-jerk reaction" that ████████ was fearful of.
5. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not receive adequate training on equipment.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to embed sustainable ongoing training for current and future staff using automated CSF drainage equipment
Wider context from the report “1. In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that "All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use..."
2. The evidence at inquest was that this training was not mandatory at present, and that at the time of the inquest, approximately 55% of the relevant staff have received the training. This has been slowed down somewhat due to a representative of the company being off sick, but further training sessions have been planned.
3. However, the evidence of ████████ (author of the PSII report and consultant neurosurgeon) indicated it was his view that the training should be mandatory, and that consideration must be given to ensuring this was rolled out in a "sustainable" way to staff - both current and future - as opposed to a "knee-jerk reaction" where training is only given to a limited number of staff following an incident.
4. There was no evidence before the court that there was any plan to embed this training and ensure that it is carried out in a "sustainable" way, with a particular focus on ensuring that future staff are adequately and properly trained. This was particularly concerning given the apparent high rotation and through-put of staff in the ITU department. It became apparent to me that the training being offered was the type of "knee-jerk reaction" that ████████ was fearful of.
5. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not receive adequate training on equipment.
” 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 Establish a nine-person core-trainer group to deliver ongoing Liquoguard training, including for rotating and new staff.
Verbatim wording from the response “5. There are currently nine core trainers, comprising senior educators, Band 7 nurses, and Advanced Critical Care Practitioners, ensuring sustainability of training delivery including for new staff rotating into the service.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make Liquoguard training a mandatory core competency for all new cardiac critical-care staff.
Verbatim wording from the response “8. Training in the use of the Liquoguard system is now a core competency within the cardiac critical care unit and is mandatory for all new staff.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train all relevant medical and nursing staff to use the Liquoguard system.
Verbatim wording from the response “2. To date, 91 out of 122 (75%) of relevant staff have completed training on the Liquoguard system, including both medical and nursing staff.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop enhanced specialist training for cardiac critical-care nursing staff.
Verbatim wording from the response “4. Enhanced training has been developed for nursing staff who choose to specialise further in cardiac critical care; these individuals will act as core trainers for new staff.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current trained staff cohort is sufficient to ensure appropriately trained personnel are present whenever automated CSF drains are used.
Verbatim wording from the response “6. The cohort of trained staff is now sufficient to ensure that whenever these devices are used (approximately 10–12 times per year), appropriately trained personnel are present.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
14 Oct 2025 William Roath · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure of doctors to document Nil by Mouth instructions pending SALT assessment View source Failure to ensure doctors promptly refer patients at risk of aspiration to the SALT team 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
William Roath · 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
William Roath was admitted to hospital after falling down concrete steps and sustaining skull fractures and a traumatic brain injury. He subsequently developed aspiration pneumonia and died at Worcestershire Royal Hospital on 12 December 2024. The principal concern was that, after staff identified difficulty swallowing, there was a five-day delay in referral for specialist assessment and oral feeding continued, contributing to the development or worsening of aspiration pneumonia; the report also identified a lack of action to prevent similar errors by doctors at the Trust.
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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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of doctors to document Nil by Mouth instructions pending SALT assessment
Wider context from the report “While Mr. Roath was being treated for a traumatic brain injury at the Queen Elizabeth Hospital, Birmingham, a nurse documented on 20.11.24 that he was coughing and spluttering when receiving food and documented that staff were “not to continue to feed patient”. Mr. Roath was then reviewed by a doctor that same day, who documented that there should be a SALT ( Speech & Language Therapy Team ) assessment, but did not record any advice about whether Mr. Roath should remain Nil by Mouth in the meantime . A referral was not made to the SALT team for another 5 days, during which time nursing staff continued to feed Mr. Roath orally. The consultant who gave evidence about the University Hospitals Birmingham NHS Foundation Trust’s ( the Trust’s ) own investigation into this issue told the inquest:
(a) Any member of staff can make a referral to the SALT team, and in this case it should have been clearly agreed and set out who would be making the referral recommended on 20.11.24;
(b) The reviewing doctor should also have documented that Mr. Roath was to be made Nil by Mouth until a further SALT assessment had been carried out ;
(c) Continued oral feeding between 20-25.11.24 contributed to the development/worsening of Mr. Roath’s aspiration pneumonia which was diagnosed on 21.11.24;
(d) The failure promptly to assess and treat the worsening in Mr. Roath’s swallowing ability which was identified on 20.11.24 amounted to a failure to provide a basic level of care.
Having heard evidence from a Senior Sister on Ward 409, where Mr. Roath was treated throughout his admission, I was satisfied that sufficient measures had been taken to try to ensure that nursing and healthcare staff did not repeat the omissions which had been identified at the inquest.
When the same question was asked of the consultant in respect of doctors at the Trust, the inquest was told:
“a Trust-wide communication will go out to all members of staff that SALT referrals in cases of aspiration can be made by any healthcare professional, and should be made by the professional who recognizes a risk of aspiration.”
I am therefore concerned that, so far as doctors at the Trust are concerned, nearly 12 months after the relevant events, no action has yet been taken to try to ensure that the errors made by the doctor who reviewed Mr. Roath on 20.11.24 are not repeated .
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors promptly refer patients at risk of aspiration to the SALT team
Wider context from the report “While Mr. Roath was being treated for a traumatic brain injury at the Queen Elizabeth Hospital, Birmingham, a nurse documented on 20.11.24 that he was coughing and spluttering when receiving food and documented that staff were “not to continue to feed patient”. Mr. Roath was then reviewed by a doctor that same day, who documented that there should be a SALT ( Speech & Language Therapy Team ) assessment, but did not record any advice about whether Mr. Roath should remain Nil by Mouth in the meantime. A referral was not made to the SALT team for another 5 days , during which time nursing staff continued to feed Mr. Roath orally. The consultant who gave evidence about the University Hospitals Birmingham NHS Foundation Trust’s ( the Trust’s ) own investigation into this issue told the inquest:
(a) Any member of staff can make a referral to the SALT team, and in this case it should have been clearly agreed and set out who would be making the referral recommended on 20.11.24 ;
(b) The reviewing doctor should also have documented that Mr. Roath was to be made Nil by Mouth until a further SALT assessment had been carried out;
(c) Continued oral feeding between 20-25.11.24 contributed to the development/worsening of Mr. Roath’s aspiration pneumonia which was diagnosed on 21.11.24;
(d) The failure promptly to assess and treat the worsening in Mr. Roath’s swallowing ability which was identified on 20.11.24 amounted to a failure to provide a basic level of care.
Having heard evidence from a Senior Sister on Ward 409, where Mr. Roath was treated throughout his admission, I was satisfied that sufficient measures had been taken to try to ensure that nursing and healthcare staff did not repeat the omissions which had been identified at the inquest.
When the same question was asked of the consultant in respect of doctors at the Trust, the inquest was told:
“a Trust-wide communication will go out to all members of staff that SALT referrals in cases of aspiration can be made by any healthcare professional, and should be made by the professional who recognizes a risk of aspiration.”
I am therefore concerned that, so far as doctors at the Trust are concerned, nearly 12 months after the relevant events, no action has yet been taken to try to ensure that the errors made by the doctor who reviewed Mr. Roath on 20.11.24 are not repeated .
” 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 Provide swallowing-problem and SALT-referral training to resident doctors, consultants and final-year medical students.
Verbatim wording from the response “Further, we wish to assure the court that in the intervening period since Mr Roath’s admission, both senior and resident doctors have in fact received training on roles and responsibilities in relation to patients with swallowing problems including the mechanism by which to refer patients to SALT.” Source location Response from University Hospitals Birmingham 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 Produce and disseminate a Trust-wide Patient Safety Notice on inpatient referrals to the Speech and Language Therapy team.
Verbatim wording from the response “Production and distribution of a Patient Safety Notice” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
12 Aug 2025 Robert Tom Duke SIMPSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to provide patients with the correct medication View source Failure to ensure availability and escalation of necessary prescribed medication View source
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. 5
Action
Strengthen induction and Medicines Management training on missed doses, time-critical medicines, escalation, and staff accountability for medicines administration.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025. View source
Action
Undertake spot-check assessments of registered nurses’ discharge-medicines practice and share outcomes and learning through monthly clinical assurance meetings.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025. View source
Action
Monitor compliance with medicines standards through weekly local assessments and monthly hospital, medication-safety, and group governance reporting until practice improvement is demonstrated.
Stated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025. View source
Action
Circulate a Trust patient-safety notice reinforcing procedures for obtaining and escalating time-critical medicines, using safety huddles, meetings, newsletters, and governance channels.
Stated plannedThe respondent said that this action was planned when they made their response on 14 August 2025. View source
Action
Complete corrective action plans addressing medicines-management audit findings and report progress through the monthly Care Quality agenda.
Stated completedThe respondent said that this action was complete when they made their response on 14 August 2025. View source See 2 more actions
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AI-generated summary
Robert Tom Duke SIMPSON · 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 Tom Duke SIMPSON underwent a hemicolectomy for colonic cancer on 4 June 2024, developed hospital-acquired pneumonia and an anastomotic leak, and was discharged home on 28 June while awaiting drainage. He deteriorated after discharge, was admitted as an emergency on 1 July, and died on 9 July 2024 after further treatment and two peri-arrests. Concerns included the provision of medication that did not belong to him, missed antibiotic doses because the drug was out of stock, and a lack of evidence about how these medication failures occurred or were managed.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with the correct medication
Wider context from the report “1. It was accepted by the Trust that the deceased had been provided and discharged with medication (gabapentin) that did not belong to him and had missed two doses of antibiotics (fidaxomin) due to the drug being out of stock, which had not been communicated to or escalated to treating clinicians.
2. In evidence the Trust were unable to confirm whether the issues set out in 1. above sat solely with the nursing team or also involved pharmacy.
3. Whilst evidence was given in relation to the discharge nurse having undertaken reflection and a focus group being set up to explore improvements with discharge and planning there was no evidence as to how the wrong medication was provided to the deceased and whether this was a discharge only issue or also an issue with allocation and distribution of medication by pharmacy or by ward staff.
4. There was no evidence to explain how the deceased missed two doses of antibiotics due to the drug being out of stock, why treating clinicians were not informed or why an alternative antibiotic was not administered in its place. The Trust were unable to talk to what, if any, systems were in place to ensure that patients were not left without necessary medication.
5. I am concerned that there may still be a risk to life of patients within the trust if they are provided with the wrong medication or miss necessary doses of prescribed 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure availability and escalation of necessary prescribed medication
Wider context from the report “1. It was accepted by the Trust that the deceased had been provided and discharged with medication (gabapentin) that did not belong to him and had missed two doses of antibiotics (fidaxomin) due to the drug being out of stock, which had not been communicated to or escalated to treating clinicians .
2. In evidence the Trust were unable to confirm whether the issues set out in 1. above sat solely with the nursing team or also involved pharmacy.
3. Whilst evidence was given in relation to the discharge nurse having undertaken reflection and a focus group being set up to explore improvements with discharge and planning there was no evidence as to how the wrong medication was provided to the deceased and whether this was a discharge only issue or also an issue with allocation and distribution of medication by pharmacy or by ward staff.
4. There was no evidence to explain how the deceased missed two doses of antibiotics due to the drug being out of stock, why treating clinicians were not informed or why an alternative antibiotic was not administered in its place . The Trust were unable to talk to what, if any, systems were in place to ensure that patients were not left without necessary medication .
5. I am concerned that there may still be a risk to life of patients within the trust if they are provided with the wrong medication or miss necessary doses of prescribed medication .
” 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 Strengthen induction and Medicines Management training on missed doses, time-critical medicines, escalation, and staff accountability for medicines administration.
Verbatim wording from the response “Induction training materials for healthcare professionals involved in medicines administration will be strengthened to emphasise the management of missed doses of time-critical medicines, including the requirement to escalate to the medical team where a dose is likely to be missed or has been omitted. The Trust Medicines Management Moodle training package is also under review, so will strengthen any sections on missed doses/time critical medicines for all clinical substantive professionals.” Source location Response from University Hospitals Birmingham 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 Undertake spot-check assessments of registered nurses’ discharge-medicines practice and share outcomes and learning through monthly clinical assurance meetings.
Verbatim wording from the response “Matrons and ward managers at Solihull Hospital are also undertaking spot check assessments of registered nurses’ practices when discharging patients from the medical and surgical wards. Outcomes and learning opportunities will be shared and discussed within the Clinical Assurance monthly group meetings with nurse leaders and managers. There have been no further reports of patients being discharged with incorrect medications, CDs not belonging to patients or medications belonging to another patient since this incident was raised at Solihull. The incidents have demonstrated several patient safety risks associated with the storage, handling and checking of medicines within clinical areas across Solihull Hospital. The safe and secure and handling of medicines (SaSHM) is audited bi-annually by the pharmacy department across the Trust.” Source location Response from University Hospitals Birmingham 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 Monitor compliance with medicines standards through weekly local assessments and monthly hospital, medication-safety, and group governance reporting until practice improvement is demonstrated.
Verbatim wording from the response “Monitoring of compliance against Trust standards will be undertaken locally through documentation, discharge and bedside assessments and audited weekly until practice improvement, standards and checks described in the Trust Medicines Code take place on every discharge (3.2.6 Medicines Code) and adhered to. Compliance against medicine’s standards is now being reported monthly through the Hospital’s Quality and Safety meetings and Safe Medication Practice Group. Any themes and practice safety risks are reported to both the Group Care Quality and Medicines Management Advisory Group.” Source location Response from University Hospitals Birmingham 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 Circulate a Trust patient-safety notice reinforcing procedures for obtaining and escalating time-critical medicines, using safety huddles, meetings, newsletters, and governance channels.
Verbatim wording from the response “These medicines omissions have been retrospectively reported on the Trust RADAR incidents system and immediate actions have been taken to address the procedural failings with the individual responsible nurses. The patient safety incident and learning have been shared across surgical and medical inpatient clinical teams. To strengthen awareness, a Trust patient safety notice will be circulated to reinforce the process for obtaining time-critical medicines both in and outside of normal working hours, to reduce the risk of missed administrations across the organisation. The notice will be shared in department Safety Huddles, Ward team meetings, Newsletters, Clinical Assurance and Care Quality meetings.” Source location Response from University Hospitals Birmingham 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 Complete corrective action plans addressing medicines-management audit findings and report progress through the monthly Care Quality agenda.
Verbatim wording from the response “Compliance against SaSHM standards declined from 98% to 82% in the last quarterly audit cycle at Solihull Hospital which was the largest decline in performance across all the hospital sites. Ward managers, with the support of the respective speciality’s Matron, are responsible for developing and completing action plans based on the results of the audits and report progress against compliance within the monthly Care Quality agenda. Audit outcomes have demonstrated areas of operational non-compliance however there have been no patient safety incidents or harm resulting from the standards not being met. Assurance has been received that actions have been completed with immediate effect.” Source location Response from University Hospitals Birmingham 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 UHB Pharmacy could not have prevented the missed doses because they occurred outside normal hours and Fidaxomicin was available through emergency drug cupboards.
Verbatim wording from the response “There are no actions UHB Pharmacy could have taken to prevent either of the missed doses as the incidents occurred out of normal working hours, and the drug was available in the emergency drug cupboard and dispensed directly to the ward. The expected standard for any omission of prescribed medication is that the omission is immediately escalated to the nurse in charge of the shift as per policy and procedure (medicine code).” Source location Response from University Hospitals Birmingham 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 Fidaxomicin was available throughout admission; missed doses resulted from nursing failures to record and communicate its location, not pharmacy supply failure.
Verbatim wording from the response “Fidaxomicin was available either on the ward, in main pharmacy or within the emergency drug cupboard at Solihull Hospital throughout Mr Simpson’s admission and accessed as per the medicines code. On the 16 June 2024, the drug was in the bedside secure locker however nursing handovers had failed to communicate and/or document on PICS noting, where the medication was being securely stored and the RNs were not routinely checking the bedside lockers before administrations. In the event a registered nurse cannot locate a drug dose, then the emergency drug cupboard should be utilised. Fidaxomicin has low usage as it is a restricted antibiotic used as a second line treatment for clostridium difficile or on the recommendation of a microbiologist. Fidaxomicin is a high-cost medication (£1,600 for a box) and is therefore not recommended as a stock drug on any location across UHB clinical areas.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
3 Jun 2025 Mark Anthony VILLERS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Insufficient radiologist capacity for reporting CT scans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mark Anthony VILLERS · 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
Mark Anthony Villers attended hospital with severe chest pain and was later found collapsed and unable to be resuscitated after returning to hospital. A post-mortem examination confirmed death from dissection of the ascending aorta. The report identified missed signs of aortic dissection and insufficient radiologist staffing to report CT scans as substantive concerns.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiologist capacity for reporting CT scans
Wider context from the report “1. The investigation by the hospital trust identified that at the time of Mr Villers’ presentation to hospital on 18/05/24 there were insufficient radiologists to report the large number of CT scans undertaken over the weekend period . This was one of the root causes of the very subtle abnormality indicating aortic dissection being missed when the scan was reported. The inquest heard evidence that whilst the situation had improved the number of radiologists was still not in accordance with Royal College of radiology guidelines thus creating a risk of future deaths and in my view, action should be taken.
” 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 Reconfigure weekend out-of-hours radiology reporting across three hospitals by separating emergency and inpatient streams and adding reporting capacity.
Verbatim wording from the response “Following the incident and starting from 1st September 2024, the provision of out of hours radiology reporting over weekends at Heartlands, Good Hope and Solihull Hospitals, part of UHB Trust, has been reconfigured to increase capacity and reduce the workload for individual radiologists. Previously the On-Call resident and radiologist were responsible for reporting all cross-sectional scans for both the Emergency Department (ED) and inpatients and the workload, which fluctuates, would often exceed safe reporting levels.” Source location Response from University Hospitals Birmingham 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 considers its radiology service appropriately provisioned because it uses RCR guidance as a planning benchmark and the reconfigured workload is manageable.
Verbatim wording from the response “The majority of our resident doctors and radiologists, who are part of this on call / acute reporting rota, have found the reconfigured system has improved their workload making it much more manageable.” Source location Response from University Hospitals Birmingham 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 Radiology workload may reasonably exceed RCR session figures during acute reporting, because the guidance is for departmental planning and emergency demand cannot be controlled.
Verbatim wording from the response “The Royal College of Radiologists (RCR) produced a guidance document to assist with departmental planning.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
16 May 2025 Tina Louise DOIG · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Insufficient haematology department staffing and capacity for comprehensive reviews View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tina Louise DOIG · 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
Tina Louise Doig had myelodysplasia that progressed to acute myeloid leukaemia and underwent two stem cell transplants after the first failed. She developed sepsis, multiple organ failure and cardiac arrests, and died after becoming critically unwell. The report identified concern that an understaffed haematology department was working beyond capacity, and described failures in donor-recipient testing before the first transplant.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient haematology department staffing and capacity for comprehensive reviews
Wider context from the report “1. The inquest heard evidence that the haematology department at the time of Mrs Doig’s stem cell transplant was understaffed and working beyond its capacity quite often leaving the team with very little time for comprehensive reviews . ████████ consultant haematologist at University Hospitals Birmingham NHS Foundation Trust confirmed at the inquest that the position remained the same today . This raises a concern that further deaths will occur and action is required.
” 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 Monitor recruitment to the new consultant posts and report progress through the Hospital Board.
Verbatim wording from the response “The Hospital Medical Director at Queen Elizabeth Hospital will monitor the recruitment to these new posts and report progress to the Hospital Executive Director through the Hospital Board.” Source location Response from University Hospitals Birmingham 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 Create and recruit an additional myeloid transplant consultant post.
Verbatim wording from the response “Our medium-term strategy is to create two additional consultant posts in transplant medicine, for which funding has been identified. The first appointment will be a myeloid transplant consultant, and the aforementioned trainee would be well suited to apply for this post when it is advertised.” Source location Response from University Hospitals Birmingham 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 Create a joint UHB–NHSBT consultant post covering transplant medicine, cellular therapies, laboratory oversight and cross-organisation communication.
Verbatim wording from the response “The second post is a joint appointment with NHS Blood and Transplant (NHSBT). The post will have a commitment to work 50% for NHSBT Cell, Apheresis, and gene therapies (CAGT) team and will be part of the transplant and cellular therapy team at NHSBT. The other 50% of time will be spent working within the transplant and cellular therapy team at UHB, part of which will involve treatment of AML patients requiring stem cell transplants. Working across UHB and NHSBT will give the consultant oversight over the stem cell lab and investigations and work up of patients, providing an increase in the safety and monitoring of patients going through transplant. The appointee will ensure that coherent communication between NHSBT and UHB consultants is sustained, facilitating effective discussion and information sharing on treatment, stem cell products and investigations required in this complex area.” Source location Response from University Hospitals Birmingham 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 Extend the senior specialist registrar’s training for six months, focusing on myeloid disease and allogeneic transplantation while supporting transplant clinics under supervision.
Verbatim wording from the response “In order to provide an immediate increase in capacity, one of our existing transplant consultants has been re-job planned from 1st July 2025 to reduce their general haematology clinic commitments and increase transplant-dedicated time, increasing their capacity to manage new and post-transplant AML patients. In addition, our senior specialist registrar, who has been working in the myeloid/ transplant clinic and is due to receive their certificate of completion of training (CCT) in August, will enter a 6-month extended training period during which they will focus on increasing their specialty experience in myeloid disease and allogeneic stem cell transplantation. They are already beginning to work semi-independently with consultant supervision and are directly supporting transplant clinics. The extension to training has been agreed with NHSE WTEd (West Midlands Deanery).” Source location Response from University Hospitals Birmingham 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 Increase transplant capacity by reallocating an existing consultant’s job plan to provide more transplant-dedicated time.
Verbatim wording from the response “In order to provide an immediate increase in capacity, one of our existing transplant consultants has been re-job planned from 1st July 2025 to reduce their general haematology clinic commitments and increase transplant-dedicated time, increasing their capacity to manage new and post-transplant AML patients. In addition, our senior specialist registrar, who has been working in the myeloid/ transplant clinic and is due to receive their certificate of completion of training (CCT) in August, will enter a 6-month extended training period during which they will focus on increasing their specialty experience in myeloid disease and allogeneic stem cell transplantation. They are already beginning to work semi-independently with consultant supervision and are directly supporting transplant clinics. The extension to training has been agreed with NHSE WTEd (West Midlands Deanery).” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
16 Apr 2025 Iris Joan CARTER · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to adequately record heel-skin inspections in electronic inpatient notes View source Failure to properly inspect the skin of patients’ heels for pressure sores View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Iris Joan CARTER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Iris Joan CARTER had a fall at home on 1 October 2024 and sustained a left distal femur fracture, which was surgically stabilised. After rehabilitation treatment, including treatment for a Grade 4 pressure sore on her left heel, she developed pneumonia and died in hospital on 8 November 2024. The principal concern was that the pressure sore may not have been properly inspected or that inspections were not adequately recorded during her admission at the Queen Elizabeth Hospital.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record heel-skin inspections in electronic inpatient notes
Wider context from the report “2. I heard evidence during the inquest that Iris was at heightened risk of developing pressure sores given her co-morbidities and reduced mobility post her operation and that a Grade 4 pressure sore is the most serious type of pressure sore where bone is exposed and can therefore be at risk of infection.
3. However, apart from one entry on 13th October 2024 in the QEH electronic in patient noting records when it was recorded that Iris was complaining of pain on palpation of her left heel and a pillow was placed under her heel, there is no reference in the noting to it having been observed at any point that Iris had developed a pressure sore to her left heel during her admission at the QEH .
4. This leads to a concern that either the skin to her left heel was not being properly inspected or if it was that such inspections were not adequately noted in the electronic in-patient noting .
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly inspect the skin of patients’ heels for pressure sores
Wider context from the report “2. I heard evidence during the inquest that Iris was at heightened risk of developing pressure sores given her co-morbidities and reduced mobility post her operation and that a Grade 4 pressure sore is the most serious type of pressure sore where bone is exposed and can therefore be at risk of infection.
3. However, apart from one entry on 13th October 2024 in the QEH electronic in patient noting records when it was recorded that Iris was complaining of pain on palpation of her left heel and a pillow was placed under her heel, there is no reference in the noting to it having been observed at any point that Iris had developed a pressure sore to her left heel during her admission at the QEH .
4. This leads to a concern that either the skin to her left heel was not being properly inspected or if it was that such inspections were not adequately noted in the electronic in-patient noting.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require the nurse in charge on each shift to check that care assessments, including skin inspection charts, are fully completed.
Verbatim wording from the response “While reviewing the incident in November 2024, the omissions in producing appropriate and accurate levels of documentation outlining all areas of Mrs Carter’s skin were highlighted. In response to these findings, the senior sister and her team highlighted the omission in care to the wider nursing team, whilst reiterating the associated risk and the pressure ulcer prevention strategy within the Trust. The actions taken at the time were to update the pressure ulcer prevention ward information board, and to provide feedback on Mrs Carter’s case at the daily safety huddle on the ward. Another change in practice is that the nurse in charge of each shift will carry out a safety check, ensuring all care assessments, specifically the patient skin inspection charts, are fully completed. The senior sister has also been completing spot checks since December 2024.” Source location Response from UNIVERSITY HOSPITALS BIRMINGHAM 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 Conduct ward spot checks of care documentation to verify completion of required assessments and skin inspection charts.
Verbatim wording from the response “While reviewing the incident in November 2024, the omissions in producing appropriate and accurate levels of documentation outlining all areas of Mrs Carter’s skin were highlighted. In response to these findings, the senior sister and her team highlighted the omission in care to the wider nursing team, whilst reiterating the associated risk and the pressure ulcer prevention strategy within the Trust. The actions taken at the time were to update the pressure ulcer prevention ward information board, and to provide feedback on Mrs Carter’s case at the daily safety huddle on the ward. Another change in practice is that the nurse in charge of each shift will carry out a safety check, ensuring all care assessments, specifically the patient skin inspection charts, are fully completed. The senior sister has also been completing spot checks since December 2024.” Source location Response from UNIVERSITY HOSPITALS BIRMINGHAM 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 Reviews found no pressure damage before 15 October, when a blister was identified, documented, escalated and assessed.
Verbatim wording from the response “Our review of the documentation outlined in the medical noting documents there was no pressure damage noted on 09.10.24 at 14:18 by the Ortho geriatrician team, who noted review of the lower limb and noted oedema present to Mrs Carter’s leg.” Source location Response from UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
Open published response
15 Nov 2024 Rachel Alicia Elizabeth RYAN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of a protocol identifying the correct specialism for the biopsy procedure View source Failure to convene a multidisciplinary meeting to coordinate the biopsy pathway 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
Rachel Alicia Elizabeth RYAN · 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
Rachel Alicia Elizabeth RYAN was treated for a sacral pressure ulcer that became infected and developed into osteomyelitis, alongside deep vein thrombosis and pulmonary embolism. She deteriorated and died on 21 June 2024; the stated medical cause of death was osteomyelitis due to an infected sacral pressure sore, with frailty of old age also recorded. The principal concern was delay and lack of collaboration between specialist teams in arranging a deep tissue biopsy to guide antibiotic 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol identifying the correct specialism for the biopsy procedure
Wider context from the report “1. On 23rd April Miss Ryan’s treating consultant geriatrician received advice from the infectious diseases team that a deep tissue biopsy was strongly recommended to best guide the antibiotic therapy for her infection.
2. Despite him liaising with/going back and forth between the Tissue Viability Nurse service, the Trauma and Orthopaedic team and the Plastic Surgery team (based at the Queen Elizabeth Hospital) between 23rd April and 1st May, none of these teams could, for different reasons, facilitate this procedure. As a result, it was not until 2nd May that assistance was sought from the interventional radiology team who agreed to help.
3. The procedure was initially due to take place on 7th May but had to be put off due to Miss Ryan being on warfarin and there were then further delays due to non-availability of the relevant specialist as well as the need to stop her existing antibiotics for 24 to 48 hours before the procedure. It was finally carried out on 21st May.
4. On 22nd May a new anti-biotic regime was commenced with it being noted that one of the bacterial organisms identified from the biopsy, namely Morganella morganii, was resistant to co-amoxicalve, the antibiotic which Miss Ryan had most recently been receiving from 15th April until 19th May.
5. Although I heard evidence that the delay in starting the new antibiotic regime was unlikely to have altered the sad outcome in this case in part due to Miss Ryan’s existing frailty and poor prognosis, I am concerned that in the absence of any existing protocol regarding the correct specialism for the biopsy procedure , no Multi-disciplinary meeting bringing together specialists from the different disciplines was offered or held in this case to agree the best way forward. This led to a delay and a lack of collaboration between teams which could, if repeated, result in an avoidable death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to convene a multidisciplinary meeting to coordinate the biopsy pathway
Wider context from the report “1. On 23rd April Miss Ryan’s treating consultant geriatrician received advice from the infectious diseases team that a deep tissue biopsy was strongly recommended to best guide the antibiotic therapy for her infection.
2. Despite him liaising with/going back and forth between the Tissue Viability Nurse service, the Trauma and Orthopaedic team and the Plastic Surgery team (based at the Queen Elizabeth Hospital) between 23rd April and 1st May, none of these teams could, for different reasons, facilitate this procedure. As a result, it was not until 2nd May that assistance was sought from the interventional radiology team who agreed to help.
3. The procedure was initially due to take place on 7th May but had to be put off due to Miss Ryan being on warfarin and there were then further delays due to non-availability of the relevant specialist as well as the need to stop her existing antibiotics for 24 to 48 hours before the procedure. It was finally carried out on 21st May.
4. On 22nd May a new anti-biotic regime was commenced with it being noted that one of the bacterial organisms identified from the biopsy, namely Morganella morganii, was resistant to co-amoxicalve, the antibiotic which Miss Ryan had most recently been receiving from 15th April until 19th May.
5. Although I heard evidence that the delay in starting the new antibiotic regime was unlikely to have altered the sad outcome in this case in part due to Miss Ryan’s existing frailty and poor prognosis, I am concerned that in the absence of any existing protocol regarding the correct specialism for the biopsy procedure, no Multi-disciplinary meeting bringing together specialists from the different disciplines was offered or held in this case to agree the best way forward . This led to a delay and a lack of collaboration between teams which could, if repeated, result in an avoidable death .
” 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 Clarify the pathway and contact process for requesting deep tissue biopsies from Interventional Radiology.
Verbatim wording from the response “• The pathway and means of contacting Interventional Radiology for deep tissue biopsies has been clarified by the department.” Source location Response from University Hospitals Birmingham 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 Write supplementary multidisciplinary guidance covering treatment goals, Infection Service involvement, Interventional Radiology biopsy requests, and the distinction between sharp debridement and deep tissue biopsy.
Verbatim wording from the response “• Appendiceal guidance to supplement the existing Trust guidelines will be written by the Infection Service, Healthcare of Older Adults, Tissue Viability and Interventional Radiology. A draft should be complete by February 2025. This will include the following points:” Source location Response from University Hospitals Birmingham 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 Require bedside Infection Service reviews for complex pressure ulcers and multidisciplinary discussion with ward and Tissue Viability teams, escalating appropriate osteomyelitis cases to the complex bone MDT.
Verbatim wording from the response “• The Infection Service will reiterate via their Morbidity and Mortality meeting that in cases of complex pressure ulcers, a bedside review of the patient should take place to obtain a holistic view of the most appropriate goal of treatment and form part of the multidisciplinary meeting with the ward team and Tissue Viability. Those cases involving osteomyelitis where the appropriate goal is cure rather than suppression will be taken by the Infection Service to the complex bone MDT of which they are a core member.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
1 Nov 2024 Phyllis TROMANS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Lack of pressure area care for patients positioned on trolleys in the Emergency Department View source Failure to complete wound care plans View source Failure of post-death investigations to establish why care gaps occurred View source Underestimation of pressure sore risk View source Failure to adhere to scheduled repositioning intervals View source See 2 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
Phyllis TROMANS · 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
Phyllis Tromans, a long-term resident with Parkinson’s disease who was in a frail condition, developed a grade 4 pressure ulcer while an inpatient at Queen Elizabeth Hospital and died at Cotteridge House on 24 May 2024. Concerns included an underestimated pressure sore risk assessment, prolonged periods without repositioning, an incomplete wound care plan, and an investigation that did not establish why gaps in care had occurred.
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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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of pressure area care for patients positioned on trolleys in the Emergency Department
Wider context from the report “1. It is likely that Mrs Tromans' tissue damage started during her period in the Emergency Department. On admission, her Waterlow score indicated a high risk of pressure sores. That score was underestimated and the correct score would have indicated a very high risk. She spent almost 18 hours in ED, during which time she was positioned on a trolley without pressure area 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete wound care plans
Wider context from the report “3. East Ground B ward had a paper version of a wound care plan which was designed to provide detailed monitoring of her skin condition and a treatment plan for pressure sore care. This was not completed at any stage.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of post-death investigations to establish why care gaps occurred
Wider context from the report “4. The Matron's investigation into these gaps in care did not seek to establish why they had occurred. This raises a concern about the quality and efficacy of the Trust's post-death investigations which in turn raises a concern for future deaths.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Underestimation of pressure sore risk
Wider context from the report “1. It is likely that Mrs Tromans' tissue damage started during her period in the Emergency Department. On admission, her Waterlow score indicated a high risk of pressure sores. That score was underestimated and the correct score would have indicated a very high risk. She spent almost 18 hours in ED, during which time she was positioned on a trolley without pressure area 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to scheduled repositioning intervals
Wider context from the report “2. Mrs Tromans had a repositioning schedule in place when she was admitted to the Acute Medical Unit and subsequently to ward East Ground B. This required repositioning at no greater intervals of four hours to mitigate the risk of pressure sores. On a total of 22 occasions the schedule was not adhered to. This led to occasions where Mrs Tromans was left in the same position for up to 14 hours.
” 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 Use the updated Wound Assessment Chart to document skin assessments and treatment plans.
Verbatim wording from the response “The Trust has responded by updating its wound care tools and processes:” Source location Response from University Hospitals Birmingham
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 Deliver targeted Emergency Department training on pressure-ulcer assessment, reporting, skin inspection and repositioning.
Verbatim wording from the response “In response to this, several measures are being taken to prevent future occurrences. Due to the increasing demand on the ED, which has led to patients spending longer than desirable periods in the department, the Tissue Viability team has collaborated with ED Matrons to implement a project aimed at reducing pressure ulcers in the ED. This includes:” Source location Response from University Hospitals Birmingham
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 Deliver repositioning training for Tissue Viability Link Workers with therapy-team pressure mapping and safe side-lying education.
Verbatim wording from the response “• Training: In December, two Tissue Viability Link Worker events focused on repositioning were held, with support from therapy teams using pressure mapping devices to identify pressure points and promote effective repositioning. The sessions also provided education on anatomy and physiology, with an emphasis on safe side-lying techniques to relieve pressure.” Source location Response from University Hospitals Birmingham
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 Revise post-death investigations to obtain individual statements from involved care staff and embed findings in roundtable reports.
Verbatim wording from the response “In response to this, the leadership team has reflected on the investigation process and acknowledged the need for individual fact-finding interviews with staff involved in care delivery. Moving forward:” Source location Response from University Hospitals Birmingham
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 Conduct weekly Acute Medical Unit repositioning audits, provide real-time feedback and reinforce schedule compliance through staff communications.
Verbatim wording from the response “• Compliance Monitoring: A weekly audit of repositioning practices in the AMU is now being conducted, with real-time feedback provided to staff. The AMU also receives regular communications emphasizing the importance of following the repositioning schedule and completing daily care plans.” Source location Response from University Hospitals Birmingham
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 Audit Emergency Department trolley mattresses and establish a trolley-audit programme.
Verbatim wording from the response “Furthermore, skin champions have been introduced in the ED, with staff undergoing comprehensive training. The department is also working on auditing trolley mattresses to ensure they provide effective pressure reduction, with plans for a trolley audit program in place.” Source location Response from University Hospitals Birmingham
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 Introduce pressure-relieving trolley mattresses and heel-offloading pillows for Emergency Department patients.
Verbatim wording from the response “In response to this, several measures are being taken to prevent future occurrences. Due to the increasing demand on the ED, which has led to patients spending longer than desirable periods in the department, the Tissue Viability team has collaborated with ED Matrons to implement a project aimed at reducing pressure ulcers in the ED. This includes:” Source location Response from University Hospitals Birmingham
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 Implement the Response Assessment Tool for senior-staff oversight of repositioning strategies and audit its compliance and quality.
Verbatim wording from the response “• Response Assessment Tool (RAT): The Tissue Viability team has implemented the RAT to scope trust-acquired pressure ulcer events. This tool, which will be used by senior staff to ensure repositioning strategies are being followed, will be audited for compliance and quality.” Source location Response from University Hospitals Birmingham
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 Update and relaunch the Waterlow-score documentation booklet across the Trust.
Verbatim wording from the response “• Documentation: A booklet supporting accurate completion of Waterlow scores is being updated and will soon be relaunched to ensure proper documentation across the Trust.” Source location Response from University Hospitals Birmingham
Open published response
22 Oct 2024 Joan Margaret KNIGHT · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to conduct mortality reviews correctly View source Inadequate learning from mortality review cases 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
Joan Margaret KNIGHT · 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
Joan Margaret Knight underwent treatment for severe coronary artery stenosis, including stent procedures, and developed bleeding, cardiac tamponade and multi-organ failure before dying on 25 May 2024. The report raised concern that the mortality review was completed incorrectly and contained contradictory statements about whether the death was avoidable, potentially limiting learning from cases and creating a risk of future deaths.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct mortality reviews correctly
Wider context from the report “The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being conducted correctly and that there could be inadequate learning from cases raising a risk of future deaths.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate learning from mortality review cases
Wider context from the report “The mortality review that was undertaken in this case was completed incorrectly and contained contradictory terms about whether the death was avoidable. This raises a concern that mortality reviews are not being conducted correctly and that there could be inadequate learning from cases raising a risk of future deaths.
” 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 Develop a new Mortality and Morbidity recording platform.
Verbatim wording from the response “3. A new Mortality & Morbidity recording platform has been developed and is to be piloted prioritising the two identified specialities using the Dendrite software.” Source location Response from University Hospitals Birmingham 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 Roll out the new Mortality and Morbidity recording platform across the remainder of the Trust after piloting.
Verbatim wording from the response “1. A New Mortality & Morbidity recording platform is to be rolled out across the remainder of the Trust once piloted.” Source location Response from University Hospitals Birmingham 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 Share identified learning with Hospital Medical Directors and Directors of Nursing across the Trust’s hospitals.
Verbatim wording from the response “I further note your concern regarding the risk of future deaths, which has been addressed below. The focus of the actions has been at the Queen Elizabeth Hospital Birmingham (QEHB) but the learning identified in this response has been shared with each of the responsible Hospital Medical Directors and Directors of Nursing covering QEHB, Birmingham Heartlands Hospital and Good Hope Hospital respectively for implementation.” Source location Response from University Hospitals Birmingham 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 Request that the specialty use the three Learning from Deaths methodology coding scores.
Verbatim wording from the response “1. We have requested that the speciality use the three methodology coding scores recommended by the Learning from Deaths Team in line with the rest of the Trust and we have disabled the use of all other methodology coding fields on the software.” Source location Response from University Hospitals Birmingham 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 Publish updated Mortality and Morbidity standards on the Trust intranet.
Verbatim wording from the response “2. Updated Mortality & Morbidity standards are to be published and readily available on the Trust intranet.” Source location Response from University Hospitals Birmingham 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 Disable non-recommended mortality-review methodology coding fields in the Dendrite software.
Verbatim wording from the response “1. We have requested that the speciality use the three methodology coding scores recommended by the Learning from Deaths Team in line with the rest of the Trust and we have disabled the use of all other methodology coding fields on the software.” Source location Response from University Hospitals Birmingham 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 Pilot the new Mortality and Morbidity recording platform with the two identified Dendrite-using specialties.
Verbatim wording from the response “3. A new Mortality & Morbidity recording platform has been developed and is to be piloted prioritising the two identified specialities using the Dendrite software.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
22 Oct 2024 Robert TAYLOR · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Lack of enhanced nursing observations for patients requiring them View source Failure of post-death investigations to address central issues relating to falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert 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 TAYLOR, who had prostate cancer, chronic liver disease and later high grade acute myeloid leukaemia, fell in hospital on 11 June 2024 after enhanced nursing observations had been identified as necessary but not put in place. He sustained traumatic subdural and subarachnoid haemorrhages and died on 21 June 2024. Concerns were raised about the lack of enhanced observations and the quality of the Trust’s post-death investigation.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of enhanced nursing observations for patients requiring them
Wider context from the report “1. The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations . The Nursing witness was unable to say what steps, if any, had been taken to try to put enhanced observations in place . The investigation report stated that enhanced observations had been identified as needed but did not expand on what actions were taken, if any, to obtain enhanced observation nor what actions had been taken after the death to ensure enhanced observations for patients that require them . This raises a concern for future deaths.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of post-death investigations to address central issues relating to falls
Wider context from the report “2. The witness and the investigation report did not address the central issue relating to the fall and this raises a concern about the quality of post death investigations being undertaken by the Trust . This raises a concern for future deaths.
” 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 Conduct a nursing workforce review addressing ward geography, staffing and enhanced-care capacity.
Verbatim wording from the response “There will be a nursing workforce review to cover the points above. It is accepted that this point should have been more explicit within the report and details of the actions set out below should have been included.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Identify patients at risk, communicate risks before the morning touchpoint, and implement additional safety measures where mitigation cannot be assured.
Verbatim wording from the response “• The nurse in charge currently identifies and discusses patients at risk of falls, as well as those requiring enhanced observations, with the Matron, prior to the 0800-touchpoint meeting. Since the inquest we have made changes in how this information is communicated. There is a more risk focused approach being taken and a focus on vulnerable patients in higher risk environments. If a ward area is unable to provide assurance that a risk is being mitigated, then additional safety measures to ameliorate the risk are put into place. Examples include:
○ Discussion in the morning safety huddle regarding risk of falls and patients for whom there is concern.
○ Reorganisation of workload to mitigate and reduce risk
○ Movement of patients into more appropriately positioned side rooms where possible.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Request additional clinical-bank staffing case by case and assess staffing requirements shift by shift.
Verbatim wording from the response “• Acuity was noted to be a contributing factor within this case. There is currently a SNCT (Safer Nursing Care Tool) to review acuity levels as part of the wider Trust review of acuity and dependency. Whilst this work progresses increased staffing needs will be identified on a case-by-case basis as per the UHB enhanced care policy. Staff will be requested through UHB clinical bank services in a timely manner and explored on a shift-by-shift basis.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Revise nursing witness-statement templates with prompts covering the incident, preceding care, post-fall care and learning.
Verbatim wording from the response “Since the inquest the Lead Nurse for falls has worked with the legal services team to revise the templates used for the nursing witness statement to ensure that witnesses are capturing essential information in relation to a fall to assist the Coroner at Inquest. The template provides additional prompts to enable the witness to write a logical account of the incident, including the patients care leading up to the fall, how the fall occurred, and post fall care, including any learning identified.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Re-embed the Enhanced Care policy and discuss enhanced-care risks in ward safety huddles.
Verbatim wording from the response “• The Enhanced Care policy has been re-embedded into the ward and risks are discussed in the ward huddle following shift handovers.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Involve specialist nursing leads from the beginning of Coronial investigations and inquest processes.
Verbatim wording from the response “In addition, our Legal Services Team will ensure that specialist nurse leads for the Trust, for example those involved in Falls and Tissue Viability, will be involved from the start of a Coronial investigation or inquest process to ensure they have full awareness of issues and can contribute to an investigation from a highly experienced professional standpoint.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Prepare inquest witnesses through individual and group meetings, calls and meetings with instructed solicitors.
Verbatim wording from the response “Regarding witnesses summonsed to attend inquests, the Legal Services Team are ensuring that our staff are fully prepared to attend an inquest by arranging individual and group meetings and telephone calls with witnesses and their managers together with meetings with our instructed solicitors to ensure that staff are supported and are as prepared as fully as they can be to give evidence at the inquest. In addition, a series of training for ward managers and nursing staff is being rolled out commencing early next year across all our hospital sites.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Share ward geography information with assessment-area nursing leaders and request risk-aware side-room allocations.
Verbatim wording from the response “• We have recognised that the current layout of ward 19 can be challenging when nursing patients who are at risk of falls because of having only two 6 bedded bays and 13 side rooms positioned in a T shape within the ward. In addition, only 4 side rooms have partial views (if the door is open), the other 9 have no visibility.
We have spoken to the senior nursing team in charge of the assessment area regarding environmental challenges and provided a visual map of side rooms, so they are aware of the physical layout of the ward. We have asked the assessment areas when allocating patients to be mindful of ward geography and communicate any concerns and risks that patients may have such that plans can be put in place to support enhanced care and risk of falls.” Source location Response-from-University-Hospitals-Birmingham-NHS
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 Use the Safer Nursing Care Tool within the wider acuity and dependency review to identify staffing needs.
Verbatim wording from the response “• Acuity was noted to be a contributing factor within this case. There is currently a SNCT (Safer Nursing Care Tool) to review acuity levels as part of the wider Trust review of acuity and dependency. Whilst this work progresses increased staffing needs will be identified on a case-by-case basis as per the UHB enhanced care policy. Staff will be requested through UHB clinical bank services in a timely manner and explored on a shift-by-shift basis.” Source location Response-from-University-Hospitals-Birmingham-NHS
Open published response
19 Aug 2024 Alan Stanley FALLOWS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Use of Datix templates leading to incorrect or incomplete incident information View source Automated Datix review and approval failing to ensure human identification of patient-safety incidents View source Failure to complete and review Datix reports within the required timeframe 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
Alan Stanley FALLOWS · 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
Alan Stanley Fallows was admitted to hospital after a fall at home and later sustained further unwitnessed falls while an inpatient, including a fracture to his right neck of femur. He subsequently developed severe bilateral aspiration pneumonia and died on 28 March 2024. The principal concerns were delayed completion of a Datix report, unclear automated approval processes, and the use of templates that could result in incorrect or incomplete incident information and missed patient-safety learning.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of Datix templates leading to incorrect or incomplete incident information
Wider context from the report “3. Thirdly, I was concerned to hear from Senior Ward Sister ████████ that nursing staff utilise templates or pro-forma text when completing DATIX reports . The use of templates, whilst time saving, can easily lead to incorrect or incomplete information being provided on incidents (as in Mr Fallows' case) and therefore there is a real risk that opportunities will be lost to correctly investigate incidents which affect patient safety and which may cause a risk of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Automated Datix review and approval failing to ensure human identification of patient-safety incidents
Wider context from the report “2. Secondly, I was concerned to read that the Datix relating to the fall of 12 February (code U454194) appears to have undergone some kind of automated approval and sign off process in June 2024, and regrettably staff were unable to shed any light during the inquest on what happened/happens during this process . This is in contrast to the Datix relating to the second fall (code U441480) which appears to have gone through a “manual” approval and sign off process and the matter closed on 06/06/2024 (with the name of the approver being redacted on the form). I am concerned that if the Trust has any kind of automation process for the review and approval of Datix reports, there may be missed opportunities for humans to correctly identify any incident that compromises patient safety and which give rise to a risk of death;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and review Datix reports within the required timeframe
Wider context from the report “1. Firstly, I have heard that the Datix report for Mr Fallows' first fall on 12 February was not completed at the time by staff , and the nurse in question is now retired and thus it was not possible to ascertain why it had not been completed. The report was only completed retrospectively two months later by staff once an inquest had been opened and a request for evidence was sent to the Trust. A Datix is a risk management information system which gathers information on processes and errors and allows staff to report on any issue which may compromise patient safety, which is central to good clinical governance and best practice, as well as contributing to learning. Whilst the failure to create the DATIX here could be a one-off, I am concerned that staff may not be aware of the importance of completing these reports and doing so in a timely fashion , which I understand should be completed within 24 hours of incident or knowledge of an incident. It is not difficult to see that where incidents are not being logged and reviewed, patient safety could be compromised, and future deaths could occur as a consequence ;
” 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 Update falls-team training to reinforce incident-reporting requirements after a fall.
Verbatim wording from the response “The above data provides assurance that most falls are reported within 2 days. Whilst the data is reassuring, we have updated the training provided by our falls team to reinforce the reporting requirements following a fall.” Source location Response from University Hospitals Birmingham
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 Templates are not used for incident reports; the post-fall care plan lists required actions, while staff record incident information separately.
Verbatim wording from the response “We can confirm that we do not have a template list of actions for incident report forms. Within our electronic patient record there is a post-fall section in the daily care plan which includes a number of actions that staff must take following a fall which includes; ensuring that neurological observations have been commenced, ensuring that an incident form has been submitted, ensuring that the Next of Kin have been informed etc. In this case the Senior Sister used a set list of actions to ensure all necessary falls prevention interventions were in place. I can provide assurance that templates are not used.” Source location Response from University Hospitals Birmingham
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 Incidents are not automatically approved: every incident receives individual review before closure, although low-harm records are automatically stamped after managerial review.
Verbatim wording from the response “All reported incidents are reviewed by an individual before the approval and sign off/closure process. We do not have an automated approval and sign off process for incidents and all incidents are closed following review by an individual. For low level incidents, such as the incident relating to the first fall where the level of harm is low, these incidents are closed following review by a local manager. Following this review an automatic closure process is run which ‘stamps’ the record with the final approver as ‘automated’.” Source location Response from University Hospitals Birmingham
Open published response
14 May 2024 James Patrick PEARSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Delays in obtaining blood products after major haemorrhage protocol activation View source Lack of documentation of patient observations View source Insufficient doctor staffing capacity in the department View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Patrick PEARSON · 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
James Pearson was struck by a vehicle on 14 June 2023 and later died at a hospice on 22 October 2023 after sustaining traumatic and hypoxic brain injuries, developing pneumonia, and experiencing a prolonged hospital admission. The concerns included undocumented observations, insufficient doctor coverage during his deterioration, and the time needed to obtain blood products; the report also states that an opportunity to provide fluids was missed and that this would probably have prevented his cardiac arrest and subsequent hypoxic brain injury.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining blood products after major haemorrhage protocol activation
Wider context from the report “9. I further heard from ████████ that the blood products at Birmingham Heartlands Hospital are not kept in the ED, and are kept some distance away, and could take up to 20 minutes to obtain after the major haemorrhage protocol is activated. Whilst this is unlikely to have affected the outcome for James, due to his sudden deterioration, I am concerned that a delay in obtaining blood products could lead to future deaths.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of patient observations
Wider context from the report “3. During the inquest, I heard that James was attached to a monitor, which was taking his observations every 15 minutes. None of these observations, however, were documented. This is of concern, as it is not possible to know at what point James began to decline. I am concerned that lack of proper documented observations could lead to future deaths, as staff will not be able to follow the observation pattern and notice a decline in presentation.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient doctor staffing capacity in the department
Wider context from the report “6. ████████ told me in evidence that during the time since his last review by a Doctor at 03.16am, and his cardiac arrest at 04.25am, James was not seen by a Doctor, and only Nurses were available in the department . The only Doctor on shift at that time was dealing with another very unwell patient, who also required resuscitation.
7. ████████ told me that at the point in time the deterioration in James was noted, sometime between 04.00-04.20am, James should have received fluids, and in his opinion, if he had done so, on the balance of probabilities, he would not have had a cardiac arrest. He added that this was beyond what he would expect a nurse to adduce, however, if the Doctor had been present, he believed this would have been done.
8. I am therefore concerned that there were not enough Doctors in the department at the time, meaning that there is no resilience to deal effectively with more than one very unwell patient at any given time. If this is not addressed, there is a risk of future deaths.
” 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 Audit compliance with the Major Haemorrhage Blood Protocol across all UHB sites.
Verbatim wording from the response “A review of all incidents involving activation of the MHP within Heartlands Emergency Department since Mr Pearson’s death has been undertaken. This did not demonstrate any incidents regarding delays in receipt of blood once the MHP was activated. A full audit is underway by the Hospital Transfusion Group to review overall compliance to the Major Haemorrhage Blood Protocol across all UHB sites, the outcome of this will be reported to the Trust Transfusion Committee.” Source location Response from University Hospitals Birmingham
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 Reiterate observation-recording standards at Emergency Department huddles.
Verbatim wording from the response “The standards set out above and expected documentation has been reiterated at Emergency Department huddles to ensure that recording within noting is robust and will be audited as part of the action plan following this Serious Incident Investigation to provide assurance that these standards are being adhered to.” Source location Response from University Hospitals Birmingham
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 demand-and-capacity modelling to define the substantive workforce needed for additional resilience.
Verbatim wording from the response “Whilst we are satisfied that our current model provides resilient staffing to the mean attendance profile and that our processes enable resilience of staffing with clear escalations where minimum staffing is predicted to not be achieved, we are currently reviewing the demand and capacity for the unit. This is to ensure our staffing is modelled correctly to ensure the baseline for the substantive workforce is correct. Although we meet RCEM criteria in terms of staffing on duty, to meet this we utilise a number of bank staff. The demand and capacity modelling will ensure the unit has identified what the substantive workforce should look like, to provide additional resilience. This work will be completed by August 2024.” Source location Response from University Hospitals Birmingham
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 Audit compliance with observation-recording standards as part of the Serious Incident Investigation action plan.
Verbatim wording from the response “The standards set out above and expected documentation has been reiterated at Emergency Department huddles to ensure that recording within noting is robust and will be audited as part of the action plan following this Serious Incident Investigation to provide assurance that these standards are being adhered to.” Source location Response from University Hospitals Birmingham
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 A blood fridge is not being provided because group O blood is nationally scarce and Heartlands is not a Major Trauma Centre.
Verbatim wording from the response “The recommendation to consider a blood fridge in BHH ED has been discussed in the Hospital Transfusion team. There are significant consequences to putting a fridge in the ED at BHH, not least that group O blood (which is what would need to be in the fridge if it is being used to support immediate transfusion) is in short supply nationally and needs to be used only for those patients that require it. This includes not stocking it in locations where it is unlikely to be used, which includes EDs (such as Heartlands) which are not in Major Trauma Centres.” Source location Response from University Hospitals Birmingham
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 Current emergency department staffing, rota review and escalation processes are considered sufficiently resilient and meet RCEM minimum criteria.
Verbatim wording from the response “To ensure we continue to meet minimum staffing levels in the ED there is a twice weekly forward look meeting with the rota team to confirm minimum numbers are met, and to be aware of where there are dips in cover and these undergo a process of escalation via the ED general manager in order to consider all mitigation options including agency use, locum, support from other specialty teams at middle grade level as examples.” Source location Response from University Hospitals Birmingham
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 blood arrived within 15 minutes after major haemorrhage protocol activation, so the relevant delay was in requesting blood and activating the protocol.
Verbatim wording from the response “Availability of blood products within the emergency department
You heard evidence that it can take up to 20 minutes to obtain blood products within the emergency department following activation of the major haemorrhage protocol. Whilst this delay was unlikely to have affected the outcome for Mr Pearson, you are concerned that delays in blood products being available could result in future deaths.” Source location Response from University Hospitals Birmingham
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing monitoring and NEWS2 procedures are considered sufficient despite observations not being documented every 15 minutes.
Verbatim wording from the response “Whilst observations are not documented every 15 minutes, they are monitored and any trigger actioned according to the Trust Acutely Ill Adult NEWS2 Procedure AcutelyIllAdultsNewscoreprocedure.pdf. (NEWS2 is a standardised National Early Warning Score devised to standardise the assessment and response to acute illness or deterioration.)” Source location Response from University Hospitals Birmingham
Open published response
7 May 2024 Peter Jason FANNING · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Insufficient availability of feeding-tube replacement services for patients with complex needs View source Failure to maintain nutrition after feeding-tube dislodgement View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Jason FANNING · 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 Jason FANNING, who had cerebral palsy, severe physical impairment, epilepsy and relied on a gastrostomy feeding tube, experienced repeated tube dislodgements and admissions for replacement. He developed pneumonia and died on 19 December 2023; concerns related to limited availability for complex feeding-tube replacements and maintaining nutrition after dislodgement.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of feeding-tube replacement services for patients with complex needs
Wider context from the report “1. The inquest heard evidence that there is only one radiology list per week to accommodate replacement of feeding tubes in patients with complex needs . In Peter’s case this meant he had to wait a week for the tube to be replaced meaning he had suboptimal nutrition during this period. Consideration should be given to whether additional services are required for replacement of feeding tubes in patients with complex needs.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nutrition after feeding-tube dislodgement
Wider context from the report “2. The inquest heard evidence that Peter’s nutritional status was suboptimal due to repeated tube dislodgments and waiting for radiology or theatre slots to be available. Consideration needs to be given as to how best to maintain patients’ nutrition after tube dislodgments when they rely on feeding tubes .
” 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 Increase interventional radiology capacity to four weekly lists across three sites and provide three consultants for x-ray-guided feeding-tube insertion.
Verbatim wording from the response “X-ray guided tube insertion
The Interventional Radiology department has increased capacity from one to four intervention radiology (IR) lists per week across our Heartland’s, Good Hope and Solihull Hospital sites (HGS), which can accommodate x-ray guided feeding tube insertions. We also now have three IR consultants who are able to provide this service (increased from one previously) and these changes have been in place since April 2024.” Source location Response from University Hospitals Birmingham
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 Provide a temporary additional interventional radiology theatre at Heartlands for two days per week using additional funding.
Verbatim wording from the response “Also, temporary funding has been made available to increase IR capacity on the Heartlands site and we have an additional IR theatre running in the Heartlands Treatment Centre for two days per week. A business case is currently being considered to support this becoming a full-time provision.” Source location Response from University Hospitals Birmingham
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 Consider a business case to make the additional Heartlands interventional radiology theatre provision full time.
Verbatim wording from the response “Also, temporary funding has been made available to increase IR capacity on the Heartlands site and we have an additional IR theatre running in the Heartlands Treatment Centre for two days per week. A business case is currently being considered to support this becoming a full-time provision.” Source location Response from University Hospitals Birmingham
Open published response
23 Apr 2024 Ronald Henry SPENCER · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to maintain sufficient staffing for timely patient medical care View source Inadequate cohesive planning for short-term staffing pressures and longer-term solutions 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
Ronald Henry SPENCER · 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
Ronald Henry Spencer had an oesophageal stent placed on 13 November 2023, which migrated into the small bowel and caused a suspected bowel perforation. He underwent surgery to remove the stent and repair the bowel, initially recovered, then deteriorated and died on 2 December 2023. The report raised concerns about significant staffing issues and resulting delays in treatment, as well as inadequate cohesive planning for short- and long-term staffing pressures; it stated there was no direct evidence that the delays caused or contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain sufficient staffing for timely patient medical care
Wider context from the report “1. I heard evidence that there were significant staffing issues during the Ronald's period of in-patient care that caused delays to his treatment . Whilst there was no direct evidence at the inquest that these delays caused or contributed to death, any delays in patients receiving medical care due to a lack of staff clearly presents a risk of future deaths occurring.
2. It is recognised that the reasons for delay can be multifactorial, with so called "winter pressures" causing an influx of ill patients and heightened staff absences. "Winter pressures" are now a regular annual event and put significant strain on the NHS. There can be no doubt that patients have died, and will continue to die, from avoidable deaths due to delays caused by these staffing inadequacies .
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate cohesive planning for short-term staffing pressures and longer-term solutions
Wider context from the report “5. I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. "winter pressures") or with a view to finding longer term solutions .
” Open source report
5 Apr 2024 Tracey Ann FARNDON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to recognise the seriousness of a low or unrecordable blood pressure and continue observations View source Failure to make further attempts to assess an unrecordable blood pressure View source Insufficient emergency department staffing to care for, monitor and manage patients View source Failure to recognise and consider sepsis despite its variable signs and symptoms View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tracey Ann FARNDON · 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
Tracey Ann FARNDON was admitted to hospital with diarrhoea, vomiting and severe lower back pain, deteriorated rapidly, suffered cardiac arrest and could not be saved. The post-mortem identified severe pneumonia and a septic spleen, with the medical cause of death recorded as septic shock due to sepsis secondary to community-acquired pneumonia. Concerns included delays in recognising and treating sepsis, failure to respond appropriately to an unrecordable low blood pressure, and emergency department overcrowding and insufficient staffing.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the seriousness of a low or unrecordable blood pressure and continue observations
Wider context from the report “3. Ms Farndon's BP was not recordable when she first presented at the emergency department. It was likely to be very low. This was not considered by the staff concerned and no further attempts were made to assess Ms Farndon's BP. There is a concern staff do not understand the implication of a low BP , the importance of continued observations when a key parameter cannot be recorded and that this may indicate the patient is seriously unwell . This raises a concern of future deaths.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make further attempts to assess an unrecordable blood pressure
Wider context from the report “3. Ms Farndon's BP was not recordable when she first presented at the emergency department. It was likely to be very low. This was not considered by the staff concerned and no further attempts were made to assess Ms Farndon's BP . There is a concern staff do not understand the implication of a low BP, the importance of continued observations when a key parameter cannot be recorded and that this may indicate the patient is seriously unwell. This raises a concern of future deaths.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient emergency department staffing to care for, monitor and manage patients
Wider context from the report “1. The inquest heard how the emergency department was, and continues to be, overwhelmed with patients with insufficient staff to care for, monitor and manage those patients . There is continued regular use of agency staff . This directly impacts patients' safety and is a risk of future deaths.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise and consider sepsis despite its variable signs and symptoms
Wider context from the report “2. The inquest heard how staff failed to consider a diagnosis of sepsis throughout Ms Farndon's admission . There is a concern staff do not fully understand the variable signs and symptoms of sepsis and there is a risk of future deaths.
” 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 Reduce the Emergency Department Ambulatory Area to minor injuries and on-site urgent-care GP referrals, concentrating staff in the main department.
Verbatim wording from the response “We have recognised that the current layout of the ED at QEHB causes significant challenges to operational performance. The EDAA area was initially created to mitigate the physical distancing demands of the Covid pandemic, but its layout and location away from the main department poses risks to patients clinically and staff logistically. We will therefore be reducing the size of the EDAA to treat minor injuries and referrals to the on-site urgent care GP led service only. This will occur from June 2024, and will allow us to focus staff to provide care within the main ED footprint.” Source location Response from University Hospitals Birmingham
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 Reduce reliance on external agency nursing staff through improved Emergency Department recruitment and withdraw agency requests.
Verbatim wording from the response “There has been an improvement in nursing recruitment, with a significant reduction in the use of agency staff in ED at QEHB. In May 2023, over 600 shifts per month were filled with external registered staff. This has reduced to 164 shifts in April 2024, with a projection to withdraw external agency requests at the end of June 2024.” Source location Response from University Hospitals Birmingham
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 Embed sepsis screening in Rapid Assessment and Triage to support recognition across the spectrum of presentation.
Verbatim wording from the response “Sepsis screening will be embedded in the Rapid Assessment and Triage process, and the early involvement of senior clinicians in the review process for walk in and ambulance patients will facilitate recognition of sepsis across the spectrum of presentation.” Source location Response from University Hospitals Birmingham
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 Deliver a QEHB Emergency Department sepsis training programme with staff champions, educational events, safety-board information and ongoing staff education.
Verbatim wording from the response “In response to events surrounding Ms Farndon’s death, the ED department at QEHB has initiated a programme of sepsis training. This includes:” Source location Response from University Hospitals Birmingham
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 Deliver manual blood-pressure training and competency assessment for Emergency Department staff, including escalation and alternative perfusion assessment methods.
Verbatim wording from the response “A programme of manual blood pressure training and competence was commenced for all Emergency Department staff at QEHB in March 2024. This includes education regarding the limitations of cold blood pressure measurement, for example the unreliability when patients have atrial fibrillation, and the escalation process for situations when blood pressure cannot be recorded. All band 6 and band 7 staff who are not on extended leave have completed this training, with all band 5 staff expected to have completed training by the end of May 2024. There is always a dedicated senior emergency doctor in all areas to escalate to for urgent review if the blood pressure is unable to be recorded through automatic or manual means. Training also includes education regarding additional means of assessing perfusion such as palpation of radial pulse and capillary refill time.” Source location Response from University Hospitals Birmingham
Open published response
18 Jan 2024 Dorota Marta KUKLINSKA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, particularly after refusal of lumbar puncture View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorota Marta KUKLINSKA · 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
Dorota Marta Kuklinska attended hospital with a severe headache and other symptoms suggestive of a brain bleed, but her CT scan was misreported as normal. She later collapsed, was found to have an unsurvivable brain bleed caused by a right middle cerebral aneurysm, and died in hospital. The principal concern was that, despite strong clinical signs and her refusal of a lumbar puncture, she was not referred for specialist neurosurgical advice through NORSE.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients with strong clinical signs of a brain bleed for specialist neurosurgical advice, particularly after refusal of lumbar puncture
Wider context from the report “1. The inquest heard evidence from a specialist neurosurgeons at University Hospital Birmingham that there are guidelines to confirm a patient with strong clinical signs of a brain bleed, should be referred through NORSE particularly when they have refused a lumber puncture which is the usual test undertaken in accordance with the NICE guidelines. Clinicians at Sandwell and West Birmingham Hospital City hospital site said they were unaware of those guidelines and didn't consider a referral for Mrs Kuklinska. Consideration needs to be given to establishing clear guidance with acute trusts to ensure patients with strong clinical signs of a brain bleed are referred for specialist neurosurgical advice .
” 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 Review the case and the high-suspicion, negative-CT, refused-lumbar-puncture scenario at a neurosurgical governance day.
Verbatim wording from the response “Action taken
The concerns raised have been considered and a detailed discussion has taken place at our neurosurgical governance day where the facts of this case were considered. The consensus reached was that there is long standing guidance in place for the management and referral of patients with a diagnosis of SAH. The scenario where the referring team had a high level of suspicion for SAH but there was a negative CT and LP was refused was also considered and in this scenario it was considered that the patient should be informed by the treating team of the clinical findings with a suggestion that a second opinion be obtained. A CTA should also be considered.” Source location Response from University Hospitals Birmingham
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 Circulate a letter to catchment-area emergency departments reiterating the established referral pathway and availability of on-call neurosurgical advice.
Verbatim wording from the response “Whilst it is considered that there is well established guidance in place, having considered your concern, a letter will be circulated to all emergency departments in our catchment area to re-iterate the established pathway/guidance and to highlight that, if there are concerns with particular cases, our on-call team can be contacted for advice. This letter will be circulated by 30 March 2024 and we would be happy to provide a copy to you.” Source location Response from University Hospitals Birmingham
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 Share the Trust’s internal subarachnoid-haemorrhage management guideline with SWBH to support review of its guidance.
Verbatim wording from the response “We have also discussed this case with the patient safety team at SWBH and have shared our internal guideline for managing SAH with them to assist in review of their own guidelines. A meeting has also been arranged between ████████, Hospital Medical Director QEH, and ████████, Chief Medical Officer at SWBH to discuss any additional training/guidance that we can provide to support the clinical teams at SWBH.” Source location Response from University Hospitals Birmingham
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 Established national guidance and referral practice are considered sufficient; not every patient refusing lumbar puncture requires specialist referral.
Verbatim wording from the response “There is established national guidance (NICE guideline NG288) in place for clinicians when considering a possible diagnosis of SAH. A diagnosis of SAH should be considered in any patient with a severe and sudden onset or rapidly escalating headache. It has been established for many years that where SAH is suspected, there should be a CT scan of the head and if this is negative/inconclusive, a lumbar puncture should be performed. Both of these tests are ordinarily performed at a referring hospital.” Source location Response from University Hospitals Birmingham
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 No specific guidance exists for suspected subarachnoid haemorrhage where a patient refuses lumbar puncture or another assessment.
Verbatim wording from the response “During the Inquest you heard evidence from ████████, Consultant Neurosurgeon, that there were guidelines in place which indicated that patients should be referred via the NoRSE referral system when there is a strong clinical suspicion of a brain bleed and particularly where they have refused a lumbar puncture. To provide some context to ████████ evidence, patients should be referred where there is a high index of suspicion of a bleed and specialist advice is required, but the Trust do not have specific guidelines for the particular scenario where a patient refuses lumbar puncture or any other assessment. It is therefore not the case that there are guidelines that exist which have not been provided to SWBH/other acute Trusts.” Source location Response from University Hospitals Birmingham
Open published response
30 Jun 2023 Sinon MASHA · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure to involve patients’ named obstetric consultants in multiprofessional appointments View source Failure to formally plan and consider amendments to birth-choice guidance View source Fragmented communication between professionals involved in birth-choice planning View source Failure to provide patients with a fully informed multiprofessional birth-choice discussion View source See 1 more concern
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
Sinon MASHA · 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
Sinon Masha was born at home on 17 December 2021 following a breech presentation that was not identified until labour. After a 27-minute delay before delivery of his head, he suffered a catastrophic hypoxic brain injury and died on 21 December 2021. The principal concern was that the Trust’s process for managing home births against medical advice was not operating as set out in its guidance, was fragmented, and might result in insufficiently informed birth choices that put lives at risk.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve patients’ named obstetric consultants in multiprofessional appointments
Wider context from the report “2. Specifically, Section 5 of the Birth Choices Guidance include:
“5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices.
...
5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged.
5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated.
5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.”
3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all . Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk.
4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife.
5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding. This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to formally plan and consider amendments to birth-choice guidance
Wider context from the report “2. Specifically, Section 5 of the Birth Choices Guidance include:
“5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices.
...
5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged.
5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated.
5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.”
3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk.
4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife.
5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance . Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding. This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Fragmented communication between professionals involved in birth-choice planning
Wider context from the report “2. Specifically, Section 5 of the Birth Choices Guidance include:
“5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices.
...
5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged.
5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated.
5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.”
3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk.
4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife.
5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding . This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide patients with a fully informed multiprofessional birth-choice discussion
Wider context from the report “2. Specifically, Section 5 of the Birth Choices Guidance include:
“5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices.
...
5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged.
5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated.
5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.”
3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk.
4. Evidence was given by the Director of Midwifery that although patient’s named Consultants are not involved in multiprofessional appointments with the patient there is a bi-weekly meeting of the other professionals who discuss all high risk patients and then the Consultant midwife meets with the patient’s named Consultant (who will have reviewed the patient in clinic) and discusses the individual cases and the birth plans. This system is felt to be working satisfactorily by the Consultant midwife.
5. I remain concerned that the current approach has evolved from necessity rather than being a carefully considered and planned amendment to the Trust’s guidance. Furthermore, the approach appears fragmented increasing the risk of mis-communication or mis-understanding. This system also deprives the patient of the benefit of hearing the perspectives of all the relevant professionals together in a setting where they, the patient, can witness the discussion and be satisfied that everyone has considered all the relevant factors and answered any queries or concerns they may have relevant to their decision. Consequently, I am concerned that patients may not be making fully informed decisions resulting in birth choices that put lives at risk.
” 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 Audit multidisciplinary input for high-risk home births to evidence consultant involvement in birth plans.
Verbatim wording from the response “• To ensure compliance with the standards an audit is in place to evidence multidisciplinary input for high-risk home births. The initial audit has demonstrated that for those women who had requested birth outside of guidance, there was always consultant input into their birth plan.” Source location Response from University Hospitals Birmingham 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 Hold biweekly multidisciplinary meetings for joint discussion and planning with the named consultant.
Verbatim wording from the response “• A Bi-weekly MDT meeting is in place with joint discussion and planning separately with the named consultant.” Source location Response from University Hospitals Birmingham 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 Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.
Verbatim wording from the response “• A review of the Birth Choices Guidelines (CG1200) and the home birth guidance (CG1143) is being undertaken and will be completed by 31 October 2023. Currently there are discrepancies in relation to the referral pathway, roles and responsibilities of members of the multi-professional team (including Consultant Midwife), and inclusion of the woman in birth planning discussions. Alignment of these guidelines will provide a clear and standardised pathway for referral and management for women/birthing people requesting birth outside of guidance including homebirth, and clarity of Roles and responsibilities of each member for the Multi professional team.” Source location Response from University Hospitals Birmingham 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 Maintain two consultant midwives to share birth-choice discussions and planning for women requesting homebirth outside guidance.
Verbatim wording from the response “• There are now two consultant midwives in post who share the birth choices discussion and planning for women requesting homebirth outside of guidance.” Source location Response from University Hospitals Birmingham 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 Allocate a consultant to regular multidisciplinary meetings following completion of consultant job planning.
Verbatim wording from the response “• There is a plan to agree allocated Consultant (either Delivery suite lead or Antenatal clinic lead) to regular MDT meetings. This is contingent on the current consultant job planning (due for completion by 31 August 2023). Following job planning this action will be completed before the 31 October 2023.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
28 Jun 2023 Hilary THOMAS · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Failure to follow guidance on proceeding with CT scans without waiting for blood test results View source Failure to escalate eligible emergency department patients for consultant review View source Delays in reviewing available blood test results View source Insufficient hospital resources to manage patient volume View source Failure to adopt and provide staff awareness and training on consultant review guidance View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Hilary THOMAS · 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
Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow guidance on proceeding with CT scans without waiting for blood test results
Wider context from the report “3. The doctor treating Mrs Thomas on her second attendance decided to wait for blood test result before ordering a CT scan under the misunderstanding that these were required to assess the possibility of renal toxicity from dye used during the scan . The inquest heard evidence that a CT scan should have been undertaken and there was no need to wait for blood test results . This raised a concern that staff at the Trust are unaware of this guidance .
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate eligible emergency department patients for consultant review
Wider context from the report “2. Mrs Thomas reattended hospital with severe pain, was over age 70 and an unscheduled return within 72 hours. The Doctor should have considered and followed national guidance from the Royal College of Emergency medicine published in June 2016 (consultant sign off) which confirmed Mrs Thomas should have been reviewed by a consultant. Mrs Thomas was not escalated for consultant review . There was no evidence at the inquest that this guidance has been adopted by the Trust nor that staff are aware of it and have been trained on it.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing available blood test results
Wider context from the report “1. Witnesses explained at the inquest that the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume. This had a direct impact on Mrs Thomas's death as the doctor treating her was unable to review her blood tests results until the evening handover, 6 and a half hours after the results were available by which time Mrs Thomas had left the department.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient hospital resources to manage patient volume
Wider context from the report “1. Witnesses explained at the inquest that the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume . This had a direct impact on Mrs Thomas's death as the doctor treating her was unable to review her blood tests results until the evening handover, 6 and a half hours after the results were available by which time Mrs Thomas had left the department.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to adopt and provide staff awareness and training on consultant review guidance
Wider context from the report “2. Mrs Thomas reattended hospital with severe pain, was over age 70 and an unscheduled return within 72 hours. The Doctor should have considered and followed national guidance from the Royal College of Emergency medicine published in June 2016 (consultant sign off) which confirmed Mrs Thomas should have been reviewed by a consultant. Mrs Thomas was not escalated for consultant review. There was no evidence at the inquest that this guidance has been adopted by the Trust nor that staff are aware of it and have been trained on it .
” 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 Expand the Emergency General Surgery service by two consultants by the end of 2023.
Verbatim wording from the response “• Expansion of the EGS service by another two consultants by the end of 2023. This expansion will support the initiation of so called ‘Hot clinics’ for the expedited review of ambulatory patients. This will allow patients to bypass the Surgical Admissions Unit (SAU) and thereby reducing the load on junior doctors working in that area and the Emergency Department. It will lead to improved patient experience and reduce the number of patients in ED and SAU, allowing those units to focus on caring for the more unwell patients.” Source location Response University Hospitals Birmingham 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 Discuss the emergency contrast CT guidance at relevant departmental governance meetings by 31 October 2023.
Verbatim wording from the response “1. Locally: Laminated posters of the joint statement will be displayed in acute surgical areas at all acute sites. A new trust policy that directly reflects the June 2023 guidelines will be published and disseminated to all clinical staff. The Trust will update online requesting system to reflect the new guidance. This will be discussed at all relevant departmental governance meetings. These actions will be completed by 31st October 2023.” Source location Response University Hospitals Birmingham 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 Provide two dedicated consultants for emergency surgical patients across the Birmingham Heartlands and Queen Elizabeth sites.
Verbatim wording from the response “These responses include:” Source location Response University Hospitals Birmingham 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 Operate a virtual ward managed by specialist nurses for ambulatory emergency patients.
Verbatim wording from the response “• The creation of a virtual ward, managed by new specialist nurses, so that emergency patients can be managed on an ambulatory basis. This has saved over 1000 bed days this year and reduced the workload for the junior doctors on the QE site. This will be expanded to the Trust’s other acute sites by 31 October 2023.” Source location Response University Hospitals Birmingham 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 Engage with the West Midlands Postgraduate School of Surgery to inform General Surgical specialty trainees of the updated guidance.
Verbatim wording from the response “2. Regionally: The Trust will engage with the West Midlands Postgraduate School of Surgery to ensure all General Surgical specialty trainees are informed of the updated guidance. It is anticipated that this will be within the induction programme and will be included in literature provided to junior doctors.” Source location Response University Hospitals Birmingham 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 Deliver an education programme on escalation for delayed assessment or transfer from August 2023.
Verbatim wording from the response “The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.” Source location Response University Hospitals Birmingham 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 Deliver direct teaching and display laminated posters in acute surgical areas at all acute sites by 31 October 2023.
Verbatim wording from the response “The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.” Source location Response University Hospitals Birmingham 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 Display laminated posters explaining the emergency contrast CT guidance in acute surgical areas at all acute sites by 31 October 2023.
Verbatim wording from the response “Modern contrast agents are much safer than older agents and studies have reported that blood tests are not required for emergency CT scans. In June 2023, the Royal Colleges of Radiologists & Royal College Emergency Medicine published joint guidance, strengthening previous guidance, that patients requiring emergency iodinated intravenous contrast CT imaging should proceed to scanning without delay. The Trust will ensure that relevant staff are aware of this guidance and will ensure that it is disseminated to all staff managing acute surgical emergencies.” Source location Response University Hospitals Birmingham 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 Publish and disseminate a Trust policy reflecting the June 2023 emergency contrast CT guidance to all clinical staff by 31 October 2023.
Verbatim wording from the response “Modern contrast agents are much safer than older agents and studies have reported that blood tests are not required for emergency CT scans. In June 2023, the Royal Colleges of Radiologists & Royal College Emergency Medicine published joint guidance, strengthening previous guidance, that patients requiring emergency iodinated intravenous contrast CT imaging should proceed to scanning without delay. The Trust will ensure that relevant staff are aware of this guidance and will ensure that it is disseminated to all staff managing acute surgical emergencies.” Source location Response University Hospitals Birmingham 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 Appoint specialised Emergency General and Trauma Surgeons at the Queen Elizabeth site.
Verbatim wording from the response “These responses include:” Source location Response University Hospitals Birmingham 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 Implement a policy empowering any multiprofessional team member to escalate delayed assessment or transfer to the consultant on call.
Verbatim wording from the response “The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.” Source location Response University Hospitals Birmingham 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 Update the online requesting system to reflect the emergency contrast CT guidance by 31 October 2023.
Verbatim wording from the response “1. Locally: Laminated posters of the joint statement will be displayed in acute surgical areas at all acute sites. A new trust policy that directly reflects the June 2023 guidelines will be published and disseminated to all clinical staff. The Trust will update online requesting system to reflect the new guidance. This will be discussed at all relevant departmental governance meetings. These actions will be completed by 31st October 2023.” Source location Response University Hospitals Birmingham 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 Initiate hot clinics to expedite ambulatory patient review and reduce pressure on the Surgical Admissions Unit and Emergency Department.
Verbatim wording from the response “• Expansion of the EGS service by another two consultants by the end of 2023. This expansion will support the initiation of so called ‘Hot clinics’ for the expedited review of ambulatory patients. This will allow patients to bypass the Surgical Admissions Unit (SAU) and thereby reducing the load on junior doctors working in that area and the Emergency Department. It will lead to improved patient experience and reduce the number of patients in ED and SAU, allowing those units to focus on caring for the more unwell patients.” Source location Response University Hospitals Birmingham 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 Expand the virtual ward to the Trust’s other acute sites by 31 October 2023.
Verbatim wording from the response “• The creation of a virtual ward, managed by new specialist nurses, so that emergency patients can be managed on an ambulatory basis. This has saved over 1000 bed days this year and reduced the workload for the junior doctors on the QE site. This will be expanded to the Trust’s other acute sites by 31 October 2023.” Source location Response University Hospitals Birmingham 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 Responsibility for addressing emergency department patient volume rests with the Department of Health and Social Care.
Verbatim wording from the response “This area of concern is for the Department of Health and Social Care however we acknowledge that there has been a significant increase in demand for assessment by the Emergency General Surgery (EGS) Service at UHB. This was the service to which Mrs Thomas was appropriately referred by the Emergency Department. In this case failure of assessment and escalation occurred after this referral. She was seen by the EGS service at 11:30am by an experienced Specialist Registrar (SpR) who was in the 7th Year of specialist training (ST7). When that SpR returned at 20:00 Mrs Thomas, after waiting for so long, had taken her own discharge. We acknowledge that Mrs Thomas had to wait far too long and that this was a failure of the EGS service.” Source location Response University Hospitals Birmingham NHS Foundation Trust
Open published response
19 May 2023 Norma Winifred BRUTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure of the falls risk assessment document to prompt consideration or documentation of attachments View source Failure of documentation on other forms to prompt reconsideration of the falls risk assessment View source Failure of the falls risk assessment document to prompt assessment of attachment relevance View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Norma Winifred BRUTON · 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
Norma Winifred BRUTON was admitted to hospital with a pneumothorax and other lung conditions, suffered an unwitnessed fall while walking to the bathroom, and sustained a fractured neck of femur. Her condition deteriorated after surgery and she died in hospital; concerns related to falls-risk assessments not prompting staff to consider or document attachments such as chest drains and intravenous infusions, or their relevance to falls risk.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the falls risk assessment document to prompt consideration or documentation of attachments
Wider context from the report “1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions .
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls.
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of documentation on other forms to prompt reconsideration of the falls risk assessment
Wider context from the report “1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions.
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls.
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment .
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the falls risk assessment document to prompt assessment of attachment relevance
Wider context from the report “1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions.
2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls .
3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment.
” 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 Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.
Verbatim wording from the response “Updates to falls risk assessment document
We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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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 the falls risk assessment and identify required improvements to capture equipment-related mobility risks.
Verbatim wording from the response “Updates to falls risk assessment document
We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
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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 Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.
Verbatim wording from the response “The information recorded in the manual handling assessment has not been designed to automatically feed into the falls risk assessment as this was considered to be a duplication of the information in the patient record. The recommendation is that these assessments are looked at in combination not isolation.” Source location Response from University Hospitals Birmingham NHS Foundation Trust
Open published response
11 Jan 2023 Leroy Patrick HAMILTON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 6 Lack of inpatient mental health beds View source Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments View source Failure to undertake and appropriately classify risk assessments for missing persons View source Failure to classify reported people as missing persons View source Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed View source Lack of Psychiatric decisions unit spaces View source See 3 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.
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AI-generated summary
Leroy Patrick HAMILTON · 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
Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of inpatient mental health beds
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces: The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU. Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an agreed multi-agency protocol for informal patients absconding from emergency departments
Wider context from the report “3. Multi agency protocol for informal missing patients: The inquest heard how there is no agreed protocol to deal with informal patients who abscond from emergency departments . Consideration should be given to setting up an agreed protocol so that all agencies involved understand their respective roles and responsibilities.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake and appropriately classify risk assessments for missing persons
Wider context from the report “5. WMP risk assessments for missing persons: When Mr Hamilton was first reported as missing no risk assessment was undertaken about his level of risk to himself . The call had confirmed he was at risk of harming himself . The leads to a concern that staff do not understand when and how to risk assesses incidents and when to identify high risk incidents .
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to classify reported people as missing persons
Wider context from the report “4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing . On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing . Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed
Wider context from the report “2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed . This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation . Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Psychiatric decisions unit spaces
Wider context from the report “1. Lack of inpatient mental health beds and lack of Psychiatric decisions unit (PDU) spaces : The inquest heard how there was a regional and national lack of inpatient beds and spaces in PDU . Consideration is needed urgently to fund further mental health beds and PDU spaces to ensure patients are not kept unattended in extremely busy emergency departments.
” Open source report
26 Oct 2021 Christopher COLLINSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure of the patient allocation system to identify patients who have not been seen View source Failure of the electronic prescribing system to require a secondary medication-selection check 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
Christopher COLLINSON · 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
Christopher Collinson was admitted to Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism, but was not seen by a doctor for several hours. He was prescribed a prophylactic rather than therapeutic dose of Enoxaparin, later suffered a cardiac arrest, and died on 15 June 2021. Concerns related to the patient-allocation system not making it clear when an allocated patient had not been seen, and the electronic prescribing system not requiring a secondary medication check.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the patient allocation system to identify patients who have not been seen
Wider context from the report “1. The current system for allocating patients requires a manual check to see whether a patient has actually been seen once they have been allocated . If they are not seen, there is currently no way of other clinicians being aware of that , and therefore patients could be left for long periods of time without having been assessed .
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the electronic prescribing system to require a secondary medication-selection check
Wider context from the report “2. The current electronic prescribing system does not require a Doctor to perform a secondary check that they have selected the correct medication . I am concerned that it is all too easy to select the wrong medication , particularly when the department is busy and Doctors are under pressure. This could lead to fatal outcomes for patients if given incorrect medication .
” 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 Roll out the paper-free PICS electronic patient record system across Birmingham Heartlands Hospital AMU, including waiting-time markers for patients awaiting assessment.
Verbatim wording from the response “Following Mr Collinson’s admission, the above process has been updated and we have rolled out our in-house electronic system, PICS to BHH. PICS has been in use in AMU at BHH since July 2021. PICS provides a paper-free electronic patient record system that allows for simultaneous access and entries to the record of a single patient by multiple clinicians. With PICS, it is easy to access and review patient records at any time. To ensure patients are seen without delay, there are time markers on the system which indicate when patients have been waiting to be seen for a period of time without progression. This allows” Source location 2021-0361-Response-from-Queen-Elizabeth-Hospital_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing EPMA systems and processes sufficiently minimise medication risk, so no additional prescribing double-check is introduced.
Verbatim wording from the response “Based on the review of our systems and relevant literature, we are confident that the systems and processes that we have in place are sufficient to minimise risk to our patients. We are satisfied that our decision not to introduce an additional double-check step has been carefully considered and is consistent with the collective approach of those responsible for introducing and maintaining EPMA systems.” Source location 2021-0361-Response-from-Queen-Elizabeth-Hospital_Published
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 Additional prescribing double-checks are unlikely to improve safety and may increase risk through alert fatigue.
Verbatim wording from the response “There is however little evidence to suggest that introducing an additional double-check into the individual prescriber’s workflow improves patient safety. On the other hand, there is evidence of risks associated with introducing many more alerts. This is a consequence of alert fatigue discussed in more detail below.” Source location 2021-0361-Response-from-Queen-Elizabeth-Hospital_Published
Open published response
17 Jun 2021 Leonard Arthur PRITCHARD · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Inadequate supply of mobility aids in the emergency department View source Lack of a clear completion timeframe for mobility aid procurement View source Lack of clear overall responsibility for assessment, selection and procurement of mobility aids 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
Leonard Arthur PRITCHARD · 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
Leonard Arthur Pritchard died on 18 February 2021 in Good Hope Hospital after sustaining injuries in an unwitnessed fall from a chair in an A&E cubicle on 12 February 2021. The report raised concerns about an inadequate supply of mobility aids in the emergency department and unclear responsibility and timescales for their assessment, selection and procurement.
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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate supply of mobility aids in the emergency department
Wider context from the report “1. During the course of the inquest, I heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patient's mobility, and which are given to patients who are identified as requiring an aid. I heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the emergency department; and 8 chairs in the clinical decision unit. I heard from staff that they consider this mobility aid to patient bed ratio was inadequate. There is a clear risk of death for patients who require mobility aids but can not have access to them. The Trust should consider addressing this as a matter of urgency.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear completion timeframe for mobility aid procurement
Wider context from the report “2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids, and neither is it clear when this process will be completed by . The Trust should consider ensuring that this procurement process takes places as a matter of urgency.
” 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 Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear overall responsibility for assessment, selection and procurement of mobility aids
Wider context from the report “2. Linked to 1) above, I heard evidence that procurement discussions are taking place, but from the evidence it is unclear who has overall responsibility for the assessment; selection; and procurement of aids , and neither is it clear when this process will be completed by. The Trust should consider ensuring that this procurement process takes places as a matter of urgency.
” 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 Increase emergency-department mobility-aid stock to 12 immediately available zimmer frames.
Verbatim wording from the response “I can however confirm that immediately following the Inquest 5 zimmer frames were sourced internally and were made available for immediate use within the ED the same evening. The OPAL team also obtained 5 zimmer frames, meaning that there were a total of 12 frames (inclusive of 2 existing frames) immediately available for patients within the department, which was deemed to be an appropriate number. A request for a further 10 frames to be procured was also made on 17 June by the ED team.” Source location 2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
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 Standardise and implement a cross-site process for stocking, procuring, storing, labelling, providing and documenting mobility aids for patients assessed as needing them.
Verbatim wording from the response “Following the Inquest we have also standardised the process across all of our sites so that all ED areas have a stock of zimmer frames and a process in place to ensure that patients are provided with a frame when they are assessed as needing one. The process includes the procurement, storage, labelling and auditing of their use.” Source location 2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
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 Request procurement of 10 additional zimmer frames for the emergency department.
Verbatim wording from the response “I can however confirm that immediately following the Inquest 5 zimmer frames were sourced internally and were made available for immediate use within the ED the same evening. The OPAL team also obtained 5 zimmer frames, meaning that there were a total of 12 frames (inclusive of 2 existing frames) immediately available for patients within the department, which was deemed to be an appropriate number. A request for a further 10 frames to be procured was also made on 17 June by the ED team.” Source location 2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
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 Responsibility for procuring additional mobility aids rests with the emergency department team, as needs are identified.
Verbatim wording from the response “It is now the responsibility of the ED team to procure additional mobility aids and these can be requested as and when a need is identified. The frames are also stored within the sister’s office situated within the ED, which can be accessed for use at any time.” Source location 2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations