Concerns raised 3 Failure to proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion View source Failure to reliably maintain liaison, shared responsibility and specialist mental health input during acute hospital transfers View source Lack of routine auditing and assurance of expected communication processes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Natalia Violet Cestaro (known as “Tali”) · 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
Natalia Violet Cestaro, known as “Tali”, was an 18-year-old inpatient who died on 15 November 2023 after ingesting a foreign object, undergoing endoscopic removal, and subsequently developing gastric perforation, sepsis and multi-organ failure. The principal concerns included the proactive assessment of risks from impulsive ingestion, liaison between mental health and acute services, and assurance and auditing of communication processes.
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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion
Wider context from the report “a) Proactive scope of risk assessment for impulsive ingestion (CWPT)
The evidence raised a concern that risk assessments may focus primarily on specific previously ingested items, rather than undertaking a sufficiently proactive assessment of a wider range of swallowable items within the inpatient environment . Where a patient is known to pose a persistent risk of impulsive ingestion, a predominantly reactive approach risks foreseeable hazards not being identified and mitigated in advance .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably maintain liaison, shared responsibility and specialist mental health input during acute hospital transfers
Wider context from the report “b) Interface working and demonstrable liaison between mental health and acute services (CWPT and UHCW)
The evidence before the inquest disclosed limited detail demonstrating how liaison, shared responsibility, and specialist input are consistently achieved in practice when a mental health inpatient is transferred to an acute hospital for physical healthcare . While both organisations described mechanisms for access to advice and communication, there was relatively limited evidence of how these arrangements operate reliably , how compliance is assured, and how lapses are detected and addressed. This creates a risk that relevant mental health risks are not consistently carried through the acute admission .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of routine auditing and assurance of expected communication processes
Wider context from the report “c) Assurance and auditing of expected communication processes (CWPT)
The evidence raised concern that processes described as standard practice, including regular contact following transfer, may not be subject to routine auditing or assurance . Reliance on the existence of a process alone, without effective oversight of whether it is consistently carried out in practice, risks failures persisting undetected .
” 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 Establish and routinely monitor a memorandum of understanding and transfer process clarifying roles and sharing mental health care information for patients admitted to UHCW.
Verbatim wording from the response “In response I can confirm that we have agreed the content of a Memorandum of Understanding (MOU) with CWPT (copy attached). The MOU seeks to bring clarity to roles and responsibilities for those circumstances in which an inpatient mental health patient may be admitted to UHCW for the treatment of a physical health condition.” Source location Response from University Hospitals Coventry and Warwickshire NHS Trust
Open published response
Concerns raised 6 Inconsistent coordination between specialist and non-specialist hospitals View source Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred View source Lack of consistent understanding of appropriate specialist contacts and engagement timing View source Failure to clearly define patient information for specialist renal hospitals View source Lack of consistent awareness of and access to kidney transplant care guidelines and protocols View source Lack of consistent understanding of responsibility for initiating patient transfers View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Finalise, agree, and cascade shared guidelines for managing acutely unwell kidney-transplant inpatients.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Provide UHCW renal-team attendance at GEH to review renal inpatients on request, up to twice weekly, under the agreed SLA.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Place the agreed renal-care guidelines on the Trust intranet after governance ratification.
Stated plannedThe respondent said that this action was planned when they made their response on 12 November 2024. View source
Action
Operate a daily 11:30am huddle with the Medicine Operational team, including a renal doctor, to identify and prioritise interhospital transfers.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Make UHCW the primary specialist transfer centre and accept all renal patients admitted to GEH, regardless of their parent hospital.
Stated plannedThe respondent said that this action was planned when they made their response on 12 November 2024. View source
Action
Consider using referapatient.org to document communication between renal departments and other hospitals.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 November 2024. View source
Action
Develop and share guidance with George Eliot Hospital on CMV sample tubes, urgent turnaround, contacts and escalation.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Act as the primary specialist transfer centre for renal patients admitted to peripheral hospitals, regardless of their parent specialist unit.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Share blood test results electronically in real time for patients known to the UHCW Renal Department and admitted elsewhere.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Provide onsite renal consultant inpatient review at George Eliot Hospital and South Warwickshire Foundation Trust under service-level agreements.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Agree referral indications and referral routes with George Eliot Hospital for specialist renal input.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Accept responsibility for recommending the best care location for patients referred to Renal Services.
Stated completedThe respondent said that this action was complete when they made their response on 12 November 2024. View source
Action
Consider using referapatient.org to record communication between referring centres and UHCW in real time.
Stated in progressThe respondent said that this action was in progress when they made their response on 12 November 2024. View source See 10 more actions
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AI-generated summary
John Frederick Doyle · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.
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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent coordination between specialist and non-specialist hospitals
Wider context from the report “Concern 6: Coordination Between Specialist and Non-Specialist Hospitals
There may be variation in how specialist renal hospitals engage with non-specialist hospitals that rely on their expertise , impacting collaborative efforts in patient care. Currently, there is no clear guidance on how specialist and non-specialist teams should work together effectively to ensure consistent, high-quality care for these 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent decision-making about whether patients remain in non-specialist areas or are transferred
Wider context from the report “Concern 5: Decision-Making for Patient Location
Considerations regarding whether patients should remain in non-specialist areas or be transferred may differ , potentially affecting consistency in care approaches.
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of appropriate specialist contacts and engagement timing
Wider context from the report “Concern 1: Contacting Specialist Centres
Non-specialist medical staff may have varied understanding of the appropriate contacts and timing for engaging with specialist renal 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly define patient information for specialist renal hospitals
Wider context from the report “Concern 2: Information Sharing with Specialist Centres
The specific patient information that non-specialist staff should provide to specialist renal hospitals may not always be clearly defined .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent awareness of and access to kidney transplant care guidelines and protocols
Wider context from the report “Concern 3: Accessibility to Renal Care Guidelines
Non-specialist staff may experience varying levels of awareness or accessibility to guidelines and protocols for treating kidney transplant patients . This could lead to a misunderstanding of the significance and urgency of the actions recommended by specialist renal 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent understanding of responsibility for initiating patient transfers
Wider context from the report “Concern 4: Transfer Responsibility
There may be some inconsistency across non-specialist hospitals and renal hospitals in understanding who is responsible for initiating patient transfers .
” 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 Finalise, agree, and cascade shared guidelines for managing acutely unwell kidney-transplant inpatients.
Verbatim wording from the response “As you are aware from the evidence of the medical witnesses at the inquest on 8 November 2024, the renal team at UHCW have been developing guidelines to assist George Eliot Hospital (GEH), a non-renal specialist hospital, in the management of acutely unwell kidney transplant renal inpatients. We are pleased to report that these guidelines have been finalised and agreed between the Trusts and we enclose a copy.” Source location Response 1 from Coventry and Warwickshire Partnership Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide UHCW renal-team attendance at GEH to review renal inpatients on request, up to twice weekly, under the agreed SLA.
Verbatim wording from the response “In addition, both Trusts have agreed a Service Level Agreement (SLA) which means that a member of UHCW’s renal team will attend GEH and review their renal inpatients on GEH request up to twice a week.” Source location Response 1 from Coventry and Warwickshire Partnership 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 Place the agreed renal-care guidelines on the Trust intranet after governance ratification.
Verbatim wording from the response “These guidelines have been shared and cascaded within the respective clinical teams which includes discussion as the Trust’s Renal Quality Improvement and Patient Safety meeting (QIPS). Once ratified through the usual governance processes these guidelines will be placed on the Trust’s intranet to be accessible to all staff.” Source location Response 1 from Coventry and Warwickshire Partnership 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 Operate a daily 11:30am huddle with the Medicine Operational team, including a renal doctor, to identify and prioritise interhospital transfers.
Verbatim wording from the response “The SLA which provides that a renal specialist will attend GEH on request should help identify those patients requiring urgent transfer. UHCW will be responsible to accept all renal patients admitted to GEH, regardless of their parent hospital. In addition, the internal processes to highlight which patients need urgent transfer have been changed (we now have a daily huddle at 11.30am with the UHCW Medicine Operational team where a renal doctor is present, so that interhospital transfers can be highlighted and appropriately prioritised).” Source location Response 1 from Coventry and Warwickshire Partnership 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 Make UHCW the primary specialist transfer centre and accept all renal patients admitted to GEH, regardless of their parent hospital.
Verbatim wording from the response “The SLA which provides that a renal specialist will attend GEH on request should help identify those patients requiring urgent transfer. UHCW will be responsible to accept all renal patients admitted to GEH, regardless of their parent hospital. In addition, the internal processes to highlight which patients need urgent transfer have been changed (we now have a daily huddle at 11.30am with the UHCW Medicine Operational team where a renal doctor is present, so that interhospital transfers can be highlighted and appropriately prioritised).” Source location Response 1 from Coventry and Warwickshire Partnership 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 Consider using referapatient.org to document communication between renal departments and other hospitals.
Verbatim wording from the response “The SLA and guideline set up a clear framework to ensure good communication between the Trusts including timely investigation and treatment. Additionally, processes to document communication between renal department and other hospitals, “referapatient.org” is being considered.” Source location Response 1 from Coventry and Warwickshire Partnership 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 Develop and share guidance with George Eliot Hospital on CMV sample tubes, urgent turnaround, contacts and escalation.
Verbatim wording from the response “Following the sad death of Mr Doyle, UHCW Renal and Virology teams have reviewed processes. Guidelines have been developed which describe: the correct blood tubes, how to ensure urgent turnaround, who to contact, when, and how to escalate to. These have been shared with GEH. Turnaround times for all pathology labs are published in CWPS Handbook V16 May 2024.pdf.” Source location Response 2 from Coventry and Warwickshire Partnership 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 Act as the primary specialist transfer centre for renal patients admitted to peripheral hospitals, regardless of their parent specialist unit.
Verbatim wording from the response “There is an established and effective process for referring patients who are receiving dialysis to their parent unit. UHCW has Service Level Agreements with George Eliot Hospital and with South Warwickshire Foundation Trust that UHCW will provide onsite Renal Consultant Specialist inpatient review at GEH and SWFT upon request up to twice a week. Additionally, UHCW has worked with UK Kidney Association and agreed to be the primary specialist transfer centre for all renal transplant patients admitted from referring hospitals regardless of their parent specialist unit.” Source location Response 2 from Coventry and Warwickshire Partnership 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 Share blood test results electronically in real time for patients known to the UHCW Renal Department and admitted elsewhere.
Verbatim wording from the response “Electronic patient sharing of blood test results in real-time exists for patients who are already known to UHCW Renal Department, whether admitted to GEH or SWFT. In addition, “referapatient.org” is being considered as a means of recording communication between referring centres and UHCW in real time.” Source location Response 2 from Coventry and Warwickshire Partnership Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide onsite renal consultant inpatient review at George Eliot Hospital and South Warwickshire Foundation Trust under service-level agreements.
Verbatim wording from the response “There is an established and effective process for referring patients who are receiving dialysis to their parent unit. UHCW has Service Level Agreements with George Eliot Hospital and with South Warwickshire Foundation Trust that UHCW will provide onsite Renal Consultant Specialist inpatient review at GEH and SWFT upon request up to twice a week. Additionally, UHCW has worked with UK Kidney Association and agreed to be the primary specialist transfer centre for all renal transplant patients admitted from referring hospitals regardless of their parent specialist unit.” Source location Response 2 from Coventry and Warwickshire Partnership 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 Agree referral indications and referral routes with George Eliot Hospital for specialist renal input.
Verbatim wording from the response “We confirm that staff at UHCW are aware of internal escalation routes. The escalation of concerns is via the renal registrar and renal consultant. We confirm that UHCW has shared and agreed with George Eliot Hospitals the indications for referral to us as a specialist unit, and the routes for referral.” Source location Response 2 from Coventry and Warwickshire Partnership 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 Accept responsibility for recommending the best care location for patients referred to Renal Services.
Verbatim wording from the response “We accept the responsibility for recommending best location for all patients referred to Renal Services. Based on the clinical requirements patients could be transferred to UHCW or reviewed by the UHCW renal consultant at the local hospital and transferred over later if necessary.” Source location Response 2 from Coventry and Warwickshire Partnership 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 Consider using referapatient.org to record communication between referring centres and UHCW in real time.
Verbatim wording from the response “Electronic patient sharing of blood test results in real-time exists for patients who are already known to UHCW Renal Department, whether admitted to GEH or SWFT. In addition, “referapatient.org” is being considered as a means of recording communication between referring centres and UHCW in real time.” Source location Response 2 from Coventry and Warwickshire Partnership 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 The agreed guidelines, service-level agreement and related processes are considered sufficient to address the six concerns.
Verbatim wording from the response “As you are aware from the evidence of the medical witnesses at the inquest on 8 November 2024, the renal team at UHCW have been developing guidelines to assist George Eliot Hospital (GEH), a non-renal specialist hospital, in the management of acutely unwell kidney transplant renal inpatients. We are pleased to report that these guidelines have been finalised and agreed between the Trusts and we enclose a copy.” Source location Response 1 from Coventry and Warwickshire Partnership 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 Local non-specialist hospitals are responsible for answering whether switchboards and emergency departments hold specialist centre contact details.
Verbatim wording from the response “Whilst this is a question that is best answered by our local non specialist hospitals, we are aware that both South Warwickshire NHS Foundation Trust and George Eliot Hospital switchboards and their Emergency Departments have local specialist centre contact details.” Source location Response 2 from Coventry and Warwickshire Partnership 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 Specialist renal care should rely on direct specialist contact rather than universal guideline access, because guidelines may cause misunderstanding of urgency.
Verbatim wording from the response “• As access to Guidelines could lead to a misunderstanding of the significance and urgency of required actions; the critical action in this case would be to contact the Specialist Centre” Source location Response 2 from Coventry and Warwickshire Partnership Trust
Open published response
Concerns raised 3 Failure to ensure Cardiology team awareness and access to the emergency GP telephone number View source Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion View source Failure of Medical Consultants and staff to access the UHCW switchboard View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Andrew Douglas Guillaume · 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
Andrew Douglas Guillaume was admitted to Warwick Hospital on 5 June 2023 with shortness of breath and a cough, and was later assessed as likely having severe aortic stenosis requiring urgent referral. He deteriorated, was admitted to the Cardiothoracic Critical Care unit at UHCW on 19 June 2023, and died on 20 June 2023; concerns included difficulties contacting the UHCW switchboard, lack of awareness of an emergency contact number, and the absence of a completed referral preventing discussion at a multi-disciplinary meeting.
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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Cardiology team awareness and access to the emergency GP telephone number
Wider context from the report “(2) A previous incident in which a similar concern had been raised, had led to provision of an emergency GP phone number, that can be used by the clinical teams at SWFT, which is manned 24 hours a day and is prioritised over other calls. The Cardiology team had not been aware of this, nor did they have the telephone number .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion
Wider context from the report “(3) Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023 , as the referral had not been completed .
(4) Had the referral been completed, the team at UHCW could have prioritised the patient’s transfer.
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Medical Consultants and staff to access the UHCW switchboard
Wider context from the report “(1) The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions .
” 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 Establish a 24-hour, seven-day direct communication escalation process.
Verbatim wording from the response “We have agreed to explore the technological options that may improve this however, in the interim we have agreed an escalation process that now provides a direct line of communication 24 hours, seven days per week.” Source location Response from University Hospitals Conventry and Warwickshire NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the confirmed escalation arrangement with other providers across the system.
Verbatim wording from the response “This arrangement has been confirmed with SWUFT following the tabletop review and we will also share this with the other Providers across the System. We hope this provides assurances, and I would like to assure you that we will continue to explore communication improvements as part of our digital plans.” Source location Response from University Hospitals Conventry and Warwickshire NHS Trust
Open published response
1 Nov 2018 Mr Taylor · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Lack of consultant physician support for neurosurgical patients requiring medical input View source Failure of the alcohol withdrawal protocol to provide clear instructions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Taylor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Taylor suffered a fall at home on 27 July 2018, sustaining a head injury and later being transferred to the Trust. Following a respiratory arrest, chest infection and deterioration, he died in the Trust on 31 July 2018. Concerns included insufficient consultant physician support for neurosurgical patients and an alcohol withdrawal protocol that was difficult to understand, resulting in diazepam being prescribed instead of lorazepam.
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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant physician support for neurosurgical patients requiring medical input
Wider context from the report “(1) I heard in evidence from Mr Young, the Trust's Clinical Director who had carried out a Root Cause Analysis. I heard also from ████████ one of the Trust's consultant neurosurgeons. Both consultants expressed their belief that neurosurgical patients of this nature required additional support from their consultant physician colleagues . I was told that this has been an issue for some time and remained unresolved . In particular, there was concern that a junior neurosurgical doctor was left to implement an alcohol withdrawal regimen . I was told that these difficulties are not confined to patients who are admitted with alcohol-related issues but extend across the whole range of neurosurgical patients who require medical input .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the alcohol withdrawal protocol to provide clear instructions
Wider context from the report “(2) I was told that the alcohol withdrawal protocol was difficult to understand . This resulted in the doctor prescribing diazepam when Lorazepam should have been used. I was told and shown an action plan that the Trust intends to implement to improve the process.
” 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 Supplement the Care of the Elderly team with Advanced Nurse Practitioners to provide specialist medical input to surgical patients with medical co-morbidities.
Verbatim wording from the response “As a Trust we have looked to support complex surgical specialties, such as Neurosurgery, Vascular Surgery and Orthopaedics with provision of specialist medical opinion, especially from Care of the Elderly physicians. However, due to a national shortage of consultants in this specialty, we have supplemented our Care of the Elderly team with Advanced Nurse Practitioners. We will be looking to increase this further so as to provide specialist medical input to surgical patients with medical co-morbidities.” Source location Stephen-Taylor-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 A national shortage of Care of the Elderly consultants prevents full provision of specialist medical input to surgical patients with medical co-morbidities.
Verbatim wording from the response “As a Trust we have looked to support complex surgical specialties, such as Neurosurgery, Vascular Surgery and Orthopaedics with provision of specialist medical opinion, especially from Care of the Elderly physicians. However, due to a national shortage of consultants in this specialty, we have supplemented our Care of the Elderly team with Advanced Nurse Practitioners. We will be looking to increase this further so as to provide specialist medical input to surgical patients with medical co-morbidities.” Source location Stephen-Taylor-Response
Open published response
25 Jul 2017 Mr Robert Dymond · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 3 Failure to make the operating Consultant Orthopaedic Surgeon and Anaesthetist aware of relevant DVT investigations and treatment View source Failure to include relevant DVT investigations and treatment in the second pre-operative assessment View source Failure of the DVT investigation protocol to provide repeat proximal leg vein ultrasound scanning after a positive D-dimer test and negative proximal leg ultrasound scan View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Robert Dymond · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Robert Dymond underwent elective left knee replacement surgery on 9 March 2017 and suffered a massive thromboembolic event the following morning, dying on 11 March 2017. Concerns included the management and follow-up of suspected deep vein thrombosis, the apparent failure to communicate the November 2016 DVT investigations and treatment to the surgical and anaesthetic teams, and their omission from the second pre-operative assessment.
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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make the operating Consultant Orthopaedic Surgeon and Anaesthetist aware of relevant DVT investigations and treatment
Wider context from the report “(2) Neither the Consultant Orthopaedic Surgeon nor the Anaesthetist performing the operation on 9 March 2017 had been made aware of the DVT investigations/treatment in November 2016 ;
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include relevant DVT investigations and treatment in the second pre-operative assessment
Wider context from the report “(3) The DVT investigations/treatment in November 2016 did not appear to feature in the second pre-operative assessment carried out on 12 January 2017.
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the DVT investigation protocol to provide repeat proximal leg vein ultrasound scanning after a positive D-dimer test and negative proximal leg ultrasound scan
Wider context from the report “(1) Following referral to the UHCW DVT Clinic by his GP on 22 November 2016 with a suspected DVT, Mr Dymond, having a Wells score of 2, was assessed as being ‘likely’ to be suffering from a DVT – the investigations included a D-Dimer blood result of 0.97 – and he was discharged home with instructions to self-administer therapeutic LMWH (Clexane) doses at home twice daily in his stomach pending an ultrasound scan booked for 25 November 2016. The scan performed on 25 November 2016 apparently revealed no evidence of a DVT and he was discharged back to the care of his GP. Although the clinical management appeared to conform with the UHCW protocol in place at the time, this protocol did not appear to conform with NICE Guideline 144 (specifically section 1.1.3) which (since 2012) advises a repeat proximal leg vein ultrasound scan 6-8 days later for all patients with a positive D-dimer test and a negative proximal leg ultrasound scan ;
” 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 Undertake routine extended whole-leg scans covering veins below the knee to the calf trifurcation.
Verbatim wording from the response “The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as a routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan. Therefore we believe that the Trust’s pathway goes beyond the minimum requirements and accordingly we exclude very low numbers of venous thromboembolism following discharge from the DVT service.” Source location 2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Contact high-risk patients with raised D-dimers after 5–7 days and arrange repeat scanning when symptoms have not settled.
Verbatim wording from the response “Further, the Trust’s standard practice in patients with a high risk Wells score and raised D-Dimers is to contact the patient 5-7 days later and arrange a repeat scan if the symptoms are not settling. Only a small proportion of patients who present with isolated distal DVTs extend to the proximal veins. Those that do not extend, rarely lead to clinically significant emboli as recognised by the British Society of Haematology national guidelines, a copy of which is attached by way of information.” Source location 2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine repeat scans are unnecessary because whole-leg scans are routinely performed and follow-up scans are arranged when symptoms fail to settle.
Verbatim wording from the response “The reason that this practice is not adopted by the Trust is because at UHCW, we undertake a more extended scan as a routine which shows the leg veins below the knee to the trifurcation in the calf. This is discussed in NICE guideline 144 section 4.1 which states that whole leg scans do not routinely need a repeat scan. Therefore we believe that the Trust’s pathway goes beyond the minimum requirements and accordingly we exclude very low numbers of venous thromboembolism following discharge from the DVT service.” Source location 2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The available investigations did not identify DVT, so it would not have affected pre-operative assessment or the operating team’s decisions.
Verbatim wording from the response “The haematologists do consider it unlikely that the patient did have a proximal DVT as he was untreated and would not appear to have had any further problems up until his surgery 4 months later. As no DVT was identified by the investigations it would not have been relevant to the pre-operative assessment and would not have been relevant to the operating team.” Source location 2017-0333-Response-by-University-Hospitals-Coventry-and-Warwickshire-NHS-Trust
Open published response
19 Aug 2016 George Watson · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 6 Failure to monitor and assess staff working permanent night shifts View source Failure to designate additional staff resources for a specific purpose View source Failure to cooperate with police investigations View source Failure to derive wider organisational learning from investigations View source Failure to have steps for responding when required staff are absent or unavailable View source Failure to ensure patients are discharged with appropriate medication View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
George Watson · 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 Watson fell from his bed at approximately 04:30 on 3 September 2014 after being admitted following a fall, and died on 21 October 2014 from a subdural haemorrhage, skull fracture and compound fracture of his left humerus. The principal concerns included supervision and staffing arrangements, raised bed rails, discharge without necessary oral pain relief and inadequate investigatory processes, including cooperation with police inquiries.
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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor and assess staff working permanent night shifts
Wider context from the report “(3) The ability of UHCW to monitor and assess staff who work on permanent night shifts was raised at the inquest. Evidence was adduced that this issue is being considered at present but it was unclear whether steps have been, or will be taken to address this issue .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to designate additional staff resources for a specific purpose
Wider context from the report “(2) Issues around staffing allocation and resourcing were discussed in detail at the inquest. It remained unclear how, when additional resources recognised as being required, these staff members were ‘labelled’ as being needed for a specific purpose. Furthermore, it was not clear what steps should be taken when the staff member does not attend, or is not available.
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to cooperate with police investigations
Wider context from the report “(4) Although UHCW provided oral evidence regarding some steps that have been taken to improve its investigatory processes, given the significance of the issues that were raised, I believe it is necessary to ask the Trust to confirm these in writing and provide further evidence that it has addressed the issues that arose in the investigation of this case. In particular, the need to cooperate with police investigations was noted to be a learning point for one witness but wider learning for the Trust as a whole was not adduced in evidence.
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to derive wider organisational learning from investigations
Wider context from the report “(4) Although UHCW provided oral evidence regarding some steps that have been taken to improve its investigatory processes, given the significance of the issues that were raised, I believe it is necessary to ask the Trust to confirm these in writing and provide further evidence that it has addressed the issues that arose in the investigation of this case. In particular, the need to cooperate with police investigations was noted to be a learning point for one witness but wider learning for the Trust as a whole was not adduced in evidence .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to have steps for responding when required staff are absent or unavailable
Wider context from the report “(2) Issues around staffing allocation and resourcing were discussed in detail at the inquest. It remained unclear how, when additional resources recognised as being required, these staff members were ‘labelled’ as being needed for a specific purpose. Furthermore, it was not clear what steps should be taken when the staff member does not attend, or is not available .
” 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients are discharged with appropriate medication
Wider context from the report “(1) UHCW acknowledged that Mr Watson’s discharge did not proceed satisfactorily. However, no evidence was provided as to what steps have been taken to address this issue. In particular, it is not clear whether the risk that patients are discharged without appropriate medication has been addressed .
” Open source report
11 Sep 2013 Caroline LEE · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 2 Failure of the laboratory to inform ward staff of abnormal potassium results View source Failure of medical staff to recognise the significance of potassium results 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
Caroline LEE · 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
Caroline LEE died in circumstances recorded in a narrative verdict, which is not provided here. The concerns identified were that medical staff failed to recognise the significance of abnormal potassium results and that laboratory staff failed to inform ward staff about them.
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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the laboratory to inform ward staff of abnormal potassium results
Wider context from the report “(1) failure of the medical staff to recognise the significance of the potassium results
(2) failure of the laboratory to inform the Ward staff of the abnormal potassium 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 Coventry and Warwickshire NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of medical staff to recognise the significance of potassium results
Wider context from the report “(1) failure of the medical staff to recognise the significance of the potassium results
(2) failure of the laboratory to inform the Ward staff of the abnormal potassium results
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations