Concerns raised 2 Unavailability of alternative provision when Speech and Language Therapy assessment is absent View source Unavailability of Speech and Language Therapy assessments for care home residents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Graham Keith HOLLIS · 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
Graham Keith Hollis, who had dementia and increasing frailty, developed swallowing difficulties and experienced coughing and choking episodes while being fed under an agreed modified-diet plan. He was admitted to hospital with aspiration pneumonia and died on 14 August 2025. The principal concern was that staffing shortages prevented a further face-to-face Speech and Language Therapy assessment, resulting in a best-interests decision to feed him at risk without specialist assessment; safeguards relating to his diet and medical review were also not consistently followed.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of alternative provision when Speech and Language Therapy assessment is absent
Wider context from the report “The Speech and Language Therapy team advised the care home that, due to current staffing levels, the service was unable to undertake assessments of care homes residents, and that this issue had been escalated to the Integrated Care Board. This was the position in July 2025, and the evidence confirmed that it remained unchanged at the time of the inquest in June 2026.
In the absence of a SALT face to face assessment and with no alternative provision available , a best interests meeting was convened involving the care home manager, the social worker, the GP Surgery’s care coordinator, and the deceased’s daughter. It was agreed that the deceased would be fed with accepted risk on a Level 5 diet without specialist assessment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Speech and Language Therapy assessments for care home residents
Wider context from the report “The Speech and Language Therapy team advised the care home that, due to current staffing levels, the service was unable to undertake assessments of care homes residents , and that this issue had been escalated to the Integrated Care Board. This was the position in July 2025, and the evidence confirmed that it remained unchanged at the time of the inquest in June 2026 .
In the absence of a SALT face to face assessment and with no alternative provision available, a best interests meeting was convened involving the care home manager, the social worker, the GP Surgery’s care coordinator, and the deceased’s daughter. It was agreed that the deceased would be fed with accepted risk on a Level 5 diet without specialist assessment.
” 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 Deliver community SALT activity using a secured two-day-per-week Band 7 locum therapist.
Verbatim wording from the response “We have however been able to make some very recent progress. Upon recent interview we have secured a Band 7 Locum Speech and Language Therapist to deliver the community based activity. Whilst we had attempted to fill with a full time position, the individual concerned is only available 2 days per week.” Source location Response from University Hospitals of Derby and Burton NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue providing remote community SALT advice to care homes and domiciliary settings by telephone and email.
Verbatim wording from the response “I confirm that University Hospitals of Derby and Burton NHS Foundation Trust (UHDB) are commissioned by the South Staffordshire and Stoke on Trent ICB (SSOT ICB) to provide community SALT services to domiciliary settings and residential care homes in East Staffordshire.” Source location Response from University Hospitals of Derby and Burton NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore appointing a temporary Band 6 practitioner using potentially remaining locum funding to increase community SALT capacity.
Verbatim wording from the response “The team are now exploring if a temporary Band 6 practitioner post can be appointed for the wider SALT team based at Queens Hospital Burton, utilising the potentially remaining 0.6 whole time equivalent Locum funding, to further enhance capacity to deliver the community based activity. This is of course subject to candidates accepting offers of recruitment, but does offer us more positive progress than on previous recruitment drives.” Source location Response from University Hospitals of Derby and Burton NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore alternative community SALT service delivery options with Integrated Care Board support.
Verbatim wording from the response “need to be done in a safe way with a new provider. To achieve this the Trust is exploring alternative service delivery options and is supported by the ICB.” Source location Response from University Hospitals of Derby and Burton NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Face-to-face community SALT assessments cannot currently be provided because staffing and recruitment constraints limit team capacity.
Verbatim wording from the response “The UHDB SALT team has been unable to provide face-to-face assessments since January 2025 due to capacity constraints. As a mitigation, the team has continued to provide advice remotely where requested, including via telephone and email.” Source location Response from University Hospitals of Derby and Burton NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Long-term community SALT delivery should transfer from the acute Trust to a community NHS provider, supported by the ICB.
Verbatim wording from the response “It is the Trust's position that ultimately that community SALT services need to be delivered by community NHS providers rather than an from an acute provider. This remains under active discussion with our Integrated Care Board colleagues. The long-term aim is to draw Trust commissioning of the service to a close, but this will” Source location Response from University Hospitals of Derby and Burton NHS Foundation Trust
Open published response
Concerns raised 2 Failure of bank staff to access patient notes before assessments View source Failure of computer systems to enable different NHS Trusts to access patient notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alix Elizabeth Knowles · 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
Alix Elizabeth Knowles, aged 30, attended hospital on 8 December 2023 after attempting to cut her throat and threatening suicide, but was discharged home after a mental health assessment. In the early hours of 9 December 2023, she jumped from a bridge onto the road below and was hit by two motor vehicles. The substantive concerns were that bank staff could not access patient notes before assessments and that different NHS Trusts could not access one another’s patient notes because of incompatible computer systems.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of bank staff to access patient notes before assessments
Wider context from the report “1. Bank Staff are not able to access patient notes before assessments ;
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of computer systems to enable different NHS Trusts to access patient notes
Wider context from the report “2. Different NHS Trusts are unable to access patient notes , because the computer systems used do not allow this .
” 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 Work with MPFT to arrange Meditech V6 access for current short-term Liaison Psychiatry bank staff who lack it.
Verbatim wording from the response “We are also working together with MPFT to arrange access to Meditech V6 for any of their current short term bank staff in the Liaison Psychiatry team who do not already have access.” Source location Response from University Hospitals of Derby and Burton
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 Reiterate to MPFT the available routes for obtaining emergency Meditech V6 access for bank staff.
Verbatim wording from the response “If it had been communicated to UHDB at the time that the bank staff member from MPFT could not access Meditech V6, Emergency Department staff could have shown the bank staff member themselves, printed a copy out on request, or with sufficient notice, have arranged emergency IT access for them using the same processes we have in place when using agency or bank staff at UHDB. We have re-iterated to MPFT these are options available to them if emergency access is required, and to formalise this, we are in the process of developing a written standard operating procedure for both organisations.” Source location Response from University Hospitals of Derby and Burton
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 a written standard operating procedure with MPFT formalising emergency access arrangements for bank staff.
Verbatim wording from the response “If it had been communicated to UHDB at the time that the bank staff member from MPFT could not access Meditech V6, Emergency Department staff could have shown the bank staff member themselves, printed a copy out on request, or with sufficient notice, have arranged emergency IT access for them using the same processes we have in place when using agency or bank staff at UHDB. We have re-iterated to MPFT these are options available to them if emergency access is required, and to formalise this, we are in the process of developing a written standard operating procedure for both organisations.” Source location Response from University Hospitals of Derby and Burton
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 Bank staff access risk is mitigated by working with an authorised colleague and using established emergency access processes when required.
Verbatim wording from the response “As was confirmed by MPFT in court, their substantive staff in Liaison Psychiatry do have access to Meditech V6 records at UHDB, and they have subsequently confirmed that long-term bank staff also have access to Meditech V6. The issue that arose in this case is that the individual MPFT bank nurse from the Liaison Psychiatry team did not have access to the Meditech V6 records as UHDB had not been notified of the need for access on this occasion and therefore UHDB were not aware of until after Miss Knowles' death. As we heard during the inquest hearing, MPFT explained that they mitigate the risk of bank staff not having access to Meditech V6 by always ensuring that they are on shift with a member of staff who does have access. The bank nurse confirmed in her evidence that the Meditech V6 notes were accessed by a colleague from MPFT Liaison Psychiatry team on the night in question.” Source location Response from University Hospitals of Derby and Burton
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 Cross-organisation record access is addressed where possible through access arrangements and information-sharing protocols, despite wider interoperability limitations.
Verbatim wording from the response “Across the NHS in England there are health and care services using different clinical systems that do not interact with each other, and it is accepted that there is a need for interoperability across the system. This is a national issue whose feasibility is being looked at as part of the long-term plan for the NHS. Given the broader context that applies and the complexities around digital infrastructure and transformation, we are unable to comment any further on this, except to say that we recognise the importance of effective information sharing between organisations. It is for this reason that we arrange access where possible and having sharing protocols in place as described above.” Source location Response from University Hospitals of Derby and Burton
Open published response
Concerns raised 2 Failure of electronic patient records to automatically share renal team entries between hospitals View source Failure of allergy information to automatically cross-populate between records View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Glennis CONNELLY · 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
Glennis CONNELLY died at home on 11 November 2022 from end-stage renal failure due to tubulo-interstitial nephritis caused by tazocin, despite a previously identified allergy to the drug. The principal concerns were that this allergy was not recorded in the hospital records at Queens Hospital Burton upon Trent and that electronic patient records across the same trust did not automatically share allergy information.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of electronic patient records to automatically share renal team entries between hospitals
Wider context from the report “Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records . Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital , "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of allergy information to automatically cross-populate between records
Wider context from the report “Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records. Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital, "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020.
” 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 multidisciplinary allergy working group to ensure robust systems for managing allergies and alerts.
Verbatim wording from the response “4. Setting up an allergy working group” Source location Response from Derby and Burton NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide cross-record patient links between the two electronic patient records and links to the GP Summary Care Record through the Master Patient Index.
Verbatim wording from the response “Pending implementation of a unified system, the Trust has created a Master Patient Index, enabling us to create a patient context link from each EPR to the other, meaning that staff would be able to click a link to be taken to a mobile version of the other EPR/eCasenote systems without needing to log in or search for the patient again. Similarly, access was created to link the GP surgery held Summary Care Record (SCR). Patients have to agree to share their information on SCR in order for the information to be accessible.” Source location Response from Derby and Burton NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the unified electronic patient record across Trust sites, with staged rollout underway and allergy functionality planned for the first phase.
Verbatim wording from the response “Whilst the incident was multifactorial, the unification of the EPR systems is something the Trust is working hard to remedy. As noted, the Trust currently has two enterprise wide systems which include all patient administrative and clinical functionality, appointments, waiting lists, test results, medications, emergency care, maternity and clinical noting.” Source location Response from Derby and Burton NHS
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 Trust cannot extend an existing EPR across all sites because of contractual, technical, support-life and specialist-function constraints.
Verbatim wording from the response “Implementing an entirely new system is not a small undertaking. It is important to get this right for the five hospital sites now and into the future. These EPR systems are not created by the Trust, but rather bought under contracting arrangements with their associated contractual periods, support and shelf life. As was heard at inquest, it has not been possible to extend one of the existing systems to the whole site as they need to function effectively across all specialisms. In the case of one system it is reaching the end of its support life. Any system has to be then integrated into the wider Trust in a safe way, operating alongside our other systems.” Source location Response from Derby and Burton NHS
Open published response
14 Mar 2024 Zachary Victor TAYLOR-SMITH · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Lack of a formal mechanism for assessing the safety of planned inductions against ward and neonatal unit activity and capacity View source Failure to recognise the significance of the first four hours after birth when assessing possible neonatal deterioration View source Lack of an effective system for keeping required reviews live until completion View source Persisting relationship and communication problems between maternity and neonatal staff View source Failure to obtain and use the timing between rupture of membranes and pre-term birth when assessing neonatal infection risk View source See 2 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. 16
Action
Introduce recurring staff communications and safety briefings covering maternity and neonatal learning and risk-assessment messages.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Introduce a telephone consultation record and handover process for outstanding maternity-neonatal reviews.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Introduce Band 7 flow coordinators to prioritise and coordinate acute and planned maternity activity.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Operate daily multidisciplinary safety huddles with documented workload, staffing and capacity review.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Publish and socialise the Culture and Civility workshop outputs and charter.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 March 2024. View source
Action
Review and update guidance on Group B streptococcus, induction, labour care and pre-term labour care.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Implement the NEWTT2 framework for newborn assessment, escalation and review.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Install live whiteboards to record and track outstanding neonatal reviews across clinical areas.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 March 2024. View source
Action
Formalise the neonatal SitRep within the maternity escalation policy and embed neonatal involvement in activity planning.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 March 2024. View source
Action
Implement a midwife-led junior doctor induction session on roles, relationships and supportive teamwork.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Update and maintain the internal maternity and neonatal escalation policy, including induction delay when capacity is reduced.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Launch BadgerNet to calculate rupture-to-birth intervals, flag at-risk babies and support risk-assessment audits.
Stated plannedThe respondent said that this action was planned when they made their response on 21 March 2024. View source
Action
Run the Culture and Civility improvement project and track its action plan through programme governance.
Stated in progressThe respondent said that this action was in progress when they made their response on 21 March 2024. View source
Action
Expand Team of the Shift huddles to include neonatal team members.
Stated plannedThe respondent said that this action was planned when they made their response on 21 March 2024. View source
Action
Amend and implement NEWTT2 guidance to standardise escalation for neonatal respiratory distress.
Stated completedThe respondent said that this action was complete when they made their response on 21 March 2024. View source
Action
Conduct audits of prophylactic antibiotics, holistic risk assessments and prolonged membrane-rupture identification.
Stated plannedThe respondent said that this action was planned when they made their response on 21 March 2024. View source See 13 more actions
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AI-generated summary
Zachary Victor TAYLOR-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
Zachary Taylor-Smith was born preterm after an induced labour and died aged 14 hours at Royal Derby Hospital on 17 November 2022. The inquest found that he contracted an infection and that his death was contributed to by neglect, including failures relating to prophylactic antibiotics, recognition of the duration since rupture of membranes, and treatment of signs of early-onset infection. Concerns included staff understanding of infection indicators, communication between maternity and neonatal teams, systems for ensuring reviews were completed, and the safety of planned inductions given service capacity.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal mechanism for assessing the safety of planned inductions against ward and neonatal unit activity and capacity
Wider context from the report “e. Absence of a formal mechanism for reviewing whether it is safe for planned inductions to take place in the context of ward and neonatal units levels of activity and capacity .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the significance of the first four hours after birth when assessing possible neonatal deterioration
Wider context from the report “a. Staff lacking appreciation and proper understanding of the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system for keeping required reviews live until completion
Wider context from the report “d. Absence of an effective system in place to ensure required reviews remain live until completed .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Persisting relationship and communication problems between maternity and neonatal staff
Wider context from the report “c. The persisting cultural issues affecting the relationships and communication between maternity and neonatal staff . Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and use the timing between rupture of membranes and pre-term birth when assessing neonatal infection risk
Wider context from the report “b. Staff lacking appreciation of the significance of the timing between rupture of membranes in a pre-term birth and birth and therefore failing to note or ask to be furnished with that information to inform their assessment of the risks of infection in babies .
” 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 Introduce recurring staff communications and safety briefings covering maternity and neonatal learning and risk-assessment messages.
Verbatim wording from the response “• Communication” Source location Response from University Hospitals of Derby and Burton
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 Introduce a telephone consultation record and handover process for outstanding maternity-neonatal reviews.
Verbatim wording from the response “• Changes pending BadgerNet introduction” Source location Response from University Hospitals of Derby and Burton
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 Introduce Band 7 flow coordinators to prioritise and coordinate acute and planned maternity activity.
Verbatim wording from the response “Band 7 Flow maternity coordinators commenced March 2024, providing daily prioritisation, flow optimisation and coordination of all acute and planned activity.” Source location Response from University Hospitals of Derby and Burton
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 daily multidisciplinary safety huddles with documented workload, staffing and capacity review.
Verbatim wording from the response “and encourages a shared mental model of the entire team’s workload. Team of the Shift is now to be expanded to the entire MDT including Neonatal team members.
○ Daily safety huddles are carried out at 08:15 with the operational matron, flow co-ordinator and operational ward managers. Staffing and elective work is discussed, the OPEL sitrep is completed, and any potential issues raised. A second huddle takes place at 15:30 to review workload and staffing into the afternoon/evening.
○ A virtual cross-site safety briefing huddle takes place at 11:00 each day. It is mandatory for all professional groups to attend (MDT including neonatology, obstetrics, and anaesthetics). Workload across the maternity service is reviewed - Information and discussions are documented on a huddle proforma.” Source location Response from University Hospitals of Derby and Burton
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish and socialise the Culture and Civility workshop outputs and charter.
Verbatim wording from the response “The Culture & Civility Work Programme hosted two Culture and Civility workshops with places offered to clinical staff in March 2024. The outputs from these workshops included 'what good culture looks like to me' and a good culture and civility charter. These are in the process of being published and socialised to the teams.” Source location Response from University Hospitals of Derby and Burton
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 Review and update guidance on Group B streptococcus, induction, labour care and pre-term labour care.
Verbatim wording from the response “• Guidelines review” Source location Response from University Hospitals of Derby and Burton
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the NEWTT2 framework for newborn assessment, escalation and review.
Verbatim wording from the response “• Implementation of the Newborn Track and Trigger 2 (NEWT T2) framework Immediate Care and Observations of the Newborn – Maternity / Neonatal.” Source location Response from University Hospitals of Derby and Burton
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 Install live whiteboards to record and track outstanding neonatal reviews across clinical areas.
Verbatim wording from the response “• Whiteboard” Source location Response from University Hospitals of Derby and Burton
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 Formalise the neonatal SitRep within the maternity escalation policy and embed neonatal involvement in activity planning.
Verbatim wording from the response “Actions in progress:” Source location Response from University Hospitals of Derby and Burton
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a midwife-led junior doctor induction session on roles, relationships and supportive teamwork.
Verbatim wording from the response “• Junior doctor induction” Source location Response from University Hospitals of Derby and Burton
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and maintain the internal maternity and neonatal escalation policy, including induction delay when capacity is reduced.
Verbatim wording from the response “The internal escalation policy for both maternity and neonatal services has been reviewed and updated to ensure clear process of management of escalation, including delay of induction of labour if capacity is significantly reduced. This policy is reviewed regularly.” Source location Response from University Hospitals of Derby and Burton
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 Launch BadgerNet to calculate rupture-to-birth intervals, flag at-risk babies and support risk-assessment audits.
Verbatim wording from the response “• BadgerNet” Source location Response from University Hospitals of Derby and Burton
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 Run the Culture and Civility improvement project and track its action plan through programme governance.
Verbatim wording from the response “• Culture and civility” Source location Response from University Hospitals of Derby and Burton
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand Team of the Shift huddles to include neonatal team members.
Verbatim wording from the response “• Safety huddles” Source location Response from University Hospitals of Derby and Burton
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 Amend and implement NEWTT2 guidance to standardise escalation for neonatal respiratory distress.
Verbatim wording from the response “Following learning from the Inquest a further amendment to NEWTT2 has been completed (see exert from guidelines below) and was implemented week commencing 15.04.24. This is to ensure consistency of escalation in babies with signs of respiratory distress and further support the recognition of babies at risk. Our amendment to guidance states:” Source location Response from University Hospitals of Derby and Burton
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 Conduct audits of prophylactic antibiotics, holistic risk assessments and prolonged membrane-rupture identification.
Verbatim wording from the response “• Audit” Source location Response from University Hospitals of Derby and Burton
Open published response
9 Jun 2023 Alice Jean FOX · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 6 Delays in obtaining blood results needed to confirm suspected infection View source Lack of protocols ensuring safe and appropriate multi-party discharge arrangements View source Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival View source Lack of close checks and observations for patients in the hospital discharge lounge View source Failure to complete core admission assessments after late-night arrival at the rehabilitation hospital View source Failure to respond appropriately to suspected infection when NEWS scores are low 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.
×
AI-generated summary
Alice Jean FOX · 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
Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining blood results needed to confirm suspected infection
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results . On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of protocols ensuring safe and appropriate multi-party discharge arrangements
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later . There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of close checks and observations for patients in the hospital discharge lounge
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care . She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete core admission assessments after late-night arrival at the rehabilitation hospital
Wider context from the report “1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward-based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments . Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond appropriately to suspected infection when NEWS scores are low
Wider context from the report “2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier.
” Open source report
20 Apr 2023 Jodie Catherine McCann · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 7 Failure to record and share airway plans A, B, and C View source Failure to follow the Mortality Review policy and complete serious incident reviews promptly View source Limited universal use of NAP4 difficult-airway algorithms and checklists View source Failure to robustly check difficult-airway trolley equipment daily and replace broken or misplaced key equipment View source Limited use of comprehensive difficult-airway strategies with structured planning and preparation View source Unavailability of equipment and skills to carry out difficult-airway plans View source Limited progress in implementing the Patient Safety Incident Response Framework View source See 4 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
Jodie Catherine McCann · 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
Jodie Catherine McCann, a 22-year-old woman, developed gallstone pancreatitis, suffered a cardiac arrest, and required critical care and ventilation. After her tracheostomy tube became displaced and could not be replaced, she suffered a prolonged cardiac arrest caused by lack of oxygen and died. Concerns included inadequate planning and preparation for difficult airway management and tracheostomy displacement, equipment and staffing availability, and delays in the serious incident review.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record and share airway plans A, B, and C
Wider context from the report “There is limited evidence to date for the introduction and continuing use of comprehensive airway strategies, with structured planning and preparation, when a difficult airway is anticipated. There should be airway plans A, B, and C recorded, shared , and the equipment and skills to carry them out must be 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the Mortality Review policy and complete serious incident reviews promptly
Wider context from the report “The Mortality Review policy was not followed , leading to a significant delay in completing the serious incident review , delaying Trust learning, and delaying the family’s understanding of the circumstances of Jodie’s death. There is limited evidence of progress in implementing the national Patient Safety Incident Response Framework at 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited universal use of NAP4 difficult-airway algorithms and checklists
Wider context from the report “There is limited evidence to date for the universal use of the NAP4 algorithms and checklists , which should be available on the difficult airway trolley , and be familiar to all ICU nursing and medical staff, and to the wider anaesthetic team
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to robustly check difficult-airway trolley equipment daily and replace broken or misplaced key equipment
Wider context from the report “There is limited evidence to date, for the robust daily checking of all necessary equipment on the difficult airway trolley , to ensure immediate replacement of all key equipment if it is broken or misplaced
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited use of comprehensive difficult-airway strategies with structured planning and preparation
Wider context from the report “There is limited evidence to date for the introduction and continuing use of comprehensive airway strategies, with structured planning and preparation, when a difficult airway is anticipated . There should be airway plans A, B, and C recorded, shared, and the equipment and skills to carry them out must be 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of equipment and skills to carry out difficult-airway plans
Wider context from the report “There is limited evidence to date for the introduction and continuing use of comprehensive airway strategies, with structured planning and preparation, when a difficult airway is anticipated. There should be airway plans A, B, and C recorded, shared, and the equipment and skills to carry them out must be 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited progress in implementing the Patient Safety Incident Response Framework
Wider context from the report “The Mortality Review policy was not followed, leading to a significant delay in completing the serious incident review, delaying Trust learning, and delaying the family’s understanding of the circumstances of Jodie’s death. There is limited evidence of progress in implementing the national Patient Safety Incident Response Framework at the Trust
” Open source report
16 Mar 2023 Rachael Chloe WALKER · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 3 Failure to test the procedure for calling and responding to a major maternal haemorrhage View source Failure to ensure essential equipment is obtained and located View source Failure to ensure timely updating and incorporation of clinical policies and guidance 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
Rachael Chloe WALKER · 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
Rachael Chloe Walker died in hospital on 19 June 2021 after a placental haemorrhage and amniotic fluid embolism at 37 weeks of pregnancy. The report identified missed opportunities involving the recording and implementation of an earlier delivery plan and national guidance. The principal concern was whether the Trust had sufficiently robust processes for updating clinical guidance and ensuring essential equipment and procedures were in place.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to test the procedure for calling and responding to a major maternal haemorrhage
Wider context from the report “My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death.
It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest .
I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure essential equipment is obtained and located
Wider context from the report “My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located , I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death.
It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest.
I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure timely updating and incorporation of clinical policies and guidance
Wider context from the report “My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating , and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death.
It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance . I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance . Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest.
I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the interests of preventing future deaths, and that those processes should ensure timely revisions and associated actions .
” Open source report
18 Oct 2022 Kenneth PERKINS · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Lack of clear, detailed transfer documentation covering medication, medical history and recurrent falls View source Failure to request a transfer document View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kenneth PERKINS · 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
Kenneth Perkins, who had a history of recurrent falls and several co-morbidities, was admitted to Royal Derby Hospital after presenting with left-sided weakness, facial droop and confusion. While confused and lacking capacity, he wandered without assistance despite a risk assessment requiring one carer when mobilising, fell and hit his head, and later died on 11 September 2018 after subarachnoid bleeding could not be treated. The principal concern was the absence of a clear, detailed transfer handover covering his medication, medical history and recurrent falls, and the receiving hospital’s failure to request one, which may have prevented enhanced care and observation being put in place.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear, detailed transfer documentation covering medication, medical history and recurrent falls
Wider context from the report “Mr Perkins was transferred from Ilkeston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls The Royal Derby Hospital did not (but should have) requested a transfer document. That history would have allowed an enhanced level of care and observation to be put in place so as to prevent further falls.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to request a transfer document
Wider context from the report “Mr Perkins was transferred from Ilkeston Community Hospital to the Royal Derby Hospital. There was no clear detailed handover or transfer document which would have detailed his medication, medical history and history of recurrent falls The Royal Derby Hospital did not (but should have) requested a transfer document. That history would have allowed an enhanced level of care and observation to be put in place so as to prevent further falls.
” 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 Use standardized SBAR transfer documentation to communicate patients’ clinical history, needs and risks between care providers.
Verbatim wording from the response “In line with the evidence already submitted to the Court, DCHS staff are required to follow the procedures set out in the Trusts Admission, Discharge and Transfer Policy for DCHS Community Hospitals Policy. The Policy is in place to support well organised, safe and timely admissions, discharges and transfers for all patients. The Policy (attached) also covers emergency transfers such as was the case for Mr Perkins.” Source location Response from University Hospital of Derby and Burton
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 UHDB considers established transfer, admission-assessment and information-sharing processes sufficient to support safe information exchange between care providers.
Verbatim wording from the response “The information from the transferring care provider is taken into consideration by the Trust, but it is not decisive. On admission to the Trust staff should complete further assessments to assess the patient's abilities and needs at that specific time, including mental capacity and falls risk assessment.” Source location Response from University Hospital of Derby and Burton
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 DCHS considers its established Admission, Discharge and Transfer Policy and SBAR process sufficient for safe patient transfers.
Verbatim wording from the response “In line with the evidence already submitted to the Court, DCHS staff are required to follow the procedures set out in the Trusts Admission, Discharge and Transfer Policy for DCHS Community Hospitals Policy. The Policy is in place to support well organised, safe and timely admissions, discharges and transfers for all patients. The Policy (attached) also covers emergency transfers such as was the case for Mr Perkins.” Source location Response from University Hospital of Derby and Burton
Open published response
14 Oct 2020 Mr Edward Cowey · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Failure to ensure doctors are aware of relevant Trust local policies View source Falls form failing to direct doctors to relevant head injury guidance View source Failure to keep patient transfer information on one database View source Head injury treatment policies failing to align with NICE Guidelines View source Anticoagulation guidance failing to cover preventative anticoagulation 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
Mr Edward Cowey · 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 Edward Cowey was admitted to Royal Derby Hospital on 22 January 2020, suffered a fall with a head injury on 23 January, and died on 28 January 2020 from a subdural haematoma, with anticoagulation recorded as a contributing factor. Concerns included fragmented patient information across electronic and paper systems, inconsistent local and national guidance on head injuries, gaps in anticoagulation guidance, and a falls form that did not direct doctors to relevant head-injury guidance.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors are aware of relevant Trust local policies
Wider context from the report “2. Trust local policy regarding treatment for head injuries is not consistent with NICE Guidelines and doctors cannot be expected to be aware of all trust local policies ;
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Falls form failing to direct doctors to relevant head injury guidance
Wider context from the report “4. The Trusts local falls form does not direct doctors to the relevant guidance regarding head injuries simply asks if a CT head scans indicated
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep patient transfer information on one database
Wider context from the report “1. That patient electronic and paper based transfer information is not kept on one database . Mr Coweys’ handover notes were kept on extra Med, his neurological observations on Patient Track and the falls form on his hard copy notes ;
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Head injury treatment policies failing to align with NICE Guidelines
Wider context from the report “2. Trust local policy regarding treatment for head injuries is not consistent with NICE Guidelines and doctors cannot be expected to be aware of all trust local policies;
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Anticoagulation guidance failing to cover preventative anticoagulation
Wider context from the report “3. Anticoagulation guideless do not cover a situation where anticoagulation is being given as a preventative measure as opposed to a treatment ; and
” Open source report
26 Aug 2019 Maureen Veronica Martin · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Failure to maintain best possible visibility from Nurses’ Stations View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maureen Veronica Martin · 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
Maureen Martin was admitted to Queens Hospital with cardiac problems and fell on the ward while attempting to mobilise by herself. She sustained a severe head injury that was not suitable for surgery and died in hospital five days later. A concern was raised that the Nurses’ Station desk was facing the wrong way at the time of her fall, potentially reducing visibility.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain best possible visibility from Nurses’ Stations
Wider context from the report “Her son pointed out that at the time of her fall, the desk for the Nurses’ Station on the ward was facing the wrong way . Possibly this was linked to some temporary decoration works. When Mrs Martin’s son mentioned this, the desk was repositioned appropriately . I would be grateful if you could check that the desks at Nurses’ Stations in Queens Hospital are properly positioned and, if they do temporarily have to be moved, that the best possible visibility is maintained .
” 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 Remove the Ward 5 nursing station desk and provide staff with a mobile desk to improve patient visibility.
Verbatim wording from the response “1. Mrs Martin’s fall on Ward 5 was the subject of an internal investigation which concluded that the nursing station was indeed moved and it was found not to promote visibility of the patients as the nurse, if sat at the station, was facing the incorrect way. The action that arose out of this investigation was to remove the nursing station desk on that Ward and provide the staff with a “desk on wheels” so that this can be wheeled with the staff as they walk around the Bays.” Source location 2019-0220-Response-by-University-Hospitals-of-Derby-and-Burton-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 Review all nursing station desks at Queen’s Hospital Burton to confirm correct positioning and visibility.
Verbatim wording from the response “2. A walkaround review has also been undertaken of all of the nursing stations/desks at Queen’s Hospital Burton to see if they are positioned in the correct places. I would like to assure you that they are all in the correct places and are facing the correct way. Indeed, most of the nursing desks are on wheels to allow nurses to complete their paperwork whilst they are in the Bays caring for patients; this encourages more visibility of the nursing staff and allows more time for the nurses to be with patients.” Source location 2019-0220-Response-by-University-Hospitals-of-Derby-and-Burton-NHS-Trust
Open published response
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
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
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.
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 of Derby and Burton 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 of Derby and Burton 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
4 Feb 2019 Mrs Maureen Brown · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 2 Failure of the electronic transfer system to support recording and transmission of all information necessary for an effective handover View source National transfer policy failing to require all information necessary for an effective handover 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
Mrs Maureen Brown · 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
Mrs Maureen Brown was admitted to the Royal Derby Hospital with an infection and was identified as being at high risk of falls. Information from her daughter about her confusion and previous fall was not included in the electronic handover, and Mrs Brown subsequently fell from her bed and suffered a fatal subdural haemorrhage. The report raised concerns that electronic transfer information can omit relevant information needed for effective handover and that national policy still treats it as the only information necessary for transfer.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the electronic transfer system to support recording and transmission of all information necessary for an effective handover
Wider context from the report “1. Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred . Other relevant information, that is necessary for an effective handover to take place, can be missed as the electronic transfer system limits how much information can be recorded .
2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation National transfer policy failing to require all information necessary for an effective handover
Wider context from the report “1. Evidence emerged during the inquest that the electronic transfer information is the only information that the receiving ward is given before a patient is transferred. Other relevant information, that is necessary for an effective handover to take place, can be missed as the electronic transfer system limits how much information can be recorded.
2. Evidence was heard regarding the steps that the Royal Derby Hospital has made to remedy this issue. However, the national policy still states that the only piece of information necessary for a transfer is the electronic transfer information .
” Open source report
28 Oct 2016 Barbara Turner · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 5 Failure to provide resuscitation equipment and drugs for medical emergencies during transfer View source Failure to provide appropriate vital signs monitoring during transfer to and from the CT scanner View source Failure of resuscitation call-out criteria to identify critically ill unresponsive patients with initially normal vital signs View source Failure to provide appropriately qualified clinical escort during transfer to and from the CT scanner View source Failure to provide equipment and drugs to protect and manage the airway during transfer 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.
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AI-generated summary
Barbara Turner · 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
Barbara Turner, an 81-year-old woman, was admitted for an elective left total knee replacement and was later found unresponsive. She underwent a CT scan and was admitted to intensive care, where she died on 11 May 2015. The report identified concerns about resuscitation-call criteria, failures to recognise and respond to her critical illness, missed vital-sign observations, and the unsafe arrangements for transporting her to and from the CT scanner.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide resuscitation equipment and drugs for medical emergencies during transfer
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA, with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate vital signs monitoring during transfer to and from the CT scanner
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA, with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of resuscitation call-out criteria to identify critically ill unresponsive patients with initially normal vital signs
Wider context from the report “(1) The Trust Policy and Protocol for Resuscitation states at Appendix 3 that the call out criteria for the Adult Resuscitation Team is :
All Cardiac Arrests
All Respiratory arrests
Any Unresponsive patient or visitor with
Heart rate > 150
Heart rate < 40
Respiratory rate >40
Respiratory rate < 8
Systolic BP < 80 mmHg
Oxygen Saturations < 90%
Had these criteria been applied to Mrs Turner then the resuscitation team would not have been called, despite clinicians who gave evidence to the court that she was critically ill.
The court heard evidence that person's suffering an intracerebral event or head injury can be critically ill and in need of resuscitation but have initial normal vital signs parameters.
It may be that in the policy and protocol the parameters for critically ill unresponsive patients are too broad and as a consequence a proportion of critically ill patients will be denied the best possible chance of being treated by a skilled resuscitation team .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriately qualified clinical escort during transfer to and from the CT scanner
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA , with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway.
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide equipment and drugs to protect and manage the airway during transfer
Wider context from the report “(2) The method by which Mrs Turner was conveyed to the CT Scanner and back to the ward was described by the ITU consultant, who gave evidence, as ‘dangerous.’ He stated that at the very least Mrs Turner should have been escorted by an anaesthetist and ODA, with appropriate vital signs monitoring and resuscitation equipment and drugs to deal with any medical emergency en route and equipment and drugs to protect and manage her airway .
” Open source report
12 Nov 2014 Patricia Ann Mellor · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Failure to include warnings about cardiac arrest risks in inhalational anaesthetic product information for patients with LQTS View source Failure to update guidance to require specific examination of the QTc interval in all pre-operative ECGs View source Failure to update pre-operative assessment guidance to require consideration of drug-induced LQTS before omitting a 12 lead ECG View source Failure to include warnings about cardiac arrest risks in product information for other drugs used during inhalational anaesthesia in patients with LQTS View source Failure to update guidance to require 12 lead ECG recording and QTc examination for patients receiving drugs at high or intermediate risk of inducing cardiac arrest in LQTS View source Failure to highlight issues involving antidepressant agents and LQTS in regular agency bulletins 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.
×
AI-generated summary
Patricia Ann Mellor · 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
Patricia Ann Mellor suffered a cardiac arrest during general anaesthesia in 2004, resulting in a hypoxic brain injury and severe disability. She died from aspiration pneumonia on 24 January 2014. The investigation identified acquired Long QT Syndrome associated with a combination of citalopram, nortriptyline and ranitidine, and concerns were raised about the need to identify and manage this risk before anaesthesia.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include warnings about cardiac arrest risks in inhalational anaesthetic product information for patients with LQTS
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update guidance to require specific examination of the QTc interval in all pre-operative ECGs
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update pre-operative assessment guidance to require consideration of drug-induced LQTS before omitting a 12 lead ECG
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to include warnings about cardiac arrest risks in product information for other drugs used during inhalational anaesthesia in patients with LQTS
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to update guidance to require 12 lead ECG recording and QTc examination for patients receiving drugs at high or intermediate risk of inducing cardiac arrest in LQTS
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” 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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight issues involving antidepressant agents and LQTS in regular agency bulletins
Wider context from the report “There were further communications with the MHRA suggesting that;
· The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS
· The product information for other drugs such as 5HT₃ anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia
· The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency
Furthermore, ████████ reported that recommendations be sent to NICE updating guideline CG3 to;
· Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG
· Instruct anaesthetists to specifically examine the QTc interval in all pre-operative ECGs performed for any indication
· To require a 12 lead ECG to be recorded and the QTc to be specifically examined in all patients receiving aged deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS
· ████████ advised that despite the above notifications and recommendations, no action has been taken by these agencies .
” Open source report
Concerns raised 1 Failure to report inappropriate patient-handling incidents 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
Elsie May Treece · 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
Elsie May Treece died in hospital on 2 August 2013 after falls at her care home, including a fall that caused a broken arm and an inoperable brain bleed. Concerns included an alleged incident during her hospital care that may not have been reported and the absence of a CT scan after her earlier hospital attendance.
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 of Derby and Burton NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report inappropriate patient-handling incidents
Wider context from the report “(1) I received information from the family that on the afternoon of the 26 July 2013, following difficulties in moving Mrs Treece, for a while hospital staff left one of Mrs Treece’s daughters (aged 70) supporting her mother. One of them then returned with a blue lifting bag with handles but she was not properly supported and fell back heavily on the bed with some force. Investigation has been carried out by ████████ the Ward 6 manager and I received a report which indicates there is no record of any such incident either in paper records, electronic records or from speaking to staff on duty . I did not investigate this incident fully because on balance it is unlikely to have been significant so far as the death is concerned. However the view I took on the evidence I did hear was that there had been an incident which should have been reported and may well not have been . I therefore write to you to enquire if staff need to be reminded or may need further training regarding the requirement to report inappropriate incidents even if no major harm seems to come to the patient involved .
(2) While writing to you perhaps you could also find out for me the reasons why Mrs Treece did not have a CT scan of her head following the attendance on the 18 July 2013. This is not strictly a matter for this formal report but an answer would be appreciated.
” 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 Link with the University to raise student nurses’ awareness of incident reporting and feedback mechanisms.
Verbatim wording from the response “More recently, we have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting and the feedback mechanisms which occur.” Source location 2013-0376-Response-by-Burton-Hospitals-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional incident-reporting training and support for Ward 6.
Verbatim wording from the response “Currently training is provided at Trust induction days, mandatory update training days, online training and ad hoc sessions in ward and department areas and provided for medical staff in different forum. Ad hoc training is provided as requested, and in light of this request for information from HM Coroner, we have arranged to provide additional training and support for Ward 6.” Source location 2013-0376-Response-by-Burton-Hospitals-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement paper-based documentation and incident reporting, with subsequent manual entry into the electronic system during HISS downtime.
Verbatim wording from the response “Whilst it has been acknowledged that there was a period of downtime for the HISS computer system which occurred during the time of Mrs Treece’s admission, contingency plans were put in place which instigated the use of paper based documentation, and including paper based incident forms. Those paper incident forms received during and following the downtime were manually entered into the electronic system.” Source location 2013-0376-Response-by-Burton-Hospitals-NHS
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Request correction
Addressed to Burton Hospitals NHS Foundation Trust, now represented here by University Hospitals of Derby and Burton NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations