Concerns raised 20 Failure to grade fatal severe harm correctly View source Failure to examine the Trust's own clinical governance processes View source Unreliability of Trust safety and complaints data View source Failure to ensure midwives complete current mandatory training View source Failure of harm-only reporting to identify underlying safety problems View source Failure to notify external and internal patient-safety bodies of serious incidents View source Lack of a system of remedial training View source Inconsistent categorisation of harm for cooled babies with hypoxic injury View source Lack of document version control and audit View source Failure to learn from identified safety issues and themes View source Lack of a culture of candour View source Lack of assured ongoing funding for MSNI investigations View source Insufficiently skilled and trained clinical governance personnel View source Failure of clinical reporting to provide a holistic and complete account of evidence View source Failure to categorise a death-causing harm event correctly View source Inadequate Trust investigations failing to identify safety issues View source Failure to investigate senior staff roles in disputed safety-report decisions View source Failure to provide relevant information transparently and openly View source Chaotic clinical governance arrangements View source Untrained clinical governance staff View source See 17 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 17
Action
Implement a Trust-wide clinical governance reform covering document control, mandatory governance training, oversight restructuring, outcome-focused learning and family-centred care.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Operate multidisciplinary daily triage and cross-care-group reviews of concerns, incidents and feedback to support early escalation and coordinated learning.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Strengthen cultural leadership through visible executive engagement, leadership safety conversations, behavioural performance assessment and quarterly culture reviews.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Operate structured maternity complaints monitoring, central tracking through resolution, leadership review of responses and opportunities for families to discuss concerns.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Employ three full-time Learning Response Leads to conduct investigations and oversee the PSIRF process.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Evaluate the operating effectiveness and consistency of serious-incident controls following PSIRF adoption.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Operate twice-weekly Executive Review Group oversight of validated moderate-or-above harm incidents, complaints and organisational concerns.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Implement PSIRF through proportionate learning responses, co-produced investigations, and training for staff involved in incident responses.
Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025. View source
Action
Review embeddedness of the Kirkup recommendations or successor practices through internal audit.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Enhance engagement with level 3 centres to improve handover of maternity events and concerns relevant to external reporting.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Map critical clinical training requirements across the Trust and ensure staff compliance.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Conduct regular mortality reviews and triangulation meetings to inform governance, training, resourcing and risk-prevention decisions.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Implement immediate changes to the Being Open policy following evidence given at the inquest.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Embed the Duty of Candour process across the Trust, with standardised letters, family contact arrangements and governance monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 26 March 2025. View source
Action
Embed enhanced quality assurance for Patient Safety Incident Investigations through a structured clinical governance review process.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Provide internal audit assurance that divisional governance arrangements operate within the Trust’s accountability frameworks.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source
Action
Provide training and development where compliance concerns identify gaps in skills, knowledge or behaviours.
Stated plannedThe respondent said that this action was planned when they made their response on 26 March 2025. View source See 14 more actions
×
AI-generated summary
Ida Jean Lock · 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
Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.
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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to grade fatal severe harm correctly
Wider context from the report “14. The Trust graded Ida’s level of harm as “moderate”, even after her death . This grading should have been adjusted to "severe" by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia.
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to examine the Trust's own clinical governance processes
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes , which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unreliability of Trust safety and complaints data
Wider context from the report “5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to ████████ and ████████'s 1 June 2020 complaint., Together with the Trust's failure to categorise Ida's death as only "Moderate Harm" (see point 4 above) cause me also to have concern about the reliability of Trust's data .
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure midwives complete current mandatory training
Wider context from the report “11. The Band 5 midwife supporting ████████ in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as ████████ had not completed her mandatory training.
12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of harm-only reporting to identify underlying safety problems
Wider context from the report “15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone , clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery .
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify external and internal patient-safety bodies of serious incidents
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel , none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system of remedial training
Wider context from the report “13. There was no remedial training was put in place for either the midwives involved in Ida's delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for ████████, ████████, ████████ and ████████
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent categorisation of harm for cooled babies with hypoxic injury
Wider context from the report “16. ████████ confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification and guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour.
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of document version control and audit
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents , untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from identified safety issues and themes
Wider context from the report “2. ████████s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn . ████████'s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest.
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour
Wider context from the report “1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Duty of Candour
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assured ongoing funding for MSNI investigations
Wider context from the report “18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date . These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children.
19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida's will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficiently skilled and trained clinical governance personnel
Wider context from the report “6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical reporting to provide a holistic and complete account of evidence
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence , did not provide relevant information until it was extracted from the witness in testimony , that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to categorise a death-causing harm event correctly
Wider context from the report “4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust's internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust's Patient Safety Summits .The matter was reported to the Coroner a year after Ida's death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death” .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate Trust investigations failing to identify safety issues
Wider context from the report “9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate senior staff roles in disputed safety-report decisions
Wider context from the report “8. ████████ is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust's acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, ████████ is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant information transparently and openly
Wider context from the report “3. The Trust's approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day.
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Chaotic clinical governance arrangements
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Untrained clinical governance staff
Wider context from the report “7. As a result of the Trust's deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust's clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements , defensive attitudes and inappropriate self-congratulation. The clinicians' reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence.
” 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 Implement a Trust-wide clinical governance reform covering document control, mandatory governance training, oversight restructuring, outcome-focused learning and family-centred care.
Verbatim wording from the response “We have undertaken a comprehensive reform of our Trust-wide clinical governance framework. This includes:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate multidisciplinary daily triage and cross-care-group reviews of concerns, incidents and feedback to support early escalation and coordinated learning.
Verbatim wording from the response “Daily Triage and Cross-Care Group Reviews” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen cultural leadership through visible executive engagement, leadership safety conversations, behavioural performance assessment and quarterly culture reviews.
Verbatim wording from the response “Cultural Leadership and Accountability” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate structured maternity complaints monitoring, central tracking through resolution, leadership review of responses and opportunities for families to discuss concerns.
Verbatim wording from the response “In 2022, a structured process was implemented to monitor and track complaints within maternity services. This includes weekly meetings between the Patient Experience Team and maternity service representatives to ensure timely review and action.” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employ three full-time Learning Response Leads to conduct investigations and oversee the PSIRF process.
Verbatim wording from the response “What we are going to do next:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Evaluate the operating effectiveness and consistency of serious-incident controls following PSIRF adoption.
Verbatim wording from the response “The Board has asked the internal auditors to:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate twice-weekly Executive Review Group oversight of validated moderate-or-above harm incidents, complaints and organisational concerns.
Verbatim wording from the response “The ERG is chaired by the Chief Medical Officer or Chief Nursing Officer. The group is convened twice weekly to oversee all incidents reviewed by the Divisions that have been validated as causing moderate or above harm. In addition to this, the group may review other incidents that trigger organisational concern. The group also reviews all complaints and claims received in the previous week. This process enables executive oversight of any immediate issues which need addressing. The group has the power to investigate any” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement PSIRF through proportionate learning responses, co-produced investigations, and training for staff involved in incident responses.
Verbatim wording from the response “Implementation of the Patient Safety Incident Response Framework (PSIRF)” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review embeddedness of the Kirkup recommendations or successor practices through internal audit.
Verbatim wording from the response “The Board has asked the internal auditors to:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance engagement with level 3 centres to improve handover of maternity events and concerns relevant to external reporting.
Verbatim wording from the response “We acknowledged that poor handover of maternity events and concerns to level 3 centres would impact on their decisions around reporting to the CQC and the Coroner and so have enhanced our engagement with these centres.” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Map critical clinical training requirements across the Trust and ensure staff compliance.
Verbatim wording from the response “What we are going to do next:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regular mortality reviews and triangulation meetings to inform governance, training, resourcing and risk-prevention decisions.
Verbatim wording from the response “Promoting a Culture of Transparency and Accountability” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement immediate changes to the Being Open policy following evidence given at the inquest.
Verbatim wording from the response “Actions taken after the request:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed the Duty of Candour process across the Trust, with standardised letters, family contact arrangements and governance monitoring.
Verbatim wording from the response “To reinforce a culture of candour within the Trust - where openness, honesty, and learning are embedded at all levels - we have implemented a range of measures that go beyond compliance and aim to change behaviours, mindsets, and systems. In addition, we continue to monitor the impact of these changes through ward to board governance arrangements. The changes we have made are detailed below.” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed enhanced quality assurance for Patient Safety Incident Investigations through a structured clinical governance review process.
Verbatim wording from the response “What we are going to do next:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide internal audit assurance that divisional governance arrangements operate within the Trust’s accountability frameworks.
Verbatim wording from the response “The Board has asked the internal auditors to:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide training and development where compliance concerns identify gaps in skills, knowledge or behaviours.
Verbatim wording from the response “What we are going to do next:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further investigation was considered beneficial because significant time had elapsed, relevant disclosures were made, and key senior leaders had left.
Verbatim wording from the response “Our Director of Midwifery has taken HR advice and concluded that given:” Source location Response from University Hospitals of Morecambe Bay NHS Foundation Trust
Open published response
9 Jul 2024 Nancy ROGERS · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 1 Failure to undertake learning or teaching following comparable deaths View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nancy ROGERS · 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
Nancy ROGERS collapsed on 18 November 2023, attended the emergency department, and was discharged home before being found unresponsive the following morning. The inquest recorded bilateral haemothorax due to a ruptured dissecting aortic aneurysm. Concerns were raised about her discharge after emergency attendance and the reported absence of learning or teaching following a similar death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake learning or teaching following comparable deaths
Wider context from the report “(1) At the inquest into Shirley Potter's death the hospital report indicated no learning was required as her presentation was not typical . The circumstances in both these cases are remarkably similar in that both ladies attended the emergency department at Furness General and were allowed home only to die within a day of the same cause and as far as the attending clinician at today's hearing knew no learning or teaching has taken place since Nancy's death .
” 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 Write an action plan addressing the causes and prevention of missed aortic dissection diagnoses.
Verbatim wording from the response “A meeting was held between the Clinical Lead - Emergency Medicine (FGH), the Clinical Lead - Emergency Medicine (RLI), the Clinical Lead - Urgent Treatment Centre WGH and the Deputy Medical Director (Education, Research, Workforce and Innovation) to discuss the causes of Shirley Potter and Nancy Rogers and another case that we had noted in the jurisdiction of the Senior Coroner Lancashire and Blackburn with Darwen. The discussion at the meeting centred on the best way to disseminate information regarding aortic dissection, in order to reduce the risk of this diagnosis being missed in the future. An action plan was written and since the meeting, the following actions have been put in place:” Source location Response from Morecambe Bay NHSFT
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Display an aortic dissection poster with a linked educational video in emergency department clinical and triage areas.
Verbatim wording from the response “• An A4 poster has been created (copy attached) and is displayed in the Emergency Department (ED) clinical areas and triage, for quick reference. The QR code links to a video on the Aortic Dissection Charitable Trust's website.” Source location Response from Morecambe Bay NHSFT
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 aortic dissection in the August induction programme for new doctors.
Verbatim wording from the response “• Aortic dissection is now included in the new doctor induction in August.” Source location Response from Morecambe Bay NHSFT
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the aortic dissection video to medical and nursing staff across emergency, urgent treatment, same-day emergency care and acute medical units, tracking viewings and adding new starters.
Verbatim wording from the response “• The video on the Aortic Dissection Charitable Trust website is being drawn to the attention of senior and junior medical staff at ED meetings at both of the Trust’s main hospitals, between July and the end of September. A list of the” Source location Response from Morecambe Bay NHSFT
Open published response
12 May 2016 Mrs Constance Pridmore · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Delays in timely radiologist review and reporting of diagnostic X-rays and CT scans View source Insufficient availability of trained consultant radiologists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Constance Pridmore · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Constance Pridmore, who was living independently, fell accidentally on 3 May 2015 and was admitted to hospital with pneumonia. She died on 7 May 2015 from a haemothorax associated with fractured ribs, during insertion of a chest drain. The principal concern was that rib fractures and the associated haemothorax were not identified promptly because her admission chest X-ray was not reviewed by a radiologist until after her death, amid a shortage of radiologists.
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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in timely radiologist review and reporting of diagnostic X-rays and CT scans
Wider context from the report “(1) It was confirmed in evidence by Consultant Radiologist ████████ that:
a) X-rays undertaken on admission to the Accident & Emergency ward at Furness General Hospital are not immediately reviewed by a radiologist , but are assessed by the requesting physician.
b) The X-rays are eventually reviewed by a radiologist on a non-urgent basis when capacity in the system permits . In the case of Mrs Pridmore, her x-ray was reviewed on 11th May 2015, 8 days after being taken and 4 days after she had died.
c) X-rays are not reviewed sooner by a radiologist due to a shortage of available radiologists within the Trust.
(2) It was confirmed in evidence by Consultant Physician ████████ that:
a) If Mrs Pridmore’s x-ray had been reviewed by a radiologist on 3rd May 2015, it is likely that the rib fractures and associated haemothorax would have been identified and that Mrs Pridmore would have been cared for differently.
b) on the balance of probabilities, the outcome for Mrs Pridmore would have been the same due to her age and the nature of her injury. However the failure in identifying the fractures denied Mrs Pridmore the opportunity of a more appropriate course of treatment (e.g. pain management and symptom control) and the possibility, all be it remote, of a different outcome
(3) It was confirmed in evidence by independent Consultant Radiologist, ████████
████████ that:
a) the rib fractures were only discretely visible on the x-ray and would have required a trained radiologist to identify them
b) The shortage of radiologists within the Morecambe Bay trust which prevented Mrs Pridmore’s x-ray from being reviewed by a radiologist sooner is reflective of a critical shortage of radiologists in the U.K.
c) There are presently approximately 400 vacant consultant radiologist posts unfilled in the U.K.
d) the target set in ████████2013 report entitled “NHS Services, Seven days a Week” (Paper NHS121315) for urgent x-rays of inpatients to be completed (including the reporting by a radiologist) within 12 hours is far from being achieved both locally by Morecambe Bay Trust, but also nationally by all Health Trusts . This is due in part to a general increase in the use of scans and x-rays as diagnostic aids, but mainly due to the acute shortage of radiologist who are available and trained to interpret the relevant data accurately and in a timely manner. The Keogh targets whilst intended to become reality by the end of 2016/17 are becoming a more distant ideal than a realistically approaching target.
It is probable that current delays on both a local and national basis in obtaining in a timely manner, accurate radiologist reports of x-rays and CT scans taken for diagnostic purposes , creates a foreseeable risk that further deaths may well arise as a consequence.
Locally, a review of your procedures with regard to the assessment of x-rays is required and nationally, a review into the implementation of the recommendations of the Keogh report is likely to be necessary.
” 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 Morecambe Bay NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient availability of trained consultant radiologists
Wider context from the report “(1) It was confirmed in evidence by Consultant Radiologist ████████ that:
a) X-rays undertaken on admission to the Accident & Emergency ward at Furness General Hospital are not immediately reviewed by a radiologist, but are assessed by the requesting physician.
b) The X-rays are eventually reviewed by a radiologist on a non-urgent basis when capacity in the system permits. In the case of Mrs Pridmore, her x-ray was reviewed on 11th May 2015, 8 days after being taken and 4 days after she had died.
c) X-rays are not reviewed sooner by a radiologist due to a shortage of available radiologists within the Trust.
(2) It was confirmed in evidence by Consultant Physician ████████ that:
a) If Mrs Pridmore’s x-ray had been reviewed by a radiologist on 3rd May 2015, it is likely that the rib fractures and associated haemothorax would have been identified and that Mrs Pridmore would have been cared for differently.
b) on the balance of probabilities, the outcome for Mrs Pridmore would have been the same due to her age and the nature of her injury. However the failure in identifying the fractures denied Mrs Pridmore the opportunity of a more appropriate course of treatment (e.g. pain management and symptom control) and the possibility, all be it remote, of a different outcome
(3) It was confirmed in evidence by independent Consultant Radiologist, ████████
████████ that:
a) the rib fractures were only discretely visible on the x-ray and would have required a trained radiologist to identify them
b) The shortage of radiologists within the Morecambe Bay trust which prevented Mrs Pridmore’s x-ray from being reviewed by a radiologist sooner is reflective of a critical shortage of radiologists in the U.K.
c) There are presently approximately 400 vacant consultant radiologist posts unfilled in the U.K.
d) the target set in ████████2013 report entitled “NHS Services, Seven days a Week” (Paper NHS121315) for urgent x-rays of inpatients to be completed (including the reporting by a radiologist) within 12 hours is far from being achieved both locally by Morecambe Bay Trust, but also nationally by all Health Trusts. This is due in part to a general increase in the use of scans and x-rays as diagnostic aids, but mainly due to the acute shortage of radiologist who are available and trained to interpret the relevant data accurately and in a timely manner . The Keogh targets whilst intended to become reality by the end of 2016/17 are becoming a more distant ideal than a realistically approaching target.
It is probable that current delays on both a local and national basis in obtaining in a timely manner, accurate radiologist reports of x-rays and CT scans taken for diagnostic purposes, creates a foreseeable risk that further deaths may well arise as a consequence.
Locally, a review of your procedures with regard to the assessment of x-rays is required and nationally, a review into the implementation of the recommendations of the Keogh report is likely to be necessary.
” 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 Undertake workforce planning to review staff skill mix and age profile.
Verbatim wording from the response “• Workforce planning to review skill mix and age profile of staff” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 Continue recruitment, including international recruitment, to develop reporting capacity.
Verbatim wording from the response “The Dalton Review reported that the UK has around 48 trained radiologists per million population. This figure has remained static for the last five years and represents half the total in other EU countries. The paper considers different ways of working in terms of outsourcing, skill mix and the use of technology to overcome the challenge and UHMB has already implemented some of these ideas. In the UK, no appointment was made to 41% of unfilled consultant posts advertised and the North West showed a higher vacancy rate than other regions. This reflects the experience in UHMB where there are currently 5 vacancies, based on workload calculations from 2011, since which time CT and MR have both doubled in volume and increased in complexity.” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 Explore home reporting with the new PACS to improve recruitment and retention opportunities.
Verbatim wording from the response “• Home reporting to be explored with the advent of new PACS from September 2016, which should improve recruitment and retention opportunities” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 Offer additional programmed activities and payment to consultants reporting work beyond contracted hours.
Verbatim wording from the response “• Additional programmed activities and payment are on offer to substantive consultants to report additional work beyond their normal employed hours” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 Roll out voice recognition technology across radiology staff to speed report turnaround.
Verbatim wording from the response “• Voice recognition technology has been rolled out across all radiology staff, streamlining the process and speeding up report turnaround times” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 ad hoc reporting support through eight honorary contracts with external radiologists.
Verbatim wording from the response “• 8 honorary contracts with external radiologists who provide ad hoc support” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 Appoint three radiologists to increase reporting capacity.
Verbatim wording from the response “Clearly recruitment is central to developing further capacity and the Trust has made progress and appointed three radiologists in the past 12 months with ongoing recruitment efforts, including international recruitment.” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 The existing scope of referrer evaluation and its standard operating procedure are considered reasonable and safe, so wider expansion is not preferred.
Verbatim wording from the response “A small number of studies are considered suitable for 'referrer evaluation' and the opinion documented will be that of the referrer, with an option to ask for the film to be reviewed and reported by a radiologist. In these cases there would be no formal report issued by a radiologist. Examples of x-rays that are considered suitable for referrer evaluation at UHMB include x-rays of the teeth reviewed by a dentist and follow up x-rays of healing fractures in adults reviewed by an orthopaedic surgeon.” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 Insufficient radiology reporting capacity prevents all imaging studies from being reported promptly, reflecting a wider national radiologist shortage.
Verbatim wording from the response “The number and range of imaging investigations performed per day varies but the reporting workload is broadly predictable and University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) does not have sufficient reporting capacity to promptly report all the images that are acquired. As identified in your report, there is a shortage of radiologists and this is reflective of a national problem. The Royal College of Radiologists (RCR) has produced several snapshot surveys demonstrating the scale of the issue. The most recent RCR survey (February 2016) showed that in fact, UHMB was in the upper quartile with no studies >1 month.” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-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 prioritisation flow diagram is not being constructed because clinical complexity across modalities does not permit reliable simplification.
Verbatim wording from the response “The waiting images are actively managed by a radiographic manager who will also send work to outsourcing companies as required.” Source location 2016-0491-Response-by-University-Hospitals-of-Morecambe-Bay-NHS-Trust
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations