1 Apr 2026 Benjamin Daniel Rowley · Prevention of Future Deaths report Greater Lincolnshire
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Concerns raised 1 Failure of the permanent bond between CVC venous ports and silicone rubber tubing View source
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AI-generated summary
Benjamin Daniel Rowley · 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
On 7 November 2025, Benjamin Daniel Rowley attended dialysis when a connector on his central venous catheter disconnected, causing blood loss. He was taken to hospital, where his death was later confirmed; the stated clinical cause included haemorrhage from the catheter port. The investigation raised concerns about mechanical failure of the catheter and a possible wider vulnerability affecting this brand or dialysis lines.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the permanent bond between CVC venous ports and silicone rubber tubing
Wider context from the report ““The CVC consists of a number of parts that are assembled during the manufacturing process. The two ports consist of a brown and a blue plastic Luer Lock connector permanently bonded to silicone rubber tubes that enter the ‘Y’ shaped connector. A white plastic sleeve is present at the point the ports enter the rubber tubing. These ports are not intended to ever be removed or detached from the silicone rubber tubes. The integrity of the permanent bond between the ports and the tubing is essential for the safety of the CVC.
[Mr Rowley] died due to exsanguination caused by a mechanical failure of the CVC. The direct cause was failure of the bond between the venous port of the CVC and the tubing, allowing the port to detach thereby causing blood returning from the machine to the patient to be expelled.”
In relation to the later incident of 11 December 2025, the relevant section of the preliminary report states:
“The nature of the failure of this CVC appears to be identical to that of Mr Rowley, namely detachment of one port of the CVC from the silicone rubber tube.
The direct cause was failure of the bond between the venous port of the CVC and the tubing, allowing the port to detach thereby causing blood returning from the machine to the patient to be expelled. The nature of the failure appears identical...”
The report concludes that:
“I am concerned that these events could represent a more widespread vulnerability of this brand or of dialysis lines and recommend reporting these events to the Medicines and Healthcare products Regulatory Agency (MHRA).”
I endorse those concerns.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update patient information materials with actions to take if catheter integrity is compromised.
Verbatim wording from the response “As part of the Trust’s ongoing response and learning from this incident, the following actions have been agreed:” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a formal risk assessment of haemodialysis catheter recurrence risk and controls.
Verbatim wording from the response “A formal risk assessment has since been completed by the UHL renal service. This concluded that:” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide home haemodialysis patients using catheters with guidance on luer-end integrity checks and escalation procedures.
Verbatim wording from the response “Following the incidents, DaVita issued a national safety bulletin across all of its UK dialysis units. Within UHL, the incident and associated learning were shared with all dialysis nursing teams, and staff were instructed to undertake mandatory checking of the luer connection during every dialysis session. The incident and actions taken were also discussed at the Midlands Lead Dialysis Nurses Forum. In addition, education and guidance regarding luer-end integrity checks and escalation procedures were provided to home haemodialysis patients using dialysis catheters.” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update dialysis access care plans to document luer-end checks and catheter details.
Verbatim wording from the response “As part of the Trust’s ongoing response and learning from this incident, the following actions have been agreed:” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require dialysis staff to check the catheter luer connection during every dialysis session.
Verbatim wording from the response “Following the incidents, DaVita issued a national safety bulletin across all of its UK dialysis units. Within UHL, the incident and associated learning were shared with all dialysis nursing teams, and staff were instructed to undertake mandatory checking of the luer connection during every dialysis session. The incident and actions taken were also discussed at the Midlands Lead Dialysis Nurses Forum. In addition, education and guidance regarding luer-end integrity checks and escalation procedures were provided to home haemodialysis patients using dialysis catheters.” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The likelihood of recurrence is low, and there is no evidence of widespread haemodialysis catheter device failure locally or nationally.
Verbatim wording from the response “• The likelihood of recurrence is low;” Source location Response from University Hospitals of Leicester NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continued use of current haemodialysis catheters with enhanced surveillance is considered safer and clinically appropriate than routine elective replacement.
Verbatim wording from the response “• Routine elective replacement of long-term haemodialysis catheters would introduce greater patient risk, including procedural complications, venous stenosis, and potential loss of vascular access, when compared with continued use supported by enhanced surveillance and monitoring arrangements.” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
Concerns raised 2 Failure of doctors to obtain all relevant patient information before prescribing warfarin View source Failure to communicate all relevant patient information to doctors dosing warfarin 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
John Kenneth PARRY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Parry, aged 72, was admitted to Leicester Royal Infirmary on 4 July 2023 after feeling unwell and later suffered two unwitnessed falls. He died on 7 July 2023 after a spontaneous intracerebral bleed was diagnosed. The inquest raised concerns that neurological observations after the falls were not carried out in accordance with hospital policy, the calculations were inaccurate, and a CT head scan that should have occurred within one hour was not performed. A separate concern concerned communication and information-sharing when prescribing warfarin.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of doctors to obtain all relevant patient information before prescribing warfarin
Wider context from the report “The evidence heard raised a concern about the safe prescribing of warfarin. When a doctor is asked by a nurse to dose the warfarin, the accepted practice is that the doctor relies on the nurse to give all relevant information and the doctor only checks the INR blood results from the laboratory . There is no requirement or expectation that the doctor looks at the patient’s medical records or seeks information about the patient . At the inquest evidence was heard that the nurse had not communicated all relevant information. Although in this case it did not have an adverse outcome, it was accepted that there was a risk that if a doctor does not have all relevant information, warfarin could be prescribed and administered and there could be a risk of death . Evidence was given that this lack of appropriate communication was believed to be unusual but it was accepted that it is not necessarily known how unusual because it would probably only become apparent in cases of an adverse outcome.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate all relevant patient information to doctors dosing warfarin
Wider context from the report “The evidence heard raised a concern about the safe prescribing of warfarin. When a doctor is asked by a nurse to dose the warfarin, the accepted practice is that the doctor relies on the nurse to give all relevant information and the doctor only checks the INR blood results from the laboratory. There is no requirement or expectation that the doctor looks at the patient’s medical records or seeks information about the patient. At the inquest evidence was heard that the nurse had not communicated all relevant information . Although in this case it did not have an adverse outcome, it was accepted that there was a risk that if a doctor does not have all relevant information, warfarin could be prescribed and administered and there could be a risk of death . Evidence was given that this lack of appropriate communication was believed to be unusual but it was accepted that it is not necessarily known how unusual because it would probably only become apparent in cases of an adverse outcome.
” 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 Re-emphasised clear anticoagulation communication, shared case learning with clinical leaders and forums, and delivered repeated daily-brief reminders to clinical teams.
Verbatim wording from the response “Following on from the issues raised in your Regulation 28 Report we have re-emphasised the importance of clear and effective communication between all colleagues in particular regarding anticoagulation. This includes sharing learning from this case with all ward leaders, matrons and through our chief nurse forums. A reminder to all clinical teams via the daily brief of the importance of giving clear information was included in the week commencing 29/07/24 and was repeated in the week commencing 05/08/24. The daily brief has three key messages and is read out to all clinical teams at every huddle every day for a week.” Source location Response from University Hospitals Leicester
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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 Incorporate warfarin prescribing into the digital system to provide clinicians with more patient information.
Verbatim wording from the response “We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-in to another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system.” Source location Response from University Hospitals Leicester
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 Continue developing the electronic patient record to make patients’ available clinical information accessible in one system.
Verbatim wording from the response “We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-in to another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system.” Source location Response from University Hospitals Leicester
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
Verbatim wording from the response “To help improve communication further, we will embed a digital reminder for all MDT colleagues to include pertinent clinical information or any changes to the patient’s condition when generating a digital warfarin dosage request for the patient. Due to a need to ensure appropriate testing and governance, these changes will take time to fully implement across the whole of UHL, but we anticipate this will occur by December 2025. Our eHospital team, which is chaired by our Medical Director will oversee these changes.” Source location Response from University Hospitals Leicester
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 Deploy electronic clinical notation in the emergency department.
Verbatim wording from the response “We are also developing our electronic patient record system to enable clinicians to review all available information about a patient on one system. Earlier this year we successfully deployed electronic clinical notation in our emergency department and aim to roll this across our inpatient areas pending additional developments of the system with the vendor. In addition, we have now incorporated warfarin prescribing into our digital system allowing clinicians access to more information about the patient without having to log-in to another system. As we further roll out electronic notation, clinicians will increasingly be able to access more information about the patient in one system.” Source location Response from University Hospitals Leicester
Open published response
Concerns raised 1 Insufficient medical practitioner cover for assessing patients' care needs 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
Patricia Ann WALTON · 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 Walton fell while visiting her granddaughter on Christmas Day 2022 and was later admitted to hospital with a fractured right ankle and shoulder injury. She subsequently received warfarin and dalteparin without a clear review or stopping plan; the dalteparin was not stopped when her INR rose above 2, and she later developed a haemorrhage, pneumonia and deteriorating health before dying on 9 January 2023. The principal concern was insufficient medical cover to assess patients’ ongoing care needs over the New Year Bank Holiday period.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient medical practitioner cover for assessing patients' care needs
Wider context from the report “The evidence at the inquest that no medical practitioner saw this lady from the 30 December 2022 to the 03 January 2023, over the New Year Bank Holiday period. My concerns are that whilst there might be a doctor available on call to treat emergencies that occur, there is insufficient cover to assess the subtleties of care required by patients , the absence of which may be as detrimental to the patient as not having emergency cover.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the potential for increasing medical staffing across all sites during weekends and bank holidays.
Verbatim wording from the response “We have reviewed the potential for increasing our medical workforce across all our sites during bank holidays and weekends. However, as is the case for other NHS trusts, there are considerable workforce challenges that limit us in our ability to maintain a consistent number of inpatient medical staff 7 days a week, 365 days a year. These challenges become particularly acute during public holidays when our staffing levels reflect the social cultural context of UK society taking holidays, especially during the winter holiday period.” Source location Response from University Hospital of Leicester
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase site medical staffing, including weekend and bank-holiday consultant, registrar and junior-doctor coverage.
Verbatim wording from the response “In relation to the preventing future deaths action regarding medical staffing. We have already increased medical staffing at the site where the incident occurred. During bank holiday and weekend periods, we are rostering for a medical consultant to be present 9am to 5pm onsite, the consultant is supported by a medical registrar onsite 24hr/7days a week and by a junior doctor onsite 24hrs/7days a week.” Source location Response from University Hospital of Leicester
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bank holiday staffing did not impact the patient’s care, and clinical deterioration did not require earlier escalation.
Verbatim wording from the response “Whilst Patricia was an inpatient over a bank holiday weekend, we are confident this did not impact on her care. Irrespective of the time of year, based on the clinical deterioration triggers there was no cause to raise clinical concerns sooner during her admission. If Patricia’s clinical condition had worsened earlier, our escalation policies” Source location Response from University Hospital of Leicester
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing escalation policies would ensure clinical review regardless of bank holiday staffing levels.
Verbatim wording from the response “Whilst Patricia was an inpatient over a bank holiday weekend, we are confident this did not impact on her care. Irrespective of the time of year, based on the clinical deterioration triggers there was no cause to raise clinical concerns sooner during her admission. If Patricia’s clinical condition had worsened earlier, our escalation policies” Source location Response from University Hospital of Leicester
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Workforce shortages and disruption to elective services constrain consistently increasing inpatient medical staffing during weekends and bank holidays.
Verbatim wording from the response “We have reviewed the potential for increasing our medical workforce across all our sites during bank holidays and weekends. However, as is the case for other NHS trusts, there are considerable workforce challenges that limit us in our ability to maintain a consistent number of inpatient medical staff 7 days a week, 365 days a year. These challenges become particularly acute during public holidays when our staffing levels reflect the social cultural context of UK society taking holidays, especially during the winter holiday period.” Source location Response from University Hospital of Leicester
Open published response
Concerns raised 4 Lack of standard patient discharge information materials View source Failure of local policy to reflect NICE guidelines in full View source Failure to communicate AES discharge instructions and correct use View source Failure to provide AES View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Dorothy Joan Strickley · 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
Dorothy Joan Strickley underwent emergency surgery for appendicitis on 10 June 2018 and was discharged without the anti-embolic stockings prescribed to her or information about continuing to wear them and seeking urgent medical attention. She became short of breath at home and died 19 days after surgery from a massive pulmonary embolism; concerns included failures to provide the stockings, communicate their use, and ensure discharge documentation and local policy reflected relevant guidance.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of standard patient discharge information materials
Wider context from the report “A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent.
Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information .
There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use.
Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool.
The current local policy does not reflect NICE guidelines in full.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of local policy to reflect NICE guidelines in full
Wider context from the report “A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent.
Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information.
There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use.
Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool.
The current local policy does not reflect NICE guidelines in full .
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate AES discharge instructions and correct use
Wider context from the report “A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level . She died from the very complication that the stockings would have helped to prevent.
Various ways of communicating this to the patient were not utilized , such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information.
There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use .
Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool.
The current local policy does not reflect NICE guidelines in full.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide AES
Wider context from the report “A basic and routine prescription for AES was not successfully brought to the patient’s attention at the time of discharge and Mrs Strickley was unaware of the need to continue to wear stockings until she returned to her usual daily activity level. She died from the very complication that the stockings would have helped to prevent.
Various ways of communicating this to the patient were not utilized, such as the hospital discharge letter. There appeared from the evidence to be no standard literature or pamphlet providing patient discharge information.
There was a failure of both nursing and surgical teams to ensure AES were provided and the patient and/or her family were advised of the correct use.
Further training may therefore be considered necessary, together with a review of the documentation such as the nursing discharge tool.
The current local policy does not reflect NICE guidelines in full.
” Open source report
Concerns raised 4 Failure to routinely involve carers and families in the care of mentally unwell patients View source Lack of self-harm training for frontline staff encountering patients with self-inflicted injuries View source Lack of remote access to medical records for on-call psychiatry clinicians View source Failure to monitor the outcomes of amended induction processes View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Charles Hazlewood · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely involve carers and families in the care of mentally unwell patients
Wider context from the report “2. Mr Hazlewood’s partner was repeatedly expressed to be his main or only protective factor from self-harm. She was not approached for information regarding his overdose, or her concerns regarding his escalating behavior and this missed an opportunity for the fuller picture to be captured when considering care planning and mental health assessment. This is an issue that I have raised with the Leicester Partnership Trust before in the matter of ████████ and it appears that carers/families are still not being routinely involved in the care of mentally unwell patients . This can create intolerable pressures upon families and leads to poor outcomes such as in these 2 cases. LPT are urged to consider how this matter can be embedded in training and practice.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of self-harm training for frontline staff encountering patients with self-inflicted injuries
Wider context from the report “4. University Hospitals of Leicester staff, both Dr and nurse gave evidence to the Court that they had not received any training in self harm , notwithstanding they were both highly likely to encounter patients attending with self-inflicted injuries regularly in both the Emergency Department and in the Acute Medical Admissions unit. With self-harm statistics sad soaring, this is an increasing matter of concern. It is not appropriate to rely on “buying in” psychiatric services and leaving front line staff treating patients with no basic knowledge of this complex area and potential triggers . Training would empower the staff and is likely to assist them both in caring for the patients but also the carers/families who may need advice and support. NICE guidelines CG16 is clear that training should be provided to all staff who may encounter such patients and UHL should therefore reconsider this matter.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of remote access to medical records for on-call psychiatry clinicians
Wider context from the report “1. The court heard that the on call Dr for psychiatry did not have remote access to Mr Hazlewood’s medical records and this prevented her from being informed of his significant psychiatric history , and furthermore prevented her from writing a note of her discussions regarding his request to self-discharge. Therefore the knowledge that he had presented again via ED with a serious overdose was not available to his Consultant so an opportunity was missed to escalate his care. Many of the on call team do have remote access and the Leicester Partnership Trust are asked to consider this issue for all relevant clinicians in order to avoid future difficulties of communication.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor the outcomes of amended induction processes
Wider context from the report “3. The court was assured that the induction process had been changed to improve knowledge regarding on call procedures and availability of medical record access. No information was available, via audit, of whether this amended process is successful . LPT should ensure that the outcomes of their welcome changes are being effectively monitored to ensure clinicians have appropriate training and understanding given the frequent rotations of staff and the importance of the on call system being robust and reliable.
” 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 Present a paper recommending stronger, more robust safeguarding training for staff caring for people who self-harm.
Verbatim wording from the response “As you would expect we keep our safeguarding training under regular review and our Head of Safeguarding, ████████, will be presenting a paper to the Safeguarding Assurance Committee on the 15th August 2018 which will recommend strengthening and making more robust our training for all staff who care for people who self-harm. As well as we need to involve an external organisation in the development of this training it is anticipated that this will take approximately 6 months to put in place. In the meantime, and as a result of this inquest, our Head of Safeguarding is to ensure that all UHL staff receive a communication to remind them of the escalation process that they can use if they have any concerns about a patient who they feel is at risk of self-harm. We are working with LPT on this communication and we expect this to be sent out before the 15th August 2018.” Source location 2018-0189-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
Concerns raised 6 Failure of screening committee oversight to ensure referrals are received and actioned View source Failure to direct screening referrals to the vascular screening team View source Uncertainty within general practice about the screening programme and referral criteria View source Absence of a system to direct screening requests to the correct department View source Failure by radiology to appropriately process screening referrals View source Failure to take further action when screening requests are refused View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael John Halfpenny · 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
Michael John Halfpenny requested screening for an aortic aneurysm in March 2016 because of a strong family history, but the referral was sent to the wrong department, rejected, and not followed up. He later presented with severe abdominal pain on 9 December 2016, but diagnosis was delayed until he was peri-arrest; he died following emergency surgery for a ruptured abdominal aortic aneurysm. Concerns included inadequate referral and follow-up processes, uncertainty about the screening programme, and failures to ensure screening requests reached the correct team.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of screening committee oversight to ensure referrals are received and actioned
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned .
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to direct screening referrals to the vascular screening team
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty within general practice about the screening programme and referral criteria
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a system to direct screening requests to the correct department
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by radiology to appropriately process screening referrals
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to take further action when screening requests are refused
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 Inform GPs through the monthly newsletter about referral procedures for the Screening Programme.
Verbatim wording from the response “In addition to the above our Head of GP Services has sent out a new communication to GPs in our monthly GP newsletter to explicitly inform them of how to refer in to the Screening Programme.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Maintain the UHL Screening Committee to oversee screening referrals, rejected cases and related incidents.
Verbatim wording from the response “3. With respect to the UHL Screening Committee, this group was established in January 2017 to provide oversight and governance to the increasing number of national screening programmes now in place. This committee was therefore not in place at the point that the request from the GP regarding Mr Halfpenny was made to the Trust. A key function of this Committee is to review the process of referrals, the validity of rejected cases (i.e. those that fall outside the scope of the screening programme) and of course, any incidents reported relating to screening programmes. This committee will augment the rigorous quality assurance element already required for screening programmes which is monitored by the Regional Screening Group.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Deliver rolling Vascular Service awareness sessions for GPs through Protected Learning Time events.
Verbatim wording from the response “The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Strengthen and update the imaging-referral rejection guideline with mandatory rejection reasons and CRIS documentation of referral letters.
Verbatim wording from the response “1. We have reviewed the process for rejecting imaging within the Trust. The guideline ‘Process for the Rejection of Imaging Referrals’ is being strengthened and updated and will now include an explicit requirement that rejected referrals need to have a clear statement of why the rejection has been made and a comment must be put on CRIS (the Radiology IT system) that a rejection letter has been sent to the referrer. This is being led by our Service Manager for Imaging and it is anticipated that this guideline will be available by the end of July 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Operate a system for redirecting incorrectly assigned imaging referrals and notifying referrers of the action and any required follow-up.
Verbatim wording from the response “2. We have implemented a new system for redirecting any imaging referrals that inadvertently get sent to the incorrect team. The Imaging Team, led by the Clinical Director for Imaging, has provided clear instructions to their administration and clerical staff to forward screening requests to the relevant service. A rejection letter will be sent to the referrer detailing the action that has been taken and any further actions required by them.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-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 Add AAA patient referral pathways to the PRISM referral-guidance system in collaboration with Primary Care colleagues.
Verbatim wording from the response “The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
Concerns raised 1 Failure to ensure accurate and complete discharge information is communicated to primary care teams View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Mary Dempsie · 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
Margaret Mary Dempsie, who had advanced dementia and frailty, was admitted to hospital for treatment of infected leg ulcers, later deteriorated with sepsis, and died two days after discharge for end-of-life care. The discharge letter contained inaccurate and incomplete clinical information, including an incorrect reference to aspiration pneumonia and omission of pyelonephritis, raising concerns that vulnerable patients could receive inappropriate care based on incorrect discharge 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate and complete discharge information is communicated to primary care teams
Wider context from the report “The discharge letter from the University Hospitals of Leicester NHS Trust addressed to the primary care team contained inaccuracies . It stated that Mrs Dempsie had been suffering from aspiration pneumonia when no pneumonia had been identified and did not mention pyelonephritis, which had been present. The Consultant who was looking after Mrs Dempsie was not surprised and admitted in the inquest that the Discharge Letters for patients were being completed with mistakes by the Junior Doctors , that this was something that happens and that GP's regularly have to phone the hospital to ascertain the correct facts . He said that sometimes the junior doctors who complete the discharge letters have never seen the patient. This situation was also confirmed by the General Practitioner who was also present at the inquest. I have concerns that the wrong information is being passed on to primary carers who are then, of course, obliged to act upon the information they are furnished with in the Discharge Letter and that this could lead to serious mistakes being made in the care of vulnerable patients newly discharged from hospital.
” 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 Increase the frequency of discharge-letter audits for each monthly QMG cycle.
Verbatim wording from the response “1. The frequency of internal audits for discharge letters will be increased for each QMG every month with immediate effect and our Head of Outcomes and Effectiveness will lead on this.” Source location 2016-0374-Response-by-University-of-Leicester-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 Strengthen the Letters Policy to clarify discharge-letter procedures and senior medical oversight.
Verbatim wording from the response “5. Our Head of Outcomes and Effectiveness will strengthen our “Letters Policy” to ensure that there is clarity concerning the process for discharge letters and the importance of senior medical oversight. This should go to the Policy and Guideline Committee Meeting in January 2017.” Source location 2016-0374-Response-by-University-of-Leicester-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 Discuss the case with the consultant involved to encourage reflective learning.
Verbatim wording from the response “4. Our Medical Director will ensure that this case is discussed with the Consultant involved before the end of December 2016 to encourage reflective learning. ████████ has met with the junior doctor who wrote the discharge” Source location 2016-0374-Response-by-University-of-Leicester-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 Use a standardised discharge-letter template covering admission reasons and discharge diagnoses.
Verbatim wording from the response “Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.” Source location 2016-0374-Response-by-University-of-Leicester-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 Extend GP feedback collection, review findings, discuss necessary actions, report to the Executive Quality Board, and repeat the audit at intervals.
Verbatim wording from the response “2. Our Chief Medical Information Officer and Head of Services for GP’s will encourage GP’s to provide individualised and patient specific feedback concerning poor discharge letters throughout December 2016 to assess the level of inaccuracies and perception of poor Discharge letters. Our Chief Medical Information Officer will then review any feedback and discuss necessary actions with the doctors involved and the GP dependant upon the findings. He will report on this matter to the Executive Quality Board in March 2017. Our Head of Services for GP’s will promote the opportunities to feedback errors on discharge letters directly to her in the December GP Newsletter. This extended audit will then be repeated at regular intervals, depending on the findings.” Source location 2016-0374-Response-by-University-of-Leicester-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 Provide junior doctors with e-learning reinforcing accurate information in discharge letters to GPs.
Verbatim wording from the response “Whilst we strive to ensure that all discharge letters contain all relevant and accurate information, we recognise that we do not get this right on every occasion. To minimise the risk of inaccurate information being provided to GP’s, the Trust has developed a standardised template for discharge letters which detail the reason for admission and main diagnosis at discharge. Additionally the Trust provides an e-learning package for junior doctors to reinforce the importance of providing accurate information to GP’s.” Source location 2016-0374-Response-by-University-of-Leicester-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 Request GP feedback and conduct regular audits of discharge-letter information quality.
Verbatim wording from the response “In addition, the Trust has for some time requested individualised feedback from GP’s regarding any poor or inaccurate information received from the Trust and undertakes regular audits to provide assurance on the quality of the information provided in Discharge Letters. These audits show an improvement in the quality of the information that we provide to GP’s.” Source location 2016-0374-Response-by-University-of-Leicester-NHS-Trust
Open published response
Concerns raised 3 Failure of nursing staff to follow post-operative instructions View source Failure to report post-operative observations to medical staff when EWS is rising View source Lack of clarity in communication between the Intervention Radiology team and nursing staff about observations to be carried out View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alan Tear · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alan Tear was receiving palliative treatment for cholangiocarcinoma and died after a biliary drain insertion. He died from an intraperitoneal bleed caused by a misplaced drain and peritoneal perforation. Concerns included missed post-operative observations, failure to report a rising EWS to medical staff, and unclear communication between the interventional radiology and nursing teams.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing staff to follow post-operative instructions
Wider context from the report “1. Post-operative instructions were not followed by the nursing staff.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report post-operative observations to medical staff when EWS is rising
Wider context from the report “2. Post-operative observations were not reported to medical staff as required when the EWS was rising.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity in communication between the Intervention Radiology team and nursing staff about observations to be carried out
Wider context from the report “3. It was not clear that the Intervention Radiology team knew or understood what observations the nursing staff would carry out and the communication between the teams needs to be reconsidered .
” 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 Provide continuous teaching for Clinical Management Group staff on interventional radiology procedures, complications, observation frequencies, complication recognition and escalation.
Verbatim wording from the response “Additionally, as part of our wider learning, our Clinical Director for the Clinical Management Group (CMG) will, along with the Medical Lead for Imaging ensure that there is a continuous teaching session for CMG staff on the issue of Interventional Radiology for Surgical patients; describing the technique, complications, frequency of observation for each different procedure, identification of complications and escalation. This will have occurred before the end of December 2015.” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Rewrite the EWS training package to clarify actions when scores are unreliable or require escalation, incorporating learning from the case.
Verbatim wording from the response “However we remain committed to improving our on-going education at the Trust on the EWS scoring tool. Our Interim Deputy Medical Director and Assistant Chief Nurse are currently rewriting the EWS training package and will use what occurred in this case to ensure that clinical staff are given clarity on the actions that they must take when there is either doubt as to the reliability of any particular EWS score or the EWS score is considered to require escalation. This work is due to be completed by the end of March 2016.” Source location Response from University Hospitals of Leicester 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 Redesign the observation-frequency handover sheet by procedure type and require signatures from interventional radiology and receiving-ward nurses at the radiology theatre.
Verbatim wording from the response “As a result of this inquest we will be redesigning the sheet which documents the required frequency of observations to be undertaken on the receiving ward. The sheet and required frequency will vary according to the type of the procedure performed. To optimise the hand over the sheet will be signed by the Interventional radiology nurse and receiving ward at the radiology theatre. Our Medical Lead for Imaging, in consultation with surgical colleagues, will have completed this work by the end of December 2015.” Source location Response from University Hospitals of Leicester 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 Meet ward nursing staff to discuss the incident and reinforce checking required observation frequencies on handover sheets.
Verbatim wording from the response “As an immediate action after the inquest the matron met with all nursing staff on the ward to discuss what had occurred in this case. In particular ward staff” Source location Response from University Hospitals of Leicester 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 Audit compliance with nursing instructions after radiology procedures, repeat the audit according to findings, and report results to the Clinical Management Group Board.
Verbatim wording from the response “Furthermore our Head of Nursing for the CMG will ensure that there is an audit undertaken to monitor the compliance with nursing instructions following radiology procedures. This audit will have been completed by the end of November 2015 and repeated thereafter according to its findings. The findings will be reported to the CMG Board.” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
Concerns raised 4 Delays in patient care allowing further deterioration and loss of treatment options View source Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability View source Failure to arrange immediate emergency ambulance transfer for potential stroke symptoms View source Failure to escalate stroke-patient collection requests to a medical emergency response View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
George Boulton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in patient care allowing further deterioration and loss of treatment options
Wider context from the report “4. This culmination of events in this particular case allowed for the unexpected intervention of the District Nurse; while this is very case specific, similar delays in another patient's care may allow further deterioration and the loss of treatment options .
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability
Wider context from the report “2. The bed bureau did not appear from the evidence available in court to have a system for identifying calls that should have been re-routed to an emergency admission , and not be dependent on a bed , as early scanning was essential for proper diagnosis.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange immediate emergency ambulance transfer for potential stroke symptoms
Wider context from the report “1. It was recognised by all witnesses to the inquest that response to potential stroke symptoms should be on an emergency basis , in accordance with "FAST" criteria ie a timely response. The GP attempted to arrange admission but accepted delays via bed bureau rather than convert to a 999 call and obtain immediate ambulance transfer .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate stroke-patient collection requests to a medical emergency response
Wider context from the report “3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time , rather than the actual allocated 2 hour response time .
” Open source report
Concerns raised 5 Failure to apply the NICE guidance that diazepam was not recommended View source Failure to identify and pursue appropriate quick-acting medication alternatives for rapid tranquilisation View source Failure to recognise the dangers of prolonged prone restraint View source Failure to ensure priority access to limited supplies of Lorazepam View source Lack of staff awareness and training in the application of the restraint policy View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Rafal Delezuch · 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
Rafal Delezuch was seen behaving bizarrely and showing paranoia in Leicester before being restrained by police under section 136 of the Mental Health Act and taken to hospital. The inquest concluded that he died from amphetamine-induced delirium in association with prolonged struggle. Concerns included staff awareness and training on restraint, lack of familiarity with the dangers of prolonged prone restraint, difficulties obtaining and selecting medication for rapid tranquillisation, and an overlooked warning about diazepam in NICE 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply the NICE guidance that diazepam was not recommended
Wider context from the report “(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy.
(2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position
(3) When it was decided that the patient was in need of rapid tranquilisation then:
a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications
b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated.
(4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and pursue appropriate quick-acting medication alternatives for rapid tranquilisation
Wider context from the report “(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy.
(2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position
(3) When it was decided that the patient was in need of rapid tranquilisation then:
a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications
b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued . The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated.
(4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the dangers of prolonged prone restraint
Wider context from the report “(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy.
(2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position
(3) When it was decided that the patient was in need of rapid tranquilisation then:
a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications
b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated.
(4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure priority access to limited supplies of Lorazepam
Wider context from the report “(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy.
(2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position
(3) When it was decided that the patient was in need of rapid tranquilisation then:
a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications
b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated.
(4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness and training in the application of the restraint policy
Wider context from the report “(1) Although the Trust had a policy for Restraint for dealing with aggressive patients, it became clear from the witnesses from the Trust who gave evidence, that many of the staff in the Emergency Department (including the Senior Registrar in charge of the case) were either wholly unaware of the Policy or unaware of, and had no training in, the application of the policy.
(2) It also became clear that the Senior Registrar was not familiar with the dangers of prolonged restraint of a patient in the prone (face-down) position
(3) When it was decided that the patient was in need of rapid tranquilisation then:
a) A supply of Lorazepam from the manufacturer was apparently not available and no policy appeared to have been devised for the priority use of any limited supply of Lorazepam within the Trust and there was no awareness amongst the clinicians of the availability of alternative medications
b)The possibility of a licensed product or of the alternative of Promethazine does not appear to have been pursued. The importance of quick-acting drugs, for the purpose of rapid tranquilisation did not appear to have been fully appreciated.
(4) Although the NICE guidelines were printed off and consulted in dealing with the rapid tranquilisation, a reference there to the fact that diazepam was “not recommended” was overlooked.
” 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 Develop a shared rapid tranquillisation guideline with the Leicestershire Partnership Trust, including appropriate consideration of relevant NICE guidance.
Verbatim wording from the response “In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.” Source location 2015-0024-Response-by-University-Hospitals-of-Leicester
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 Ensure Emergency Department clinical staff understand the Restraint Policy and dangers of prolonged prone restraint.
Verbatim wording from the response “The Clinical Director and Head of Service for the Emergency Department between them have ensured that all clinical staff in the Emergency Department are aware of the Trust’s Restraint Policy and of the particular dangers of prolonged restraint in the prone position.” Source location 2015-0024-Response-by-University-Hospitals-of-Leicester
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 Put the shared rapid tranquillisation guideline in place in the Emergency Department.
Verbatim wording from the response “In addition, our Chief Pharmacist has met with the Leicestershire Partnership Trust to develop a shared rapid tranquillisation guideline; our Clinical Director will ensure that this guideline is in place by the end of May 2015. This Guideline will also deal with appropriate consideration of the relevant NICE Guidelines.” Source location 2015-0024-Response-by-University-Hospitals-of-Leicester
Open published response
Concerns raised 2 Failure to maintain an up-to-date and accessible on-call rota View source Failure to restrict on-call rota amendments to a single central point View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Andrew Pollard · 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
Michael Andrew Pollard, aged 14, collapsed at home on 23 June 2014 and was admitted with an upper gastrointestinal bleed. He became unresponsive before an endoscopy was arranged and died from massive haemorrhage several hours later on 24 June 2014. Concerns included delays in escalation to senior colleagues, lack of early intensive care involvement, inadequate resuscitation with blood products, and an out-of-date on-call rota that delayed contacting the appropriate consultant.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an up-to-date and accessible on-call rota
Wider context from the report “During the night Michael died, it was necessary to contact the on call GI bleed Consultant to discuss the need for an emergency endoscopy. This is accomplished via the hospital switchboard. The rota held by the switchboard staff was out of date , and they called a Consultant who was not on call and was on leave, travelling to the airport at the time. Time was lost in identifying the appropriate Consultant . I was advised that the Trust have not yet resolved a new system to avoid such difficulties in the future.
In my opinion the following matters need to be considered
(1) The on call rota must be up to date, accessible by both switchboard and those clinicians who need access to it
(2) Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota
(3)
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict on-call rota amendments to a single central point
Wider context from the report “During the night Michael died, it was necessary to contact the on call GI bleed Consultant to discuss the need for an emergency endoscopy. This is accomplished via the hospital switchboard. The rota held by the switchboard staff was out of date, and they called a Consultant who was not on call and was on leave, travelling to the airport at the time. Time was lost in identifying the appropriate Consultant. I was advised that the Trust have not yet resolved a new system to avoid such difficulties in the future.
In my opinion the following matters need to be considered
(1) The on call rota must be up to date, accessible by both switchboard and those clinicians who need access to it
(2) Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota
(3)
” 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 Procure a Trust-wide web-based system to manage on-call rotas.
Verbatim wording from the response “The Trust is in the process of procuring a trust-wide web-based system to manage our on-call rotas. Our Chief Medical Information Officer expects to have this system available for use throughout the Trust by the end of this calendar year. Once adopted this system should strengthen and improve our processes with information being uploaded in real-time and visible to clinicians.” Source location 2015-0078-Response-by-University-Hospitals-of-Leicester-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 the on-call rota system through the Switchboard Management Team.
Verbatim wording from the response “As indicated in the Investigation Report there is to be a review of the system by the Switchboard Management Team. These matters will be reported to our Adverse Events Committee which requires assurance that actions identified in such Trust Reports are followed up and I can confirm that this will occur here.” Source location 2015-0078-Response-by-University-Hospitals-of-Leicester-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 Remind all doctors of their responsibility to notify Switchboard about on-call rota amendments.
Verbatim wording from the response “As a result of this inquest our Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will, by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to keep the on-call rota updated.” Source location 2015-0078-Response-by-University-Hospitals-of-Leicester-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 Remind Switchboard staff of their responsibility to keep the on-call rota updated.
Verbatim wording from the response “As a result of this inquest our Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will, by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to keep the on-call rota updated.” Source location 2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A central amendment point and clinician access process already address the need for accurate, accessible on-call rota information.
Verbatim wording from the response “Clinicians who need to access the on-call information can do so via Switchboard.” Source location 2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
Concerns raised 6 Conflict between policies governing hospital-community transfer arrangements and equipment provision and ordering View source Insufficient training of discharge staff on the intended and appropriate use of bed rails View source Inappropriate discharge care planning View source Inadequate co-ordination between services View source Non-implementation of the alert system for communication between all stakeholders View source Failure to follow up or assess hospital-ordered equipment in the community View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Henry Denis Whitwell Powell · 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
Henry Denis Whitwell Powell, who had advanced dementia and required 24-hour care, died on 11 August 2014 after a fall while climbing over bed rails, suffering a head injury and not regaining consciousness. The principal concerns were inappropriate discharge care planning, misunderstanding and insufficient training regarding bed rails, and inadequate coordination and follow-up between hospital and community services for equipment provision.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Conflict between policies governing hospital-community transfer arrangements and equipment provision and ordering
Wider context from the report “(2) There is a conflict currently between the policies governing transfer arrangements between hospital (UHL) and community (LPT) and the provision and ordering of equipment , which can now be done directly by the hospital.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of discharge staff on the intended and appropriate use of bed rails
Wider context from the report “(1) The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff .
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate discharge care planning
Wider context from the report “(1) The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate co-ordination between services
Wider context from the report “(3) Co-ordination between services is inadequate , resulting in equipment being ordered by the hospital but not thereafter being followed up or assessed in the community.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Non-implementation of the alert system for communication between all stakeholders
Wider context from the report “(4) Equipment is supplied by a single gatekeeper, NRS Healthcare, and an alert system is intended to ensure communication has taken place between all stakeholders, but I was advised this system has not been implemented ; early implementation would assist in resolving the current difficulties.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up or assess hospital-ordered equipment in the community
Wider context from the report “(3) Co-ordination between services is inadequate, resulting in equipment being ordered by the hospital but not thereafter being followed up or assessed in the community .
” 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 Develop and ratify a joint bed-rail policy covering assessment, care planning, and handover between hospital and community services.
Verbatim wording from the response “On your second and third concerns I am pleased to be able to confirm that my Trust and Leicestershire Partnership Trust are working together to remove any conflict between our respective bed rail policies. Our Lead Discharge Nurse is working collaboratively with representatives from community hospitals, community nursing and NRS to agree a joint working policy for the safe use of bedrails. The working group have met twice to agree the process of assessment; development of a care plan and handover arrangements following transfer from hospital. A further meeting is scheduled for 10th April 2015, to make final adjustments to the policy, before this is sent for ratification. Our Acting Chief Nurse will ensure that this work will have occurred by May 2015. In addition, our Discharge Policy will be reviewed and will advise staff to consult the joint policy for the safe use of bedrails.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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 Require staff to forward bed-rail risk assessments and care plans to community carers, record the information on ICE transfer letters, and audit compliance.
Verbatim wording from the response “All staff authorised to order bed rails are all now aware of their responsibility to forward a copy the risk assessment and care plan undertaken by UHL staff to the person responsible for the patient's care in the community setting following discharge from UHL and the information will also be recorded on the electronic transfer letter on ICE and audited. In addition, our Acting Chief Nurse will ensure that the Manual Handling Team will review the manual handling training undertaken by Ward staff, to ensure they are able to understand and interpret the risk assessment matrix, to aid their decision making, for the use of bed rails for patients who are at risk of slipping, sliding or rolling out of bed in the hospital setting.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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 Brief authorised bed-rail ordering staff on discharge procedures and correct use of the bed-rail risk-assessment matrix.
Verbatim wording from the response “In light of what occurred in this case, our Lead Discharge Nurse has met with all staff working in the Trust, who are authorised to order bed rails for discharge, to ensure they are up to date with the procedure for ordering bed rails and to ensure they fully understand how to use the bed rail risk assessment matrix for patients who are at risk of slipping, sliding or rolling out of bed. She has used this case to emphasise the importance of strictly” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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 the discharge policy to direct staff to consult the joint policy for safe bed-rail use.
Verbatim wording from the response “On your second and third concerns I am pleased to be able to confirm that my Trust and Leicestershire Partnership Trust are working together to remove any conflict between our respective bed rail policies. Our Lead Discharge Nurse is working collaboratively with representatives from community hospitals, community nursing and NRS to agree a joint working policy for the safe use of bedrails. The working group have met twice to agree the process of assessment; development of a care plan and handover arrangements following transfer from hospital. A further meeting is scheduled for 10th April 2015, to make final adjustments to the policy, before this is sent for ratification. Our Acting Chief Nurse will ensure that this work will have occurred by May 2015. In addition, our Discharge Policy will be reviewed and will advise staff to consult the joint policy for the safe use of bedrails.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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 an electronic ordering alert that prompts bed-rail risk assessment and prevents ordering when the assessment is incomplete.
Verbatim wording from the response “On your fourth point our Lead Discharge has confirmed that an alert system is now in place on the electronic ordering system to prompt staff to consider a bed rails risk assessment. If this information is not completed, then the system will prevent bed rails being ordered.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
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 ward staff manual-handling training to ensure they can interpret the bed-rail risk-assessment matrix.
Verbatim wording from the response “All staff authorised to order bed rails are all now aware of their responsibility to forward a copy the risk assessment and care plan undertaken by UHL staff to the person responsible for the patient's care in the community setting following discharge from UHL and the information will also be recorded on the electronic transfer letter on ICE and audited. In addition, our Acting Chief Nurse will ensure that the Manual Handling Team will review the manual handling training undertaken by Ward staff, to ensure they are able to understand and interpret the risk assessment matrix, to aid their decision making, for the use of bed rails for patients who are at risk of slipping, sliding or rolling out of bed in the hospital setting.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide relevant staff with training on discharge processes and bed-rail risk assessment.
Verbatim wording from the response “adhering to the approved process for discharge including when bed rails are to be provided. Supported by our Acting Chief Nurse, she will ensure that training is provided to relevant staff on the Trust's processes for discharge and this will include training on bed rails risk assessment.” Source location 2015-0058-Response-by-University-Hospitals-of-Leicester
Open published response
Concerns raised 5 Lack of written decision-making rationale for observation frequency View source Lack of a reporting system for healthcare professionals who do not practise in accordance with accepted standards View source Lack of ongoing senior review on each shift to detect observation shortfalls early View source Failure to record basic observations View source Lack of support for healthcare professionals who report departures from accepted standards View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jane Helen Robinson · 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
Jane Helen Robinson, who had alcoholic liver disease with ascites, was admitted to hospital with shortness of breath and underwent a TIPS procedure. Her condition deteriorated and she died on 4 May 2014; the inquest recorded natural causes. Concerns included basic observations reportedly not being recorded, lack of senior review and written rationale for observation frequency, and no evidence of a reporting and support system for staff not meeting accepted standards.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of written decision-making rationale for observation frequency
Wider context from the report “(3) Lack of written decision making rational in relation to the frequency of observation
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a reporting system for healthcare professionals who do not practise in accordance with accepted standards
Wider context from the report “(4) No evidence of any reporting system of healthcare professionals that do not practice in accordance with accepted standards and no evidence of support given to those who do report.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of ongoing senior review on each shift to detect observation shortfalls early
Wider context from the report “(2) No evidence of on-going senior review on each shift whereby shortfalls in observations would be detected at an early stage
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record basic observations
Wider context from the report “(1) Basic observations reportedly not being recorded
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of support for healthcare professionals who report departures from accepted standards
Wider context from the report “(4) No evidence of any reporting system of healthcare professionals that do not practice in accordance with accepted standards and no evidence of support given to those who do report .
” 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 and embed competency assessments for healthcare assistants performing vital-sign observations.
Verbatim wording from the response “1. More frequent observations including recording of the respiratory rate should have occurred in this case which would have given an accurate Early Warning Score (EWS) and prompted escalation. Currently all Health Care Assistants (HCAs) complete a vital signs workbook as part of their induction programme. Work has begun to introduce and embed a competency assessment for HCAs. This work will be led by the Acute Response Team Lead supported by Education and Practice and CMG Heads of Nursing and will be completed by the end of October 2015. Newly Registered Nurses (including International Nurses) have a session on ‘Managing the Deteriorating Patient’ as part of their preceptorship induction programme. Additionally Sepsis management is part of the Safety Improvement work within the Trust and both nursing and medical staff are undergoing training.” Source location 2015-0051-Response-by-University-Hospitals-of-Leicester-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 Implement electronic observation recording with mandatory respiratory-rate fields, automated Early Warning Score calculation and escalation alerts.
Verbatim wording from the response “The Trust is moving towards recording all observations electronically and the software purchased will automatically calculate the EWS score and send the appropriate alerts. This software package has been programmed to ensure all observation fields, which includes respiration rate, are mandatory requirements. A pilot will be commencing in June 2015 and is then expected to be rolled out across the Trust throughout the following year. This work will be led by an Assistant Chief Nurse and is expected to be concluded by the end of 2016.” Source location 2015-0051-Response-by-University-Hospitals-of-Leicester-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 patients’ observation charts during clinical handover to verify accurate recording and appropriate escalation.
Verbatim wording from the response “2. There was no evidence that the nurse in charge was aware that Mrs Robinson’s observations were not being taken appropriately. Work has taken place to improve both the daily Board Round and also the clinical handover process. As part of this work we have strengthened the role of the named nurse. Review of all patients’ observation charts will now take place at the time of clinical” Source location 2015-0051-Response-by-University-Hospitals-of-Leicester-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 Operate reporting and disciplinary procedures for healthcare professionals whose practice standards raise concerns, including professional-body referrals when necessary.
Verbatim wording from the response “4. I can confirm that there is a reporting system for healthcare professionals when we have concerns about the standard of their practise. Improving Performance and Capability Policy and The Disciplinary policy are in place and used when appropriate with referrals made to professional bodies when necessary.” Source location 2015-0051-Response-by-University-Hospitals-of-Leicester-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 Strengthen the named-nurse role within daily board rounds and clinical handover.
Verbatim wording from the response “2. There was no evidence that the nurse in charge was aware that Mrs Robinson’s observations were not being taken appropriately. Work has taken place to improve both the daily Board Round and also the clinical handover process. As part of this work we have strengthened the role of the named nurse. Review of all patients’ observation charts will now take place at the time of clinical” Source location 2015-0051-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A reporting system for healthcare professionals with practice concerns already exists through capability and disciplinary policies, with professional referrals where necessary.
Verbatim wording from the response “4. I can confirm that there is a reporting system for healthcare professionals when we have concerns about the standard of their practise. Improving Performance and Capability Policy and The Disciplinary policy are in place and used when appropriate with referrals made to professional bodies when necessary.” Source location 2015-0051-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
Concerns raised 4 Failure to communicate known investigation-report shortcomings in a timely manner View source Failure to produce accurate and reliable investigation reports View source Action plans based on erroneous investigation findings View source Failure to revisit and correct recognized errors in investigation reports View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janet Doreen Goodacre · 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
Janet Doreen Goodacre, aged 88, was admitted to Leicester Royal Infirmary on 1 May 2013 and died there on 21 May 2013 after developing a gastrointestinal bleed while receiving warfarin, deltaparin and aspirin. The report raised concerns that the Trust’s investigation report was factually incorrect and flawed, that its identified root causes were wrong, and that the Trust did not communicate these shortcomings or revisit the report before the inquest.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate known investigation-report shortcomings in a timely manner
Wider context from the report “I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself , and it was clear no attempts had been made to revisit the report to correct the recognized errors.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to produce accurate and reliable investigation reports
Wider context from the report “I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports , and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Action plans based on erroneous investigation findings
Wider context from the report “I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to revisit and correct recognized errors in investigation reports
Wider context from the report “I am therefore concerned that the Trust is providing inaccurate and misleading investigation reports, and Action Plans based on the erroneous findings that are not only of no assistance, but in fact divert attention away from the actual difficulties in service provision that should be identified. This not only fails to achieve the intention of the investigation, but also has the potential to miss opportunities to prevent future deaths. Furthermore, there was a failure to communicate the Trust knowledge of the Investigation Reports shortcomings until the day of the Inquest itself, and it was clear no attempts had been made to revisit the report to correct the recognized errors .
” 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 Provide senior scrutiny of events causing avoidable death or harm and identify root causes, themes and required safety workstreams.
Verbatim wording from the response “3. The Trust has established a new ‘Adverse Events Committee’, reporting to the Executive Quality Board, to review all serious untoward events (SUIs).” Source location Response from University Hospitals of Leicester 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 Systematically review every action plan and track actions through to full implementation.
Verbatim wording from the response “3. The Trust has established a new ‘Adverse Events Committee’, reporting to the Executive Quality Board, to review all serious untoward events (SUIs).” Source location Response from University Hospitals of Leicester 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 Establish named RCA Chairs to oversee investigation scope, team composition, SMART action plans and report sign-off.
Verbatim wording from the response “The Trust continually works to improve the quality of the investigations of the RCA reports and we have recently introduced three further measures to assist with this.” Source location Response from University Hospitals of Leicester 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 Purchase and provide tiered external RCA training for investigation leads, senior safety investigators and RCA Chairs.
Verbatim wording from the response “The Trust continually works to improve the quality of the investigations of the RCA reports and we have recently introduced three further measures to assist with this.” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reopening investigation reports is limited to commissioner feedback supported by compelling evidence, rather than a general reopening system.
Verbatim wording from the response “With respect to re-opening investigation reports, the Trust does consider any feedback received from Commissioners and may make amendments to such reports if there is compelling evidence to do so.” Source location Response from University Hospitals of Leicester NHS Trust
Open published response
Concerns raised 5 Inadequate communication between those responsible for care and treatment View source Failure to observe and monitor in accordance with patients' needs View source Failure to properly assess fitness for discharge View source Inadequate documentation View source Failure to properly plan discharge 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
Gillian Crossley · 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
Gillian Crossley underwent elective bowel surgery, was discharged home, re-admitted the following day in extremis with bowel necrosis and perforation, and died on 28 March 2013 despite further surgery. The concerns included inadequate documentation, inadequate observation and monitoring, failure to properly assess and plan her discharge, and inadequate communication between those responsible for her care.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication between those responsible for care and treatment
Wider context from the report “I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry:
(1) Inadequate documentation
(2) Failure to observe and monitor in accordance with Mrs Crossley's needs
(3) Failure to properly assess the fitness for discharge and properly plan that discharge
(4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to observe and monitor in accordance with patients' needs
Wider context from the report “I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry:
(1) Inadequate documentation
(2) Failure to observe and monitor in accordance with Mrs Crossley's needs
(3) Failure to properly assess the fitness for discharge and properly plan that discharge
(4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly assess fitness for discharge
Wider context from the report “I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry:
(1) Inadequate documentation
(2) Failure to observe and monitor in accordance with Mrs Crossley's needs
(3) Failure to properly assess the fitness for discharge and properly plan that discharge
(4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentation
Wider context from the report “I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry:
(1) Inadequate documentation
(2) Failure to observe and monitor in accordance with Mrs Crossley's needs
(3) Failure to properly assess the fitness for discharge and properly plan that discharge
(4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly plan discharge
Wider context from the report “I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry:
(1) Inadequate documentation
(2) Failure to observe and monitor in accordance with Mrs Crossley's needs
(3) Failure to properly assess the fitness for discharge and properly plan that discharge
(4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley
” Open source report
Concerns raised 4 Uncertainty about staff knowledge of escalation procedures View source Insufficient midwifery and medical availability during extreme service demand View source Lack of a confirmed Trust policy for the midwifery SOS attendance system View source Failure to communicate labour-stage duration effectively to relevant clinical staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dayani Chauhan-Ahmed · 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
Dayani Chauhan-Ahmed was born in poor condition after a prolonged second stage of labour exceeding 5.5 hours and died after intensive care was withdrawn with parental consent. The substantive concerns included ineffective communication about the length of labour, uncertainty about staff knowledge and adherence to escalation procedures, and insufficient midwifery and medical availability during periods of extreme demand.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about staff knowledge of escalation procedures
Wider context from the report “(2)The Trust escalation policy has been changed since this death, but there seemed to be uncertainty, on how well this was known by all relevant midwifery and medical staff, and in particular ensuring knowledge for new staff . Knowledge of the procedures , and adherence to the time limits set out for escalation are key to the effectiveness and the Trust should consider further how this can be robustly incorporated into working practice.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient midwifery and medical availability during extreme service demand
Wider context from the report “(3) The Trust should consider arranging for additional midwifery and medical availability to assist during times of extreme demand on the service . The current informal “SOS” system for midwifery attendance, while promising, should be further explored and confirmed in Trust policy if considered to be effective.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a confirmed Trust policy for the midwifery SOS attendance system
Wider context from the report “(3) The Trust should consider arranging for additional midwifery and medical availability to assist during times of extreme demand on the service. The current informal “SOS” system for midwifery attendance , while promising, should be further explored and confirmed in Trust policy if considered to be effective.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate labour-stage duration effectively to relevant clinical staff
Wider context from the report “(1) Notwithstanding the presence of all material times of a Consultant on the delivery ward, the length of time of the second stage of this labour did not appear to be communicated effectively to either the Consultant or the midwife co-ordinator , due to other events occurring that night. The “white board” system of communication was ineffective as neither of the above had an opportunity to look at this. The Trust should consider a program for communication on such occasions that is effective and may include slight of the CTG trace, where applicable, by the most senior clinician available.
” 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 Disseminate the revised Escalation Policy electronically to all midwifery and medical staff in the Clinical Management Group.
Verbatim wording from the response “4. The Head of Midwifery is to ensure that by the end of September 2014 the Escalation Policy (the Transfer of Activity and Closure Policy) will be reviewed and will include guidance on the informal ‘SOS’ system. Once this has been completed the policy will be disseminated in accordance with normal Trust practice. Additionally, the Head of Midwifery and Deputy Clinical Director between them will ensure that a” Source location Response from University Hospital of Leicester 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 Advertise two additional consultant posts for the maternity service.
Verbatim wording from the response “6. Since this incident occurred the service has advertised two additional consultant posts. It is planned that the maternity service will move toward extended hours of consultant presence on both delivery suites in UHL with a phased increase in consultant numbers. As a first step it is planned that hours of consultant presence at the Leicester General Hospital will increase from its current 60 hours/week to 84 hours/week by the end of September 2014. We also plan to increase hours of cover at the Leicester Royal Infirmary. This will require a reorganisation of consultant job plans and we anticipate that there will be more robust consultant presence with prospective cover at the LRI by end of September 2014. In 2019 it is planned to move to a one-site take and this should better enable the service to manage periods of extremely high demand.” Source location Response from University Hospital of Leicester 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 Move to a one-site maternity take in 2019 to improve management of periods of extremely high demand.
Verbatim wording from the response “6. Since this incident occurred the service has advertised two additional consultant posts. It is planned that the maternity service will move toward extended hours of consultant presence on both delivery suites in UHL with a phased increase in consultant numbers. As a first step it is planned that hours of consultant presence at the Leicester General Hospital will increase from its current 60 hours/week to 84 hours/week by the end of September 2014. We also plan to increase hours of cover at the Leicester Royal Infirmary. This will require a reorganisation of consultant job plans and we anticipate that there will be more robust consultant presence with prospective cover at the LRI by end of September 2014. In 2019 it is planned to move to a one-site take and this should better enable the service to manage periods of extremely high demand.” Source location Response from University Hospital of Leicester 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 Place laminated escalation flowcharts in both delivery suites and publish key transfer actions in the quarterly Quality and Safety Newsletter.
Verbatim wording from the response “5. In addition to the above the Head of Midwifery will take further actions namely she will ensure that a laminated flowchart detailing the actions to be taken and time limits for escalation are placed within each of the two delivery suites at the Trust and she will include details of the key actions when transferring activity in the CMG’s quarterly Quality and Safety Newsletter.” Source location Response from University Hospital of Leicester 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 the Escalation Policy to include guidance on the informal SOS system.
Verbatim wording from the response “4. The Head of Midwifery is to ensure that by the end of September 2014 the Escalation Policy (the Transfer of Activity and Closure Policy) will be reviewed and will include guidance on the informal ‘SOS’ system. Once this has been completed the policy will be disseminated in accordance with normal Trust practice. Additionally, the Head of Midwifery and Deputy Clinical Director between them will ensure that a” Source location Response from University Hospital of Leicester 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 Include the Escalation Policy in induction for new midwifery and medical staff and reinforce it through annual training.
Verbatim wording from the response “Moreover, so as to ensure that new staff are aware of the Transfer of Activity and Closure Policy, the Head of Midwifery and the Head of Service will ensure that it forms part of the induction of new midwifery and medical staff, respectively. In addition, staff will be reminded of this policy as part of their annual training.” Source location Response from University Hospital of Leicester 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 Require clearer clinical communications, including precise requests for action, through staff reflection and management discussion.
Verbatim wording from the response “1. Our Head of Midwifery has asked the midwife who contacted the consultant to reflect on the importance of clarity when communicating clinical information including being precise in terms of what actions they want to see happen. The importance of clarity particularly in a situation where there is extremely high/intense activity is something that all staff can learn from. In addition our Deputy Clinical Director for Women’s and Children’s Services has discussed with the consultant the importance of ascertaining accurate information if it is not provided. In addition, our Quality and Safety Manager for Women’s and Children’s Services has reminded all clinical staff in the CMG of the importance of pulling the emergency buzzer to summon assistance in an emergency situation.” Source location Response from University Hospital of Leicester 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 Increase consultant presence through phased extended-hours cover at both delivery suites, including increased Leicester General Hospital and Leicester Royal Infirmary coverage.
Verbatim wording from the response “6. Since this incident occurred the service has advertised two additional consultant posts. It is planned that the maternity service will move toward extended hours of consultant presence on both delivery suites in UHL with a phased increase in consultant numbers. As a first step it is planned that hours of consultant presence at the Leicester General Hospital will increase from its current 60 hours/week to 84 hours/week by the end of September 2014. We also plan to increase hours of cover at the Leicester Royal Infirmary. This will require a reorganisation of consultant job plans and we anticipate that there will be more robust consultant presence with prospective cover at the LRI by end of September 2014. In 2019 it is planned to move to a one-site take and this should better enable the service to manage periods of extremely high demand.” Source location Response from University Hospital of Leicester NHS Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A communication pro forma will not be introduced because completing it during emergencies could delay effective action.
Verbatim wording from the response “2. We have carefully considered using a pro-forma to aid effective communication as such pro-formas are used in other circumstances to good effect. However, we have decided not to introduce a pro forma in the situation that occurred here. This is because it is felt that completion of a pro forma is not suitable in emergency situations and would be more likely overall to delay effective action. It is the view of the senior management team of the CMG that it would have been appropriate in this case for the midwife to have used the emergency buzzer. Accordingly, the Head of Midwifery will ensure that the guidelines for the management of the second stage of Labour (Intrapartum Care: Healthy Women and their Babies Guideline) will be reviewed by the end of September 2014, and will strengthen the guidance on the need to use the emergency buzzer in emergency situations.” Source location Response from University Hospital of Leicester NHS Trust
Open published response
Concerns raised 3 Failure to provide prophylactic antibiotic medication at discharge View source Failure to arrange the patient's next outpatient appointment View source Failure to share hospital admissions with the Immunology team View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Karen Lesley SUTTON · 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
Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.
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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide prophylactic antibiotic medication at discharge
Wider context from the report “(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge.
(2) Mrs Sutton was discharged home without prophylactic antibiotic medication
(3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012.
(4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange the patient's next outpatient appointment
Wider context from the report “(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge.
(2) Mrs Sutton was discharged home without prophylactic antibiotic medication
(3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012 .
(4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide.
” 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 Leicester NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share hospital admissions with the Immunology team
Wider context from the report “(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge .
(2) Mrs Sutton was discharged home without prophylactic antibiotic medication
(3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012.
(4) ████████ was unaware of any Trust policy to share admissions between departments . He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide .
” 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 Ask every Consultant to identify complex patients in their service for inclusion in the admission alert process.
Verbatim wording from the response “b) We have investigated the possibility of an IT solution. By the beginning of April 2014 we expect to have available to us a piece of software which will allow daily alerting to Consultants or their teams about any patient whom they have previously identified as individuals whose care needs are complex and who would therefore require specialist help from them or their team in the event of an admission to the Trust. In the run-up to the ████████ ████████████████████████████████████████ ████████████████████████████████████████████████████” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind all Consultants of their duty to contact specialist teams when complex patients require care beyond their competence.
Verbatim wording from the response “When Mrs Sutton was admitted the following process was in place and should have been followed. The admitting Consultant should ensure that s/he is aware of the clinical needs of the patient and further ensure that s/he consults appropriately with other clinical specialties where the patient has complex needs which fall outside of that consultant’s competence. As a result of your concerns we have strengthened our current process by undertaking the following actions:” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
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 Discuss systems and processes across all three Trust sites for flagging and communicating medicines that must continue after discharge.
Verbatim wording from the response “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
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 Explore ward-based technicians’ knowledge of prophylactic antibiotics required after splenectomy.
Verbatim wording from the response “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make software available to provide daily alerts about previously identified complex patients requiring specialist input after admission.
Verbatim wording from the response “b) We have investigated the possibility of an IT solution. By the beginning of April 2014 we expect to have available to us a piece of software which will allow daily alerting to Consultants or their teams about any patient whom they have previously identified as individuals whose care needs are complex and who would therefore require specialist help from them or their team in the event of an admission to the Trust. In the run-up to the ████████ ████████████████████████████████████████ ████████████████████████████████████████████████████” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind the junior doctors involved to fully consider patients’ pre-admission medication.
Verbatim wording from the response “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Patients may appropriately arrange their own outpatient appointments where clinical circumstances permit, alongside existing discharge and information-sharing arrangements.
Verbatim wording from the response “As to your third concern the circumstances surrounding the outpatient appointment with ████████ are unusual. I am informed that the on the 25th May 2012 an outpatient appointment with ████████ was booked for 4th October 2012 in accordance with normal procedures. As you are aware Mrs Sutton was subsequently admitted under the care of the respiratory team. It would seem that whilst there was a plan made on the 2nd October 2012 to cancel this appointment, as Mrs Sutton was then an inpatient, our Patient Administration system (HISS) indicates that this cancellation had not been put into effect by the 3rd October when Mrs Sutton was discharged. A plan was therefore made, prior to discharge, that Mrs Sutton should attend her pre-arranged appointment on 4th October 2012 with ████████.” Source location 2013-0223-Response-by-University-Hospitals-of-Leicester
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations