10 Aug 2020 Francis Xavier Cooney · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1 Failure to communicate inpatient medication changes to carers of patients with cognitive impairment View source
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Francis Xavier Cooney · 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
Francis Xavier Cooney fell at home, underwent surgery for a scalp laceration, developed delirium during his hospital stay, and was discharged home after an occupational therapy assessment. Following discharge he became more confused and anxious about changes to his medication, and on 27 January 2020 he was found hanging from the bannister and declared deceased. The principal concern was that medication changes were not communicated directly to his daughter and next of kin, who held lasting power of attorney, leaving her unable to explain the changes or reassure him; the report also raised concern about the lack of a root cause analysis or similar investigation into the communication breakdown.
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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 communicate inpatient medication changes to carers of patients with cognitive impairment
Wider context from the report “2. For patients with a cognitive impairment there is a risk that if changes to medication made during an inpatient stay are not communicated directly to those caring for them , confusion will arise which could result in the medication being erroneously omitted or overdosed.
3. Dr. ████████ acknowledged that if Mr. Cooney had been a patient on the Geriatric Ward, rather than a plastic surgery patient, she would have communicated the fact and reason for change to Ms. ████████ directly. She said she did not do so in this case because, as a Consultant providing an opinion for a patient under the care of another team, she did not view it as her responsibility.
4. Dr. ████████ said that her practice had now changed, and she would always communicate such a decision to the NOK of a patient with a cognitive impairment. She was also aware that the facts of this case would be raised with other geriatricians within the Trust. However, it was not clear that this awareness will result in consideration of a new instruction/procedure that for all patients with dementia and/or significant cognitive impairment, any changes to medications made during an inpatient stay should be communicated to the NOK/carer by the clinician making the change regardless of the capacity in which they come to be reviewing the patient .
” 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 Reinforce communication with relatives and carers of cognitively impaired patients through medical staff communication and departmental clinical governance meetings.
Verbatim wording from the response “Finally, I will communicate with the medical staff reinforcing the importance of communication with relatives and carers where patients have a cognitive impairment and the learning from this case will be cascaded through departmental clinical governance meetings.” Source location 2020-0154-Response-from-University-Hospitals-Birmingham-Foundation-Trust_Redacted.pdf
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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 Refresh training across all wards on discharge medication review, communication with relatives or carers, and recording and actioning blister-pack requirements.
Verbatim wording from the response “We will be undertaking a refresh of training across all wards on the importance of” Source location 2020-0154-Response-from-University-Hospitals-Birmingham-Foundation-Trust_Redacted.pdf
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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 processes are considered sufficient to ensure medication changes are appropriately discussed with patients, relatives or carers at discharge.
Verbatim wording from the response “Whilst the decision to reduce the medication was discussed with Mr Cooney, and it was considered at the time that he had understood the information provided, in light of his fluctuating confusion, it is recognised that Mr Cooney’s daughter should have been informed of the changes that had been made and unfortunately this did not happen and this is a matter of regret. We are satisfied that this was an unfortunate individual error and that there are processes in place to ensure discussion as to medications do take place appropriately on the discharge of patients.” Source location 2020-0154-Response-from-University-Hospitals-Birmingham-Foundation-Trust_Redacted.pdf
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6 Aug 2019 Prabhaker Nath Kapoor · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to update the MOODLE training package View source Failure to complete the review of safer swallowing training View source
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Prabhaker Nath Kapoor · 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
Prabhaker Nath Kapoor died on 21 November 2018 after aspirating unthickened water left near his bedside while he was in hospital following a fall and fractured humerus. His death was attributed to aspiration pneumonia caused by inhalation of liquid, with frailty also recorded. The report raised concerns that safer-swallowing training and updates to the staff training package had not been completed as planned.
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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 update the MOODLE training package
Wider context from the report “I heard evidence that a review of safer swallowing training was to be provided to staff on team training days, and that changes would be made to the MOODLE training package by the Speech and Language Manager . The RCA report carried out by Matron ████████ indicated that this should have been completed by 15th May 2019, but in oral evidence it was revealed that this had not been done, and an estimated timeframe for completion could not be provided to me . Whilst it was suggested that confirmation could be submitted to HM Coroner upon successful completion of this review, HM Coroner would be functus officio. I therefore suggest that the Trust consider carrying out this review of safer swallowing and update the MOODLE training package 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 Failure to complete the review of safer swallowing training
Wider context from the report “I heard evidence that a review of safer swallowing training was to be provided to staff on team training days , and that changes would be made to the MOODLE training package by the Speech and Language Manager. The RCA report carried out by Matron ████████ indicated that this should have been completed by 15th May 2019, but in oral evidence it was revealed that this had not been done, and an estimated timeframe for completion could not be provided to me . Whilst it was suggested that confirmation could be submitted to HM Coroner upon successful completion of this review, HM Coroner would be functus officio. I therefore suggest that the Trust consider carrying out this review of safer swallowing and update the MOODLE training package 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 Establish a task and finish group to review safer swallowing practices and align education, policy and procedure documents across the Trust.
Verbatim wording from the response “Following this incident a task and finish group was set up, chaired by our Deputy Chief Nurse, to review safer swallowing practices across the Trust and to review the ongoing work to align our education provision, policy and procedure documents.” Source location 2019-0278-Response-by-Birmingham-Hospitals-NHS-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 development and release the updated Moodle dysphagia and nil-by-mouth training package for new and existing staff.
Verbatim wording from the response “University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths regarding a review of safer swallowing and update of our Moodle training package.” Source location 2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
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Concerns raised 2 Failure to consider pacemaker box change as a potential source of infection View source Failure to provide a referral process for patients who become unwell after pacemaker surgery View source
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AI-generated summary
Geoffrey Duke · 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
Geoffrey Duke became unwell repeatedly after a pacemaker box change in June 2016 and was later found to have infection involving the pacemaker wires. The principal concerns were that the pacemaker was not considered as a possible source of infection, no cardiology referral was made, and there was no evidence of a referral process for patients who became unwell after pacemaker surgery. He died in hospital on 20 December 2017 after deterioration during treatment and surgery.
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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 to consider pacemaker box change as a potential source of infection
Wider context from the report “Mr. Duke underwent pacemaker box change on 15th June 2016. He was subsequently unwell on a number of occasions. He visited Good Hope Hospital on 6th February 2017, his GP on a number of occasions and Burton Queens Hospital in August 2017. No consideration appears to have been given that the pacemaker box change may have been the source of his undiagnosed infections. No referral was made to a Cardiologist. His problem was diagnosed on his first admission on 27th October 2017. At inquest there was no evidence of a referral process for patients having undergone pacemaker surgery who subsequently become unwell.
” 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 a referral process for patients who become unwell after pacemaker surgery
Wider context from the report “Mr. Duke underwent pacemaker box change on 15th June 2016. He was subsequently unwell on a number of occasions. He visited Good Hope Hospital on 6th February 2017, his GP on a number of occasions and Burton Queens Hospital in August 2017. No consideration appears to have been given that the pacemaker box change may have been the source of his undiagnosed infections. No referral was made to a Cardiologist. His problem was diagnosed on his first admission on 27th October 2017. At inquest there was no evidence of a referral process for patients having undergone pacemaker surgery who subsequently become unwell.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review endocarditis guidelines to confirm coverage of device-related infection and endocarditis.
Verbatim wording from the response “Having reviewed our referral process to our cardiology teams, we are satisfied that we have in place an effective referral process as a result of your report we have undertaken a review of our endocarditis guidelines to ensure they are robust and we are assured that our guidelines are comprehensive and include specific reference to device related infection and endocarditis and therefore do not require any amendment.” Source location 2019-0256-Response-by-University-Hospitals-Birmingham-NHS-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 Update pacemaker patient leaflets with instructions to seek medical attention and alert clinicians when fever exceeds 38°C.
Verbatim wording from the response “We have also reviewed the patient information leaflets which are provided to all patients following pacemaker insertion. The leaflets already contain information on symptoms which might represent possible infection and provide details of who the patient should contact if they are concerned. Whilst we are satisfied that the information leaflets contain sufficient information for patients, we will be updating them to include additional instructions where patients have symptoms of possible infection, in particular the leaflet will indicate that if the patient has a fever and temperature above 38 degrees Celsius, then they should a) seek medical attention and b) inform their treating clinician that they have a pacemaker and that device related endocarditis should be considered. Our aim is to update the leaflets by the beginning of November 2019.” Source location 2019-0256-Response-by-University-Hospitals-Birmingham-NHS-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 Deliver grand-round education to acute physicians on recognising pacemaker-related endocarditis.
Verbatim wording from the response “Our review of the literature suggests that one of the key issues in the delay in diagnosing device related endocarditis is a lack of awareness amongst both patients and acute physicians.” Source location 2019-0256-Response-by-University-Hospitals-Birmingham-NHS-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 Circulate a Lesson of the Month email to staff on pacemaker-related endocarditis signs and symptoms.
Verbatim wording from the response “We will also be sending out a 'Lesson of the Month' which is an email which goes out to all staff with the aim to raise awareness of the signs and symptoms of pacemaker related endocarditis. This will be circulated within the next 4 weeks.” Source location 2019-0256-Response-by-University-Hospitals-Birmingham-NHS-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 patient leaflets are considered sufficient regarding infection symptoms and contact details, although additional fever instructions will be added.
Verbatim wording from the response “We have also reviewed the patient information leaflets which are provided to all patients following pacemaker insertion. The leaflets already contain information on symptoms which might represent possible infection and provide details of who the patient should contact if they are concerned. Whilst we are satisfied that the information leaflets contain sufficient information for patients, we will be updating them to include additional instructions where patients have symptoms of possible infection, in particular the leaflet will indicate that if the patient has a fever and temperature above 38 degrees Celsius, then they should a) seek medical attention and b) inform their treating clinician that they have a pacemaker and that device related endocarditis should be considered. Our aim is to update the leaflets by the beginning of November 2019.” Source location 2019-0256-Response-by-University-Hospitals-Birmingham-NHS-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 existing cardiology referral process across all sites is considered effective for patients presenting with suspected acute cardiac problems.
Verbatim wording from the response “3. Cardiology referral for unwell patients who have undergone pacemaker procedure” Source location 2019-0256-Response-by-University-Hospitals-Birmingham-NHS-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 existing endocarditis guidelines are considered comprehensive, including device-related infection and endocarditis, and require no amendment.
Verbatim wording from the response “4. Action Plan” Source location 2019-0256-Response-by-University-Hospitals-Birmingham-NHS-Trust
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3 Apr 2019 Ronald William Lowe · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Failure to audit or review radiographers' training records to ensure training is documented and up to date View source Lack of a robust system for ensuring radiographers have seen all standard operating procedures relevant to their practice View source
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AI-generated summary
Ronald William Lowe · 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 William Lowe collapsed at home on 26 October 2018 and died after being found in cardiac arrest. A pulmonary embolus identified on a CT scan was not treated with anticoagulation because reporting was delayed by individual and systemic omissions. The report raised concerns about systems for ensuring radiographers had seen and understood relevant CT standard operating procedures and that their training records were complete and up to date.
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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 audit or review radiographers' training records to ensure training is documented and up to date
Wider context from the report “4. The evidence of ████████, Consultant Radiologist at QEH who conducted the RCA, was that all radiographers have now been provided with and required to sign the updated CT SOPs but there has been no audit or review of radiographs files to check that other aspects of their training are documented and up to date .
” 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 robust system for ensuring radiographers have seen all standard operating procedures relevant to their practice
Wider context from the report “4. The evidence of ████████, Consultant Radiologist at QEH who conducted the RCA, was that all radiographers have now been provided with and required to sign the updated CT SOPs but there has been no audit or review of radiographs files to check that other aspects of their training are documented and up to date.
5. I am concerned that it had previously gone unnoticed that ████████ had not signed a copy of the SOPs for CT indicating that there is not a robust system for ensuring radiographers have seen all standard operating procedures relevant to their practice . Consequently there is a risk that radiographers are practicing with an incorrect understanding of their duties and obligations which could endanger life .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add ongoing SOP reviews and staff sign-offs to the central radiographer training register.
Verbatim wording from the response “In the interim, a central register of staff has been composed for GHH, BHH and SH. This will be overseen in a manner that is modality specific e.g. CT, MRI, ultrasound rather than location and modality specific. This register will be a record of all the training required and undertaken by radiographers across these locations. The register will allow for continual monitoring and audit of the training provided to the whole radiographer workforce. It will provide additional assurance that radiographers have received all necessary training and have been exposed to all the information required in their role.” Source location 2019-0113-Response-by-University-Hospitals-Birmingham-NHS-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 Provide radiographers with updated CT SOPs and require signed confirmation that they have read and understood them.
Verbatim wording from the response “5. The evidence of ████████, Consultant Radiologist at QEH who conducted the RCA, was that all radiographers have now been provided with and required to sign the updated CT SOPs but there has been no audit or review of radiographers files to check that other aspects of their training are documented and up to date.” Source location 2019-0113-Response-by-University-Hospitals-Birmingham-NHS-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 Use a standard competency template alongside annual appraisals to review training and obtain staff fitness-to-practise self-declarations.
Verbatim wording from the response “All our staff receive an annual appraisal and as part of this process staff training will be reviewed against the register and staff will be asked to complete a ‘self-declaration’ of fitness to practice. This process will include equipment training, any rules to the specific area, Ionising Radiation Medical Exposure Regulation (IRMER) Procedures as well as any appropriate SOPs. The senior radiography education lead has produced a template of the expected radiographer competencies and this will be used in conjunction with individual appraisals going forward.” Source location 2019-0113-Response-by-University-Hospitals-Birmingham-NHS-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 Maintain a central, modality-specific register of radiographer training and competencies across Good Hope, Birmingham Heartlands and Solihull hospitals.
Verbatim wording from the response “The Imaging Practice and Education Lead for Good Hope Hospital (GHH) Birmingham Heartlands Hospital (BHH) and Solihull Hospital (SH) has met with her equivalent at the Queen Elizabeth Hospital in order to align practice.” Source location 2019-0113-Response-by-University-Hospitals-Birmingham-NHS-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 Monitor and audit training across the radiographer workforce through the central register.
Verbatim wording from the response “In the interim, a central register of staff has been composed for GHH, BHH and SH. This will be overseen in a manner that is modality specific e.g. CT, MRI, ultrasound rather than location and modality specific. This register will be a record of all the training required and undertaken by radiographers across these locations. The register will allow for continual monitoring and audit of the training provided to the whole radiographer workforce. It will provide additional assurance that radiographers have received all necessary training and have been exposed to all the information required in their role.” Source location 2019-0113-Response-by-University-Hospitals-Birmingham-NHS-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 Records showed the radiographer had signed to confirm reading and understanding the applicable CT radiographer SOP.
Verbatim wording from the response “I recognise that you heard evidence during the Inquest that ████████ had not seen the standard operating procedures for CT scanning which were applicable in September 2018. Specifically, you made the following points in your letter” Source location 2019-0113-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
22 Jan 2019 Ann Swoffer · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 6 Failure of hospital practices and procedures to conform to accepted practice and national guidelines View source Failure of the clinical department to follow accepted practice and BSG guidelines View source Failure to integrate care across Trust sites View source Unavailability of senior staff in the hospital during weekend care View source Failure of junior staff to identify deterioration and escalate to senior staff View source Failure of Trust sites to follow the same protocols View source See 3 more concerns
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AI-generated summary
Ann Swoffer · 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
Ann Swoffer died on 02/09/18 after an oesophageal perforation developed following dilatation during naso-jejunal tube insertion. The report identified concerns about the procedure being contrary to accepted practice, delayed recognition and treatment of the perforation, inadequate escalation to senior staff at the weekend, and inconsistent practices and protocols across hospital sites.
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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 of hospital practices and procedures to conform to accepted practice and national guidelines
Wider context from the report “1. I heard clear evidence that the practice and procedures in place at Good Hope Hospital at the time were not consistent with accepted practice or national guidelines . This raises a considerable concern as to why the practise was so different and what monitoring is in place to ensure consistent practices in accordance with national guidelines are in place.
” 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 clinical department to follow accepted practice and BSG guidelines
Wider context from the report “3. The department caring for the deceased at the time were not following accepted practice or BSG guidelines . It is essential that the person who leads the restructuring of the practices and protocols is an expert and can ensure that the necessary details are considered and implemented. Consideration needs to be given as to who should lead the restructure and review.
” 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 integrate care across Trust sites
Wider context from the report “4. There is a general concern that all sites within the Trust are not integrated and are not following the same protocols. It is important that any patient at any site receives the same standard of care based on current 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 Unavailability of senior staff in the hospital during weekend care
Wider context from the report “2. The deceased deteriorated as a result of a late perforation over the August Bank Holiday weekend. Junior staff did not identify the problem and did not escalate this to senior staff. I was told a “work force issue” meant senior staff were not present in the hospital at the time . Patients who become ill at the weekend need to receive the same standard of care as in the week. Consideration needs to be given to how this can be addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of junior staff to identify deterioration and escalate to senior staff
Wider context from the report “2. The deceased deteriorated as a result of a late perforation over the August Bank Holiday weekend. Junior staff did not identify the problem and did not escalate this to senior staff . I was told a “work force issue” meant senior staff were not present in the hospital at the time. Patients who become ill at the weekend need to receive the same standard of care as in the week. Consideration needs to be given to how this can be addressed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Trust sites to follow the same protocols
Wider context from the report “4. There is a general concern that all sites within the Trust are not integrated and are not following the same protocols . It is important that any patient at any site receives the same standard of care based on current guidance.
” Open source report
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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 Align protocols and guidelines across Trust sites while services remain ununified.
Verbatim wording from the response “A short-term goal includes alignment of protocols and guidelines across all sites, itself a significant task that is nevertheless proceeding at pace. In some circumstances the Trust will choose to maintain different but acceptable protocols until there is unification of service delivery. This reflects the fact that choices between valid standards of care are often determined by particular local operational considerations. In these circumstances a single protocol will be established upon service unification.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-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 Increase weekend consultant availability and establish gastroenterology consultant ward rounds at Good Hope Hospital.
Verbatim wording from the response “At the time of Ms Swoffer’s admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend. We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of day, or day of week. We have further increased routine on site attendance by a range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside the times they are present. For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased’s admission.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-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 Adopt national oesophageal cancer diagnosis, staging and management guidelines across all Trust sites.
Verbatim wording from the response “The national guidelines for the diagnosis, staging and management of oesophageal cancers are adopted on all sites within the Trust. To summarise, the national guidelines recommend that:” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-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 Consolidate upper gastrointestinal cancer pathways into one standardised pathway across all Trust sites.
Verbatim wording from the response “The Trust has an established, standardised upper gastrointestinal cancer pathways agreed and updated through a specialised multi-disciplinary structure which has been in place for over 10 years across different sites. These have been consolidated into a single pathway in place across all sites at the Trust since September 2018.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-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 single service for all aspects of oesophago-gastric cancer care, including unified clinical and management arrangements.
Verbatim wording from the response “The Trust now have in place a single MDT to support decision making in oesophago-gastric cancer care, however for the purposes of care delivery there are currently two teams. The work to establish a single service for all aspects of care is in train and will be in complete by June 2019. The core team members include clinical nurse specialists, dieticians, accredited consultants and a single management structure. This will provide even greater consistency of management, including a single location for surgery. This realignment is being overseen by the Executive Director Strategic Operations, working with Divisional Directors and Clinical Service Leads for the upper gastrointestinal surgical departments based at the Trust.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-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 Improve communication with senior medical staff so emergent complications are escalated regardless of time or day.
Verbatim wording from the response “At the time of Ms Swoffer’s admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend. We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of day, or day of week. We have further increased routine on site attendance by a range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside the times they are present. For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased’s admission.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-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 Establish a unified cross-site operational structure across Trust specialities.
Verbatim wording from the response “The long term goal of the Trust is full integration of service delivery, creating single, multisite departments across all specialities. This process has begun in a number of areas, for example upper gastrointestinal cancer services as described above. A unified, cross-site operational structure will be established by May 2019.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-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 A consultant was available on call and an upper gastrointestinal consultant was on site, contrary to the concern that senior staff were absent.
Verbatim wording from the response “At the time of Ms Swoffer’s admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend. We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of day, or day of week. We have further increased routine on site attendance by a range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside the times they are present. For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased’s admission.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National oesophageal cancer guidelines are adopted across all Trust sites and recognised and used by the Good Hope clinical team.
Verbatim wording from the response “I recognise that you heard evidence that practice at Good Hope Hospital was out-with appropriate guidelines. This was also presented as such in the Trust’s SI report. A subsequent review has identified that the guidelines are recognised and used by the clinical team at Good Hope Hospital. The default position is that oesophageal dilatation should not be undertaken unless there are specific indications, which should then be fully documented in the medical record, which unfortunately did not occur in Ms Swoffer’s case.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Different site protocols may remain where they are acceptable, nationally guided and reviewed, because patients receive the same outcome-based standard of care.
Verbatim wording from the response “A short-term goal includes alignment of protocols and guidelines across all sites, itself a significant task that is nevertheless proceeding at pace. In some circumstances the Trust will choose to maintain different but acceptable protocols until there is unification of service delivery. This reflects the fact that choices between valid standards of care are often determined by particular local operational considerations. In these circumstances a single protocol will be established upon service unification.” Source location 2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
Concerns raised 1 Lack of identifiable beds for mentally disordered patients in cases of special urgency 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
David Reginald Bert Stacey · 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
David Reginald Bert Stacey died after sustaining chest injuries in a road traffic collision on 27 November 2017. Before the collision, he had been assessed under the Mental Health Act and was left alone after the assessment team departed. Concerns included a failure to communicate that a bed was available, the assessment team leaving before safeguards were in place, and the lack of an identifiable facility for cases of special urgency in Leicestershire.
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 identifiable beds for mentally disordered patients in cases of special urgency
Wider context from the report “An expert was instructed to advise on the psychiatric aspect of Mr Stacey’s death. One of the issues he identified was a failure to identify availability of a bed for cases of special urgency . This is a statutory requirement under section 140 of the Mental Health Act 1983 that the relevant health bodies (local Clinical Commissioning Group and Local Health Board) give advice to every social services authorities within the area of arrangements that are in force for the reception of mentally disordered patients in cases of special urgency . The expert was in no doubt that Mr Stacey would have fulfilled the ‘special urgency’ category. It transpires from my further communication with the Leicestershire Partnership Trust that there is no such facility in Leicestershire . It would appear to be a statutory requirement that is currently being ignored and I am concerned that another similar situation might arise when there are no beds available to or identifiable by, the local Trust .
” Open source report
4 Jul 2018 Kathleen Margaret Allen · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to ensure non-Emergency Department clinicians are aware of the Emergency Department MEWS escalation procedure View source Failure to apply a consistent MEWS escalation pathway in the Emergency Department View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kathleen Margaret Allen · 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
Kathleen Margaret Allen died at Birmingham Heartlands Hospital on 20 March 2018 from the effects of aspiration pneumonia caused by small bowel obstruction, after she was initially diagnosed with gastroenteritis. The report states that delayed investigation, insufficient monitoring and lack of senior medical review meant the severity of her condition was not identified promptly, and that her death was preventable. A principal concern was the inconsistent application of MEWS escalation procedures in the Emergency Department, with staff receiving different instructions and a risk to patient safety.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure non-Emergency Department clinicians are aware of the Emergency Department MEWS escalation procedure
Wider context from the report “3. Evidence was provided from an ED Senior Sister that there is a Trust Standard Operating Procedure (SOP) for MEWS Triggers in the Emergency Department which is different to the Trust wide SOP. The rationale behind having a different Procedure in ED was said to be because Doctors are more widely available in ED than on the wards. Within this SOP a MEWS of between 1 and 3 is not escalated to the Nurse in Charge. It was accepted by the witness that the rationale for a different procedure based on Doctor availability does not explain why the Nurse in Charge is not informed for a patient with a MEWS of 1 to 3. It was suggested that the explanation for this may in fact be because so many ED patients have a MEWS of between 1 and 3 the Trust wide MEWS SOP would be unworkable. A copy of this Procedure was not put before the inquest but was said to still be in operation at Birmingham Heartlands Hospital.
4. It therefore appears that there is not a consistent approach to MEWS SOP in Birmingham Heartlands ED: members of staff are being told different things and there appears to be a different procedure in operation to that set out in documents within patient records. There is a risk that staff within ED will not be taking a consistent, evidence based approach to MEWS and also that non ED based clinicians, reviewing patients in ED will not be aware of the difference in MEWS procedure operating in ED and therefore will expect a different escalation pathway . This could 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 apply a consistent MEWS escalation pathway in the Emergency Department
Wider context from the report “3. Evidence was provided from an ED Senior Sister that there is a Trust Standard Operating Procedure (SOP) for MEWS Triggers in the Emergency Department which is different to the Trust wide SOP . The rationale behind having a different Procedure in ED was said to be because Doctors are more widely available in ED than on the wards. Within this SOP a MEWS of between 1 and 3 is not escalated to the Nurse in Charge . It was accepted by the witness that the rationale for a different procedure based on Doctor availability does not explain why the Nurse in Charge is not informed for a patient with a MEWS of 1 to 3. It was suggested that the explanation for this may in fact be because so many ED patients have a MEWS of between 1 and 3 the Trust wide MEWS SOP would be unworkable. A copy of this Procedure was not put before the inquest but was said to still be in operation at Birmingham Heartlands Hospital.
4. It therefore appears that there is not a consistent approach to MEWS SOP in Birmingham Heartlands ED : members of staff are being told different things and there appears to be a different procedure in operation to that set out in documents within patient records . There is a risk that staff within ED will not be taking a consistent, evidence based approach to MEWS and also that non ED based clinicians, reviewing patients in ED will not be aware of the difference in MEWS procedure operating in ED and therefore will expect a different escalation pathway. This could put lives at risk.
” 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 Make the ED MEWS Standard Operating Procedure available to directorate teams on the Trust intranet.
Verbatim wording from the response “Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion. Consequently, an ED-specific MEWS Observation Chart has now been deployed for use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit. Further, the ED MEWS SOP is available for all directorate teams to access on the Trust intranet. The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use.” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy an ED-specific MEWS Observation Chart across BHH and Good Hope Emergency Departments and Solihull Minor Injuries Unit.
Verbatim wording from the response “Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion. Consequently, an ED-specific MEWS Observation Chart has now been deployed for use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit. Further, the ED MEWS SOP is available for all directorate teams to access on the Trust intranet. The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use.” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the ED MEWS Standard Operating Procedure and remind speciality clinical teams that a separate ED escalation pathway is in use.
Verbatim wording from the response “Notwithstanding the induction process, the Trust accepts that the use of the ward MEWS Observation Chart in ED can lead to confusion. Consequently, an ED-specific MEWS Observation Chart has now been deployed for use in the BHH and, Good Hope EDs, and the Solihull Minor Injuries Unit. Further, the ED MEWS SOP is available for all directorate teams to access on the Trust intranet. The ED directorate have circulated an email to the Divisional Directors across HGS sites asking them to disseminate the ED MEWS SOP and remind their speciality clinical teams that a separate escalation pathway for MEWS in ED is in use.” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation In emergency departments, MEWS scores of 1–3 do not routinely require Nurse in Charge escalation without overriding clinical concern or deterioration.
Verbatim wording from the response “The MEWS escalation pathway in ED does differ from that which applies to the wards. As the Area Coroner identified, the escalation pathway documented on the back of Mrs Allen’s MEWS Observation Chart required, for a MEWS score of between 1 and 3, consideration of increasing the frequency of observations and escalation to the Nurse in Charge. In ED, however, for a MEWS score between 1 and 3, there is an expectation that patient’s observations are completed hourly, but escalation to the Nurse in Charge is not routinely required unless there is an overriding clinical concern or deterioration in the patient’s condition (that is to say, the MEWS is a safeguard, but clinical staff should not allow it to override their clinical judgement).” Source location 2018-0213-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
Concerns raised 12 Failure to undertake an internal investigation and learn lessons from the case View source Failure to provide the nursing home with information about monitoring a high risk plaster cast View source Lack of continuity of care View source Lack of a care plan for management and monitoring of the plaster cast View source Failure to document signs of infection View source Lack of further staff training on plaster casts View source Failure to adequately check the plaster cast for signs of infection View source Inadequate discharge planning View source Lack of clear guidelines for managing high risk fractures treated conservatively View source Failure to arrange an outpatient appointment within 3 weeks of discharge View source Failure to arrange weekly post-discharge x-rays to monitor fracture alignment View source Failure to document pus on the plaster cast View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Francis Robert Beech · 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
Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.
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 undertake an internal investigation and learn lessons from the case
Wider context from the report “7. Failing to undertake an internal investigation to ensure lessons were learnt from this case .
” 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 the nursing home with information about monitoring a high risk plaster cast
Wider context from the report “5. Failing to provide any information to the nursing home about the need to monitor the plaster cast and that it was high 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 Lack of continuity of care
Wider context from the report “2. Lack of continuity of care . Each week a different consultant took over his care . This led to a lack of continuity and inadequate discharge planning.
” 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 care plan for management and monitoring of the plaster cast
Wider context from the report “1. Failing to have any care plan for the management and monitoring of his plaster cast .
” 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 document signs of infection
Wider context from the report “3. Failing to document any signs of infection
” 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 further staff training on plaster casts
Wider context from the report “4. There has been no further training for staff on plaster casts . The nursing home should review the training needs for staff on the care and management of plaster casts.
” 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 adequately check the plaster cast for signs of infection
Wider context from the report “2. Failing to adequately check the plaster cast for signs of infection
” 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 discharge planning
Wider context from the report “2. Lack of continuity of care. Each week a different consultant took over his care. This led to a lack of continuity and inadequate discharge planning .
” 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 guidelines for managing high risk fractures treated conservatively
Wider context from the report “1. Lack of clear guidelines regarding the management of high risk fractures treated conservatively . I heard evidence that this was a high risk fracture as there were sharp edges and little skin over the ankle area. The deceased required regular monitoring as a result.
” 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 arrange an outpatient appointment within 3 weeks of discharge
Wider context from the report “4. Failing to arrange an outpatient appointment within 3 weeks of discharge .
” 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 arrange weekly post-discharge x-rays to monitor fracture alignment
Wider context from the report “3. Failing to arrange weekly x-rays after discharge to check for fracture alignment and to monitor the fracture .
” 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 document pus on the plaster cast
Wider context from the report “6. Failing to document pus on the cast when he attended for a hip x-ray on 01/07/17.
” Open source report
Concerns raised 5 Failure to act on identified missing blood gas results View source Lack of Trust-wide review and risk-control development for insulin prescribing errors View source Failure of nursing staff to check dispensed insulin doses View source Failure to ensure arterial blood gas results remain available to clinicians View source Failure to prevent inappropriate insulin prescribing for hyperkalaemia View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ahshiyah Bibi · 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
Ahshiyah Bibi died at Birmingham Heartlands Hospital on 22 December 2016 after admission with reduced consciousness and acute renal failure. During her treatment, there was a delay in commencing treatment for high potassium and an insulin prescribing and dispensing error. The report identified concerns about missing blood gas results and the absence of a Trust-wide review or system to reduce the risk of similar errors.
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 act on identified missing blood gas results
Wider context from the report “3. ████████ evidence was that although he has investigated the insulin prescribing error and it has been discussed with the individuals involved there has not been a Trust wide review of the risks of this occurring again and consideration of a system to reduce the risk of error. The problem of missing blood gas results was identified by ████████ but not considered for further action within the department or across the Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Trust-wide review and risk-control development for insulin prescribing errors
Wider context from the report “3. ████████ evidence was that although he has investigated the insulin prescribing error and it has been discussed with the individuals involved there has not been a Trust wide review of the risks of this occurring again and consideration of a system to reduce the risk of error . The problem of missing blood gas results was identified by ████████ but not considered for further action within the department or across the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Birmingham NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to check dispensed insulin doses
Wider context from the report “2. At 04:00 a drug error was made in the prescribing and dispensing of Actrapid insulin for hyperkalaemia: Mrs. Bibi was prescribed a 50 unit dose instead of a 10 unit dose, the error was identified when she had received 20 units and the infusion was stopped. The evidence of ████████ who prescribed the insulin was she knew the Trust’s protocol and standard treatment to be a dose of 10 units but made a mistake. It appears from investigations carried out by ████████ that the two members of the nursing staff who dispensed the dose did not check the dose . Professor Hanif, Consultant in Diabetes, gave independent expert evidence that in his view there is a risk of inappropriate prescribing of insulin in the management of hyperkalaemia because clinicians are more commonly called upon to prescribed a 50 unit does for Hyperglycaemia. Therefore in his opinion a system is required to avoid error in cases of hyperkalaemia. ████████ agreed that the fact she more commonly prescribes a 50 unit dose of insulin for hyperglycaemia probably did explain her error.
” 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 arterial blood gas results remain available to clinicians
Wider context from the report “1. When reviewing Mrs. Bibi at 02:14 ████████ did not have the results from an arterial blood gas performed by the nursing team at 01:52 which demonstrated high potassium therefore treatment for high potassium was not commenced until approximately 04:00 when the high potassium had been identified. It was the evidence of ████████ and ████████ that from time to time the hard copy blood gas results do get separated from the records and if the Clinician doesn’t know the test has been undertaken they will have no reason to go and source the results .
” 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 prevent inappropriate insulin prescribing for hyperkalaemia
Wider context from the report “2. At 04:00 a drug error was made in the prescribing and dispensing of Actrapid insulin for hyperkalaemia: Mrs. Bibi was prescribed a 50 unit dose instead of a 10 unit dose, the error was identified when she had received 20 units and the infusion was stopped. The evidence of ████████ who prescribed the insulin was she knew the Trust’s protocol and standard treatment to be a dose of 10 units but made a mistake. It appears from investigations carried out by ████████ that the two members of the nursing staff who dispensed the dose did not check the dose. Professor Hanif, Consultant in Diabetes, gave independent expert evidence that in his view there is a risk of inappropriate prescribing of insulin in the management of hyperkalaemia because clinicians are more commonly called upon to prescribed a 50 unit does for Hyperglycaemia . Therefore in his opinion a system is required to avoid error in cases of hyperkalaemia . ████████ agreed that the fact she more commonly prescribes a 50 unit dose of insulin for hyperglycaemia probably did explain her error.
” Open source report
26 Oct 2016 Alfie Rose · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Failure of the NORSE system to make all entries visible View source Insufficient guidance and education on neurological referrals in outlying hospitals View source Failure to communicate relevant clinical information between hospitals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfie Rose · 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
Alfie Rose, aged 17, died on 09 June 2016 following deterioration from obstructive hydrocephalus, severe brain injury and brain stem death. The report identified poor communication between the two hospitals and inadequate guidance and education for clinicians in outlying hospitals as principal concerns. The inquest concluded that earlier detailed MRI scanning, admission and treatment at the Queen Elizabeth Hospital neurosurgical unit would, on balance, have avoided 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 of the NORSE system to make all entries visible
Wider context from the report “1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen.
” 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 guidance and education on neurological referrals in outlying hospitals
Wider context from the report “2. Education. It is important the clinicians in outlying hospitals understand how neurological referrals should be made and when. Better guidance and education is needed for outlying hospitals.
” 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 communicate relevant clinical information between hospitals
Wider context from the report “1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen.
” 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 Conduct cross-hospital meetings to identify communication and patient-management improvements following the clinical incident.
Verbatim wording from the response “It is important to reflect on the effectiveness of any system when there has been a significant clinical incident. To that end the following meetings have been held to identify areas of concern that could be improved:” Source location 2016-0382-Response-by-University-Hospitals-Birmingham-NHS-Trust
Open published response
Concerns raised 2 Failure to ensure completion of outstanding tests before discharge View source Failure to document outstanding test results and required follow-up in discharge records 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
Terence Henry Stilges · 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
Terence Henry Stilges was admitted to hospital after collapsing, was discharged before an outstanding troponin result was available, and was readmitted with severe shortness of breath and chest pain. He was diagnosed with an acute myocardial infarction and died following a cardiac arrest; the principal concern was that advance preparation of discharge summaries and incorrect discharge instructions could lead to patients being discharged before tests were complete.
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 ensure completion of outstanding tests before discharge
Wider context from the report “(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home. Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding. I am concerned this could result in other patients being discharged before their tests are complete.
” 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 document outstanding test results and required follow-up in discharge records
Wider context from the report “(1) A discharge summary was prepared several days in advance for this patient. This summary did not mention the need for a further troponin result before the patient was discharged home. In addition the medical records wrongly specified that he should be discharged home . Therefore the patient was incorrectly sent home before the second troponin result was available. I heard that there was a practice of writing discharge summaries in advance despite tests results being outstanding . I am concerned this could result in other patients being discharged before their tests are complete.
” Open source report
19 Apr 2016 Leslie William Carswell · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to reliably transmit CT scans between trusts for timely review 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
Leslie William Carswell · 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
Leslie William Carswell was admitted to hospital following a transcatheter aortic valve implantation, was assessed as being at high risk of falls, and suffered a serious brain bleed after falling while going to the toilet. The report raised concern that technical difficulties transmitting CT scans delayed review and treatment planning, with potential to delay lifesaving treatment for patients with urgent conditions.
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 reliably transmit CT scans between trusts for timely review
Wider context from the report “(1) There were technical difficulties transmitting the CT scans taken at 00.50 to the Queen Elizabeth Hospital in Birmingham for review which is the protocol for these west midlands. This caused a delay in deciding a treatment plan. I heard evidence at the inquest that these concerns are ongoing and no resolution has been found . There is a concern that patients with urgent conditions could have lifesaving treatment delayed due to technical difficulties between the two trusts .
” Open source report
15 Dec 2015 Joyce Beatrice TOZER · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Administration of hypertonic Omnipaque through central lines View source Frequent administration of Omnipaque doses exceeding manufacturer guidelines View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joyce Beatrice TOZER · 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
Joyce Beatrice Tozer died after her condition deteriorated dramatically and she suffered cardiac arrest minutes after receiving 100ml of Omnipaque through a central line during an interventional radiology procedure to insert bilateral nephrostomies. The inquest concluded that she died from a reaction to the contrast material, but it could not determine whether this was an allergic response or toxicity. Concern was raised that doses exceeding the manufacturer’s guidance were frequently administered, sometimes through central lines, potentially exposing patients to toxicity risks.
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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 Administration of hypertonic Omnipaque through central lines
Wider context from the report “(1) ████████, Consultant anaesthetist for the procedure on the 12th June 2015, gave evidence that since Mrs. Tozer’s death, he has become concerned that the dose of 100ml omnipaque recorded in the notes as being administered by the radiologist minutes before Mrs. Tozer’s sudden deterioration was well in excess of the dose recommended by the manufacturer of omnipaque (1ml/kg) especially as it was being administered through a central line rather than peripheral venous access . At this time Mrs. Tozer’s weight was 52kg. ████████ stated that he was concerned that the administration of a hypertonic solution at this dose into a central line may have affected Mrs. Tozer’s heart rhythm although there was no way he could give an opinion as to whether it was the likely cause of her deterioration and death as the presentation of toxicity cannot be distinguished from an anaphylactoid reaction. ████████ gave evidence that having made enquiries about the dose with ████████ Lead Interventional Radiologist at the Trust, he has been told that a 100ml dose is often used. I am concerned that doses of omnipaque well in excess of the manufacturer’s guidelines are frequently administered, sometimes through central lines , and this practice could be exposing interventional radiology patients to risks from toxicity.
” 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 Frequent administration of Omnipaque doses exceeding manufacturer guidelines
Wider context from the report “(1) ████████, Consultant anaesthetist for the procedure on the 12th June 2015, gave evidence that since Mrs. Tozer’s death, he has become concerned that the dose of 100ml omnipaque recorded in the notes as being administered by the radiologist minutes before Mrs. Tozer’s sudden deterioration was well in excess of the dose recommended by the manufacturer of omnipaque (1ml/kg) especially as it was being administered through a central line rather than peripheral venous access. At this time Mrs. Tozer’s weight was 52kg. ████████ stated that he was concerned that the administration of a hypertonic solution at this dose into a central line may have affected Mrs. Tozer’s heart rhythm although there was no way he could give an opinion as to whether it was the likely cause of her deterioration and death as the presentation of toxicity cannot be distinguished from an anaphylactoid reaction. ████████ gave evidence that having made enquiries about the dose with ████████ Lead Interventional Radiologist at the Trust, he has been told that a 100ml dose is often used . I am concerned that doses of omnipaque well in excess of the manufacturer’s guidelines are frequently administered , sometimes through central lines, and this practice could be exposing interventional radiology patients to risks from toxicity.
” 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 Reviewed intravenous contrast administration protocols against manufacturer guidance and relevant literature.
Verbatim wording from the response “A round table meeting was held on 24th December to discuss whether an overdose was a causative factor in the death of the deceased. The roundtable review noted that the deceased had become unwell following administration of 100ml Visipaque (Omnipaque was incorrectly documented in the medical notes, the correct contrast agent is recorded on the Trust’s imaging system. 100mls is considered to be a standard dose; Visipaque is iso-osmolar and therefore theoretically less toxic than Omnipaque).” Source location Joyce-Tozer-Response
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 administered contrast dose was within accepted ranges, was not an overdose, and toxicity was unlikely to have caused the death.
Verbatim wording from the response “1. The radiographer administering the contrast acted entirely appropriately and within the limitations of the expanded practice IV protocol;” Source location Joyce-Tozer-Response
Open published response
23 Oct 2015 Hireiti Kufletsion · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves View source Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications View source Insufficient clexane dosing for pregnant women with mechanical valves View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Hireiti Kufletsion · 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
Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.
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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 Inadequate frequency of anti-factor Xa review for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose). Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week) . Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa .
” 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 clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications
Wider context from the report “(2) It was apparent from evidence given by clinicians at the Birmingham Heartlands Hospital that they did not understand the extent and gravity of the increased risk of thrombosis to pregnant women with mechanical heart valves and this affected the course of investigations into the deceased’s condition ultimately resulting in a delay in diagnosis until it was too late. Whilst this issue has now been brought to the full attention of all departments within the Birmingham Heartlands Hospital, it is reasonable to assume that there are haematologists, cardiologists and obstetricians without specialist cardio-obstetric knowledge across the country that do not appreciate the implications during pregnancies of patients with a mechanical heart valve for anti-coagulation therapy but maybe involved in the management and care of such patients.
” 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 clexane dosing for pregnant women with mechanical valves
Wider context from the report “(1) In giving evidence ████████ stated that from time to time she does see at her Obstetric/Cardiac clinic pregnant patients with mechanical valves who have had their warfarin changed to clexane at other hospitals in the region on too low a dose of clexane (i.e. not a twice daily 60mg/kg dose) . Likewise she is aware that review of anti-factor Xa may not be arranged to occur with adequate frequency (once a week). Therefore pregnant women with mechanical valves may be at risk from being prescribed insufficient doses of clexane with insufficient review of their anti-factor Xa.
” Open source report
Concerns raised 1 Failure to follow specialist advice 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
Adrian Mark Smith · 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
Adrian Mark Smith attended hospital after seizures and was later found to have a bilateral frontal brain haemorrhage and sagittal sinus thrombosis. He underwent decompression surgery after a further brain bleed and died on 8 June 2015; the inquest concluded that his death resulted from a complication of heparin treatment. The principal concern was that Good Hope Hospital did not follow specialist advice to undertake an MRI scan to confirm the possible diagnosis.
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 specialist advice
Wider context from the report “(1) Clear instruction was given by the Queen Elizabeth hospital to undertake an MRI scan to confirm the possible diagnosis. This instruction was not followed by the staff at Good Hope Hospital. Systems need to be put in place to ensure that specialist advice is followed.
” Open source report
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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 Radiologists need not automatically follow specialist requests because they independently assess clinical need, likely benefit and potential intervention.
Verbatim wording from the response “1. Clear instruction was given by the Queen Elizabeth Hospital to undertake an MRI scan to confirm the possible diagnosis. This instruction was not followed by the staff at Good Hope Hospital. Systems need to be put in place to ensure that specialist advice is followed.” Source location 2015-0378-Response
Open published response
Concerns raised 2 Failure to ensure that the electronic medication administration chart mirrors the discharge medication documentation View source Lack of a protocol for easily checking medication discrepancies 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
Lottie Reid · 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
Lottie Reid, aged 95, was readmitted to hospital with haematemesis and melaena and died on 29 January 2015. The inquest concluded that she died from bleeding duodenal ulcers on a background of other significant natural disease, with her death probably accelerated by bleeding exacerbated by anticoagulant therapy. Concerns were raised that the medication administration chart at the intermediate care centre did not mirror the hospital discharge documentation and that there was no clear protocol for checking discrepancies, particularly at weekends.
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 ensure that the electronic medication administration chart mirrors the discharge medication documentation
Wider context from the report “(1) That following discharge from Good Hope Hospital to Perry Trees Intermediate Care Centre the Printed Electronic Prescribing Medication Adm Chart did not mirror the medication referred to in the Discharge Letter and Prescription .
(2) There did not appear to be a protocol in place whereby such discrepancies could be easily checked and this appeared to be especially difficult to do at weekends
” 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 protocol for easily checking medication discrepancies
Wider context from the report “(1) That following discharge from Good Hope Hospital to Perry Trees Intermediate Care Centre the Printed Electronic Prescribing Medication Adm Chart did not mirror the medication referred to in the Discharge Letter and Prescription.
(2) There did not appear to be a protocol in place whereby such discrepancies could be easily checked and this appeared to be especially difficult to do at weekends
” 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 Improve and standardise yellow-card discharge documentation to provide optimal information for safe prescribing and administration.
Verbatim wording from the response “In addition to strengthening the processes as described above, we consider that this case is an opportunity to improve the discharge process and the documentation in particular:” Source location 2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make a final decision on extending the revised discharge documentation process to intermediate-care discharges after piloting and feedback review.
Verbatim wording from the response “Once the new documentation has been approved through our governance processes, it will be piloted within palliative care. Subject to feedback from the community staff, a final decision as to the appropriateness of implementing this process for patients being discharged into an intermediate care facility will be made. It is likely that this decision will be made in the next six months, and will be based on clarity of the prescribing and a review of any reported incidents.” Source location 2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain governance approval and pilot the revised yellow-card documentation within palliative care.
Verbatim wording from the response “This process will reduce the risk of inconsistency in the discharge documents for the patient, as there will only be one document that the clinicians will refer to on discharge. The template will be standardised to ensure it contains the optimal information for safe prescribing and administration.” Source location 2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Check available MAC charts and TTOs for medication discrepancies.
Verbatim wording from the response “6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.” Source location 2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review existing pharmacy SOPs to ensure they are robust and fit for purpose.
Verbatim wording from the response “6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.” Source location 2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind all pharmacists about the importance of identifying medication discrepancies between MAC charts and TTOs.
Verbatim wording from the response “6. To strengthen the current pharmacy processes, when available, MAC charts and TTOs are checked for discrepancies. As part of our response, the incident was discussed with the pharmacist involved. The Chief Pharmacist has also reminded all of her pharmacists about the importance of this issue. The Chief Pharmacist is also reviewing existing SOPs to ensure they are robust and fit for purpose.” Source location 2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the nursing discharge checklist to remind staff to check the PEPMAC.
Verbatim wording from the response “In order that the risk of future events can be reduced the following steps have been taken by the Trust:” Source location 2015-0241-Response-by-Birmingham-Heartlands-Hospitals
Open published response
7 Oct 2013 George Leonard Parkes · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Failure to maintain follow-up of patients with abdominal aortic aneurysms 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
George Leonard Parkes · 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
George Leonard Parkes, aged 84, died during surgery for a ruptured abdominal aortic aneurysm. The report describes him as having been lost to follow-up, allowing the aneurysm to become very large before rupture, and identifies concerns about monitoring and follow-up arrangements for patients with abdominal aortic aneurysms.
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 follow-up of patients with abdominal aortic aneurysms
Wider context from the report “I attach the summing up in relation to this case which essentially involves the situation where a patient with an abdominal aortic aneurysm was “lost to follow up” . The consequences were that it meant that his aneurysm became so big that it ruptured and he died. Potentially, this was a preventable death as if he was eligible, he would have been given the opportunity of having fenestrated endovascular repair which probably would have meant he would not have died when he did. It has been suggested to me by the witnesses that having a specialist nurse clinic (enabling open monitoring of patients with abdominal aortic aneurysms) and dedicated procedure database/register, would prevent this situation happening again. The guidance from the Chief Coroner is that in writing these Reports, the Coroner does not make a very specific recommendation and I do not in this case. I do, however, support the Consultant Vascular Surgeons at the Queen Elizabeth Hospital (specifically ████████, in actions such as the nurse clinic being set up, to prevent future loss of life, and any other measure(s) which will prevent future “lost to follow-up” situations .
” Open source report
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Addressed to Heart of England NHS Foundation Trust, now represented here by University Hospitals Birmingham NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations