Concerns raised 3 Lack of shared accessible medical notes across hospital teams View source Reliance on manual transcription of treatment decisions between medical notes View source Failure to access and act on MDT treatment decisions 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
Anne Patricia Leake · 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
Anne Patricia Leake suffered cardiac arrest and arrhythmia, underwent heart valve surgery, and was released from hospital without the planned ICD being fitted. Three days later, she suffered a cardiac arrhythmia and died. The report identified concerns about hospital teams using inaccessible ward-based notes, the absence of a shared electronic records system, and continued reliance on manual transcription of treatment decisions.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of shared accessible medical notes across hospital teams
Wider context from the report “(1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked.
(2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system.
(3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another, with the continuing potential for human error and important decisions about treatment being 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on manual transcription of treatment decisions between medical notes
Wider context from the report “(1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked.
(2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system.
(3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another , with the continuing potential for human error and important decisions about treatment being 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to access and act on MDT treatment decisions
Wider context from the report “(1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked.
(2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system.
(3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another, with the continuing potential for human error and important decisions about treatment being 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 digital vision and strategy including a goal for a new electronic patient record across the Integrated Care System.
Verbatim wording from the response “Whilst the Trust aspires to acquire a new, highly sophisticated, purpose-built single EPR system, this will necessitate securing significant capital investment, development and time to ensure safe deployment. To support this ambition, the trust is currently engaged in setting out a new digital vision and strategy, which includes the goal for a new EPR across the whole Integrated Care System (ICS).” Source location Response from University Hospitals of North Midlands 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 Introduce resident doctor induction teaching requiring clinicians to check the ICD decision before discharge.
Verbatim wording from the response “As an immediate action, the development of a new alert within iPortal will be implemented – this will be populated by the multidisciplinary team to inform clinicians that an ICD is required prior to discharge. The team are going to introduce teaching into the resident doctor induction to ensure this is checked prior to discharge.” Source location Response from University Hospitals of North Midlands 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 Draft a business case with the Integrated Care System to apply for NHS funding for an interoperable electronic patient record.
Verbatim wording from the response “The UНNM digital team together with the ICS, are drafting a business case to apply for NHS funding for an EPR that will meet our growing needs and provide the functionality and interoperability required to prevent the events that contributed to Mrs Leake’s death.” Source location Response from University Hospitals of North Midlands 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 Implement a new iPortal alert, populated by the multidisciplinary team, to notify clinicians that an ICD is required before discharge.
Verbatim wording from the response “As an immediate action, the development of a new alert within iPortal will be implemented – this will be populated by the multidisciplinary team to inform clinicians that an ICD is required prior to discharge. The team are going to introduce teaching into the resident doctor induction to ensure this is checked prior to discharge.” Source location Response from University Hospitals of North Midlands 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 single Trust-wide EPR cannot currently be implemented because it requires substantial investment, development and deployment time, and existing infrastructure is limited.
Verbatim wording from the response “Whilst the Trust aspires to acquire a new, highly sophisticated, purpose-built single EPR system, this will necessitate securing significant capital investment, development and time to ensure safe deployment. To support this ambition, the trust is currently engaged in setting out a new digital vision and strategy, which includes the goal for a new EPR across the whole Integrated Care System (ICS).” Source location Response from University Hospitals of North Midlands NHS Trust
Open published response
Concerns raised 4 Failure to refer dosage-clarification correspondence to a clinician View source Failure to refer medication-change correspondence to a clinician for consideration View source Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes View source Failure to maintain a reliable written basis for Brivaracetam dosage administration 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
Joshua Ethan BURGESS · 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
Joshua Ethan Burgess, who had epilepsy and Lennox-Gastaut syndrome, died at home on 19 November 2022 after vomiting and aspirating during an epileptic seizure. The report identifies concerns about communication and prescribing processes for Brivaracetam, including failures to update the prescription, medication being withheld for several days, and a subsequent increase to 10ml twice daily despite information that 4ml twice daily was appropriate.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer dosage-clarification correspondence to a clinician
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician .
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer medication-change correspondence to a clinician for consideration
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription .
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother . The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so .
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber, however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a reliable written basis for Brivaracetam dosage administration
Wider context from the report “1. The Neurology department of the Royal Stoke University Hospital operated a system whereby it did not instruct the prescribing GP to amend the prescription of Brivaracetam when changes to dosage had been agreed with Mr Burgess’ mother. The evidence from the Consultant Neurologist was that an assumption was made that when changes to medication had been discussed and agreed that Mr Burgess’ mother would attend the GP surgery to discuss the changes in medication. The same witness gave evidence that it was assumed a pharmacist within the GP surgery would read the correspondence from the neurology department and make the necessary changes to prescriptions without express instructions to do so.
2. The “workflow” within the Brook Medical Centre was such that letters sent from the Neurology department discussing changes in medication (albeit not containing a request to amend the prescription) were processed by support staff and not referred to a clinician to consider and so no changes were made to the prescription.
3. The letter of 27 July 2022 from the Neurology department to Brook Medical Centre seeking clarification as to the correct dosage of Brivaracetam was processed by support staff and a summary medications sent without referral to a clinician.
4. Godfrey Care were informed by Mr Burgess’ mother and the Neurology department of Royal Stoke University that the appropriate dose of Brivaracetam was 4ml twice daily. Medication was withheld between 22-26 July 2022 due to the information not being in writing from the prescriber , however the evidence at inquest was that 10ml twice daily was commenced on 26 July 2022 following a call to the 111 service .
” 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 standardised clinic-letter template specifying medication changes and clear actions for prescribing GPs.
Verbatim wording from the response “1. The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard headings. You will recall that ████████ (GP) gave evidence at the inquest to the effect that there were areas in the acute Trust settings which already provided discharge information which he considered to be of a ‘gold standard.’ The Trust is committed to working towards improving compliance with these standards. To support this, we are working towards creation of a standardised template in our ‘Medisec’ system (system where letters are created). This will include a section for changes to medications and clear actions for those in the primary care setting, for example, instructions for the prescribing GP to amend prescriptions.” Source location Response from University Hospitals of North Midlands
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 GP review and triage of all neurology correspondence received by Brook Medical Centre.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
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 Have a GP review and triage all neurology correspondence and clinic letters received by Brook Medical Centre.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised Medisec clinic-letter template specifying medication changes and clear prescribing actions for primary care.
Verbatim wording from the response “1. The Trust’s outpatient clinic letter standards describe the structure of clinic letters based on standard headings. You will recall that ████████ (GP) gave evidence at the inquest to the effect that there were areas in the acute Trust setting which already provided discharge information which he considered to be of a ‘gold standard.’ The Trust is committed to working towards improving compliance with these standards. To support this, we are working towards creation of a standardised template in our ‘Medisec’ system (system where letters are created). This will include a section for changes to medications and clear actions for those in the primary care setting, for example, instructions for the prescribing GP to amend prescriptions.” Source location Response from University Hospitals of North Midlands
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 standardised clinic-letter template cannot be created immediately because implementation across the Trust requires substantial timeframes.
Verbatim wording from the response “2. We have discussed the above process with nominated individuals from the ICS. Due to the timeframes that would be required for the creation of standardised template for clinic letters within the ‘Medisec’ system across the Trust, we are reiterating the Trust standards and ████████ has agreed, with immediate effect, that all clinic letters received from neurology will be reviewed by a GP at Brook Medical Centre. This has been implemented due to the acknowledgement that neurological conditions are often complex, and it is more likely that they will require frequent medication changes, titration and/or closer monitoring.” Source location Response from University Hospitals of North Midlands
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 delay in administering medication did not contribute to the death.
Verbatim wording from the response “4. Whilst this concern is not directly addressed to the acute Trust (UHNM) or Brook medical Centre, it has been considered as part of the wider learning following Joshua’s death. Medications for epilepsy is considered across the healthcare economy to be ‘critical’. The National Patient Safety Agency (2010) defined critical medicines as ‘medicines which can result in patient death or serious harm if there are delays in their administration’. Whist the Coroner found that the delay in administering medications on this occasion did not contribute to Joshua’s death, we believe that further education within the care home setting is required. With this in mind, we will work together with the local authority to ensure that up to date communications are shared across the Stoke on Trent and North Staffordshire health and social care economy to reiterate this message.” Source location Response from University Hospitals of North Midlands
Open published response
Concerns raised 1 Unavailability of Tissue Viability Team over weekends causing delays in patient assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Myra Maxfield · 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
Myra Maxfield, aged 89, fell at home, fractured her right hip, and subsequently developed a Grade 4 pressure sore and osteomyelitis. She died in hospital on 12 March 2022 following a further upper gastrointestinal bleed; concerns included delays in pressure-ulcer patients being assessed by the Tissue Viability Team and the lack of weekend availability at Royal Stoke University Hospital.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of Tissue Viability Team over weekends causing delays in patient assessment
Wider context from the report “1. Evidence emerged during the inquest that it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours .
2. It was said that, delays in doing so, could be causative in the death of patients.
3. Evidence emerged that at the Royal Stoke University Hospital, Tissue Viability is not available over the weekend, and this leads to substantial delay in patients being seen .
” 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 Monitor Specialist Tissue Viability Team referral-to-response times according to pressure-ulcer severity.
Verbatim wording from the response “In response to your concerns, we will continue to monitor the timeliness of pressure ulcer risk assessment completion by our Ward/Department teams via our monthly Tendable Care Excellence audits. We will also ensure that the referral criteria for Ward/Department Teams to refer patients to the Tissue Viability Team for specialist advice and support is reviewed and included in UHNМ Trust Policy C63, Prevention and Management of Pressure Ulcers. We will subsequently monitor referral to response times, according to the severity of the Pressure Ulcer, by our Specialist Tissue Viability Team.” Source location Response from University Hospitals of North Midlands
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine weekend Tissue Viability coverage is unnecessary because pathways, policies, guidance and staff training mitigate pressure-ulcer risks out of hours.
Verbatim wording from the response “We strive to provide a high standard of care to all of our patients and preventing avoidable pressure ulcers and managing existing pressure ulcers, as in the case of Mrs Maxfield, is an important quality metric. People in hospital can be at higher risk of pressure ulcer damage but we have a range of support for teams to minimise the risk of pressure ulcer development or deterioration. UHNМ provide a regular 5-Day (Monday – Friday) Tissue Viability Service, which is in line with most acute Trusts nationally. However, as demonstrated in the case of Mrs Maxwell, a limited service is provided at weekends in extenuating circumstances and on an ad hoc basis.” Source location Response from University Hospitals of North Midlands
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 applicable six-hour requirement is for pressure-ulcer risk assessment, not review by the Specialist Tissue Viability Team.
Verbatim wording from the response “1. As a point of clarification on the issues that you have raised in Point 1 of your letter, regarding the fact that ‘it was crucial that patients who were at risk of developing pressure ulcers, had ulcers already, or had developed them whilst in hospital, saw the Tissue Viability Team as soon as possible, and usually within 6 hours’.” Source location Response from University Hospitals of North Midlands
Open published response
Concerns raised 1 Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Edward SMITH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Edward SMITH died on 4 March 2019 after relapsing on 20 February 2019. The report identified significant delay in the diagnosis and treatment of his adenocarcinoma, with tests, reports, appointments and discussions taking place consecutively so that surgery was no longer possible by the scheduled date.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in diagnosis and treatment caused by sequential rather than concurrent coordination of tests, reports, appointments and discussions
Wider context from the report “1. There was significant delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma which contributed to his death on the 4th March 2019.
2. Time was of the essence, but tests, reports, appointments and discussions took place consecutively to the extent that by the time a final date for surgery was fixed it was no longer possible.
3. Had tests been conducted expeditiously and concurrently with predictable tests organised in advance it is likely that the surgery would have been able to take place significantly earlier than it did.
” 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 Agree a standard operating procedure for referrals for surgical resection of proven or suspected lung cancer.
Verbatim wording from the response “With regard to the delay in the diagnosis and treatment of Mr Smith’s adenocarcinoma SaTH has produced, in conjunction with and agreed by the UHNM visiting cardiothoracic surgeons, the attached Standard Operating Procedure [SOP] – “Referral for surgical resection of proven or suspected lung cancer”. SaTH has implemented the SOP and will be responding to you separately.” Source location 2020-0022-Response-from.-UNMH
Open published response
Concerns raised 4 Lack of communication between hospital departments about responsibility for patient care View source Failure to provide fluids during the patient's wait for a Renal Unit bed View source Failure by nursing staff to proactively manage the patient's condition View source Failure to provide senior clinician review after admission 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
Julie MORREY · 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
Julie MORREY died in Royal Stoke University Hospital on 10 January 2019 after presenting with renal failure and bronchopneumonia. The report raised concerns about inadequate communication between hospital departments, a lack of proactive nursing management, insufficient fluids for over 24 hours, and no senior clinician review during that period.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of communication between hospital departments about responsibility for patient care
Wider context from the report “1. There was a clear lack of communication between the hospital departments as to which department was responsible for the patient after she was assessed by a renal specialist and a plan made for her care and whilst she awaited a bed on the Renal Unit during which time she was looked after on the AMU. During this time she was without fluids for over 24 hours.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide fluids during the patient's wait for a Renal Unit bed
Wider context from the report “1. There was a clear lack of communication between the hospital departments as to which department was responsible for the patient after she was assessed by a renal specialist and a plan made for her care and whilst she awaited a bed on the Renal Unit during which time she was looked after on the AMU. During this time she was without fluids for over 24 hours.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure by nursing staff to proactively manage the patient's condition
Wider context from the report “2. There was a clear failure by nursing staff to pro-actively manage her condition due to a lack of policy, procedure and professional responsibility to the patient.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide senior clinician review after admission
Wider context from the report “3. There was no review of the patient by a senior clinician for 24 hours following her admission and whilst she awaited a bed on the Renal Unit.
” 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 Conduct daily senior nursing reviews of patients requiring specialty input.
Verbatim wording from the response “c. The senior Matron is now assured that patients requiring speciality input are identified in clinical areas. A daily review is undertaken by Matron/Deputy Matron or Senior Sister.” Source location 2019-0353-Response-by-University-Hospitals-of-North-Midlands-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 Escalate and document patients requiring specialty care through Emergency Department huddles and the Huddle Log.
Verbatim wording from the response “b. Any patient who requires speciality care is now escalated and discussed within ED huddles and the discussion is documented in the Huddle Log.” Source location 2019-0353-Response-by-University-Hospitals-of-North-Midlands-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 Escalate cases without an enacted management plan to the Nurse in Charge or senior decision-maker and record the escalation in nursing documentation and Datix.
Verbatim wording from the response “b. There is to be an escalation of care to the Nurse in Charge and/or senior decision maker in circumstances where no management plan has been enacted. This is to be recorded in the nursing documentation and through completion of Datix.” Source location 2019-0353-Response-by-University-Hospitals-of-North-Midlands-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 Realign the workforce so that every patient is assigned a registered nurse.
Verbatim wording from the response “e. There has been a workforce realignment to ensure all patients are assigned a registered nurse.” Source location 2019-0353-Response-by-University-Hospitals-of-North-Midlands-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 Amend Trust Internal Professional Standards to reduce failures caused by misunderstanding between departments.
Verbatim wording from the response “1. The “Renal pathway for patients referred for admission from ED/AMU” has been agreed, which includes detailed advice about clarifying the reason for referral. Trust Internal Professional Standards have been amended with the support of the Medical Director to enhance fitness for purpose and to prevent recurrence of patient care failing due to misunderstanding between departments.” Source location 2019-0353-Response-by-University-Hospitals-of-North-Midlands-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 Agree the renal admission pathway with advice clarifying the reason for referral.
Verbatim wording from the response “1. The “Renal pathway for patients referred for admission from ED/AMU” has been agreed, which includes detailed advice about clarifying the reason for referral. Trust Internal Professional Standards have been amended with the support of the Medical Director to enhance fitness for purpose and to prevent recurrence of patient care failing due to misunderstanding between departments.” Source location 2019-0353-Response-by-University-Hospitals-of-North-Midlands-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 absence of consultant review was not a separate error because existing senior-review mechanisms were robust; it resulted from misunderstanding responsibility for the patient.
Verbatim wording from the response “3. Clinical teams would like to reassure H M Coroner that both Renal and Acute medicine do have robust mechanisms for ensuring senior review of patients. In this case, if either specialty had thought the patient to be under their care, they would have had a review. On this occasion, the lack of a consultant review was not a separate or additional error; it all stems from the misunderstanding of allocation at the beginning of the patient’s care. The corrective actions outlined in 1 and 2 above will prevent such a situation from arising in the future.” Source location 2019-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Open published response
10 Jan 2019 Richard John Lockley · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 2 Poor communication during transfers between County Hospital and Royal Stoke View source Difficulties in finding gastroenterology beds at Royal Stoke View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard John Lockley · 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
Richard John Lockley had throat and neck cancer and sustained falls that resulted in cervical spine fractures. He died in hospital on 11 September 2018, with suitable feeding not arranged before his death. The concerns were poor communication during a proposed transfer between County Hospital and Royal Stoke University Hospital, and difficulties finding a gastroenterology bed at Royal Stoke.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Poor communication during transfers between County Hospital and Royal Stoke
Wider context from the report “(1) Mr Lockley’s condition was a complex one but following discussions it was decided that he should be admitted to a gastroenterology ward at the Royal Stoke University Hospital for a radiologically inserted gastrostomy. Mr Lockley was at County Hospital. There appears to have been very poor communication between County Hospital and Royal Stoke in respect of the transfer. I wonder if this could be improved generally where patients need to be transferred between County Hospital and Royal Stoke.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Difficulties in finding gastroenterology beds at Royal Stoke
Wider context from the report “(2) I am always cautious about making reports involving resources but there also appears to have been difficulties in actually finding a gastroenterology bed at Royal Stoke for Mr Lockley. I raise this just in case anything can be realistically be done about this.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate that suitable acute medical wards can facilitate feeding procedures when gastroenterology beds are unavailable.
Verbatim wording from the response “b. When reviewing this case retrospectively, it is not imperative that a patient has a bed on the gastroenterology ward for RIG placement and feeding – many of the acute medical wards at the Royal Stoke site should be able to facilitate this method of feeding and this should be considered in the future if there is a shortage of beds on a particular ward. We will ensure that this is communicated to other areas via our communications page. Mr Lockley could have been transferred in a more timely manner had an alternative ward been considered.” Source location 2019-0010-Response-by-University-Hospitals-of-North-Midlands-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 Existing cross-site bed-management, transfer and escalation arrangements are considered sufficient to minimise treatment delays.
Verbatim wording from the response “2. Managing available beds across both sites is a task which requires constant adjustment and supervision and the Trust has various measures to ensure that patients receive the appropriate treatment with minimal delay. This includes the measures below:” Source location 2019-0010-Response-by-University-Hospitals-of-North-Midlands-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 gastroenterology ward bed is not imperative for RIG placement and feeding; suitable acute medical wards can facilitate this instead.
Verbatim wording from the response “b. When reviewing this case retrospectively, it is not imperative that a patient has a bed on the gastroenterology ward for RIG placement and feeding – many of the acute medical wards at the Royal Stoke site should be able to facilitate this method of feeding and this should be considered in the future if there is a shortage of beds on a particular ward. We will ensure that this is communicated to other areas via our communications page. Mr Lockley could have been transferred in a more timely manner had an alternative ward been considered.” Source location 2019-0010-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Open published response
Concerns raised 6 Failure to apply cricoid pressure when clinically indicated View source Lack of a bronchoscope on the standard anaesthetic equipment trolley View source Unavailability of a functional bronchoscope suction button View source Unavailability of previous medical records for clinical decision-making View source Failure to provide a rapid-tilt trolley for anaesthesia View source Failure to use NG tubes when clinically indicated View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Donald John TILL · 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
Donald John TILL, a 68-year-old man with a history of small bowel adenocarcinoma, presented with abdominal pain and vomiting caused by a large bowel obstruction. After emergency surgery on 4 January 2017, he aspirated faeculent material during anaesthesia, developed aspiration pneumonia, deteriorated in intensive care, and died on 5 January 2017. Concerns included unavailable previous medical records, anaesthesia on a ward bed without rapid tilt, problems sourcing suitable bronchoscopy equipment, and the non-use of cricoid pressure and a nasogastric tube before anaesthesia.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply cricoid pressure when clinically indicated
Wider context from the report “4. Cricoid pressure and NG tubes were not used in this case .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a bronchoscope on the standard anaesthetic equipment trolley
Wider context from the report “3. A bronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a functional bronchoscope suction button
Wider context from the report “3. A bronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing .
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of previous medical records for clinical decision-making
Wider context from the report “1. The deceased’s previous medical records were not available . Different clinical decisions might have been made had they been available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a rapid-tilt trolley for anaesthesia
Wider context from the report “2. The deceased was anaesthetised on a ward bed and it would have helped if he had been on a trolley with rapid tilt .
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use NG tubes when clinically indicated
Wider context from the report “4. Cricoid pressure and NG tubes were not used in this case .
” Open source report
5 Dec 2017 Gwendoline Edith Halfpenny · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 3 Inconsistency between County Hospital and RSUH policies View source Lack of surgical cover at County Hospital View source Inconsistency between County Hospital and RSUH equipment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gwendoline Edith 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
Gwendoline Edith Halfpenny fell and broke her left arm on 1 September 2016, was admitted to County Hospital with bowel problems on 6 September, and died in hospital on 13 September after her condition deteriorated and major surgery was performed. The concerns were the lack of surgical cover at County Hospital and differences in monitoring systems, policies and equipment between County Hospital and the Royal Stoke University Hospital.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between County Hospital and RSUH policies
Wider context from the report “2. Back in September 2016 when this death occurred the MEWS systems operated at County Hospital and RSUH differed. This has subsequently been remedied. However I was told at the Inquest that there are still different policies and equipment at County Hospital than those at RSUH. The hospitals have been part of the same Trust for a considerable period now and I wonder if there should be greater efforts to achieve consistency.
” 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of surgical cover at County Hospital
Wider context from the report “1. Soon after her arrival at County Hospital Mrs Halfpenny would have benefitted from surgical input. There was no surgical cover at County Hospital. Remote advice from RSUH is not the same as a surgical presence and I wonder if there should be a mid-grade surgical doctor at County 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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistency between County Hospital and RSUH equipment
Wider context from the report “2. Back in September 2016 when this death occurred the MEWS systems operated at County Hospital and RSUH differed. This has subsequently been remedied. However I was told at the Inquest that there are still different policies and equipment at County Hospital than those at RSUH . The hospitals have been part of the same Trust for a considerable period now and I wonder if there should be greater efforts to achieve consistency.
” 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 operate a surgical referral procedure providing on-site consultant coverage, same-day review efforts, and direct referral access to the responsible consultant.
Verbatim wording from the response “In February 2015 a Standard Operating Procedure (SOP) to address the surgical referral system was introduced and provides the following:” Source location 2017-0353-Response-by-University-Hospitals-of-North-Midlands-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 Standardise and formalise processes and policies across the integrated hospitals, taking account of their different surgical functions and available funds.
Verbatim wording from the response “2. As outlined above, on integrating what were two separate hospitals, much work was undertaken to standardise and formalise processes and policies as far as possible with the assistance of external agencies. Nevertheless, it is recognised that this is an on-going process. It should also be noted that County Hospital and Royal Stoke University Hospital have very different surgical functions so efforts regarding consistency need to be balanced against these functions taking to account the available funds.” Source location 2017-0353-Response-by-University-Hospitals-of-North-Midlands-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 Realign surgical services so County Hospital has no inpatient general surgery and senior surgeons remain available on site through continuing day-case services.
Verbatim wording from the response “1. At the time of the integration of UHNS and MFST and the re-modelling of services following the closure of MFST, the University Hospitals of North Midlands undertook a substantial amount of work to ensure that services were reviewed and realigned to those sites more suitable to provide the best environment. As a result of this, with effect from 9 February 2015 there were to be no in-patient services at the County Hospital under the care of general surgery (including gastro-intestinal (GI), breast and vascular surgery). However, day case surgeries under other specialties continue to provide a service from this site, so senior surgeons are available.” Source location 2017-0353-Response-by-University-Hospitals-of-North-Midlands-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 Full consistency between County Hospital and Royal Stoke policies and equipment is limited by their different surgical functions and available funds.
Verbatim wording from the response “2. As outlined above, on integrating what were two separate hospitals, much work was undertaken to standardise and formalise processes and policies as far as possible with the assistance of external agencies. Nevertheless, it is recognised that this is an on-going process. It should also be noted that County Hospital and Royal Stoke University Hospital have very different surgical functions so efforts regarding consistency need to be balanced against these functions taking to account the available funds.” Source location 2017-0353-Response-by-University-Hospitals-of-North-Midlands-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 Existing consultant surgeons and the surgical referral procedure provide surgical availability at County Hospital, so additional mid-grade surgical cover is not indicated.
Verbatim wording from the response “1. At the time of the integration of UHNS and MFST and the re-modelling of services following the closure of MFST, the University Hospitals of North Midlands undertook a substantial amount of work to ensure that services were reviewed and realigned to those sites more suitable to provide the best environment. As a result of this, with effect from 9 February 2015 there were to be no in-patient services at the County Hospital under the care of general surgery (including gastro-intestinal (GI), breast and vascular surgery). However, day case surgeries under other specialties continue to provide a service from this site, so senior surgeons are available.” Source location 2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Open published response
28 Nov 2017 Edna Marina Collett · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Failure to move medically fit patients from hospital into suitable social placements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Edna Marina Collett · 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
Edna Marina Collett was admitted to hospital on 10 March 2017 and remained there until her death on 19 May 2017. The report identified delays in arranging a suitable community care package, meaning she stayed in hospital for more than two months despite being fit for discharge, and raised concerns about improving the system for moving patients on from hospital.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to move medically fit patients from hospital into suitable social placements
Wider context from the report “Mrs Collett was in hospital for more than 2 months. For the great majority of that time she did not need to be in hospital and the reason for her being there was that a suitable social placement could not be found for her . You will be well aware of the pressure on hospital beds. Although it may to some extent be out of your control I wonder if you could please look at the existing system to see if there can be improvements in moving patients on from hospital when they are fit to go .
” Open source report
Concerns raised 1 Excessive working hours for consultant neurologists View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Winifred HYDEN · 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
Mary Winifred Hyden had a suprasellar meningioma and died at home on 16 February 2015; the inquest recorded pulmonary thrombo-embolism and an intracranial tumour that was not successfully treated. Concerns included failures in communication about the tumour in 2013 and 2014, and the excessive working hours of a consultant neurologist, described as increasing the potential for fatal errors.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive working hours for consultant neurologists
Wider context from the report “(1) At the inquest I heard helpful evidence from ████████ Consultant Neurologist. She was frank about failures in communication in 2013 and 2014 and advised me of significant changes since Cannock Hospital was transferred to the Wolverhampton Trust. However ████████ also indicated in evidence that she is working regularly 7 days a week and the day before the inquest worked 14 hours (and again this was not unusual) . These do appear to be excessive hours with an increased potential for fatal errors . I should be grateful if you could look at this.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a new job plan reducing the consultant’s clinical sessions.
Verbatim wording from the response “Nevertheless, I understand that the Medical Director and the Clinical Director for Neurosciences have reviewed ████████ job plan (July 2015) and a new job plan will be effective from 1 October 2015. In her new job plan, ████████ clinical sessions will be reduced to allow her to have better work life balance and since November 2014, Dr Summers does not travel to Cannock Hospital to undertake clinics and ward referrals and this has significantly reduced her travel requirements.” Source location 2015-0251-Response-by-University-Hospitals-of-North-Midlands-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 Stop the consultant travelling to Cannock Hospital for clinics and ward referrals.
Verbatim wording from the response “Nevertheless, I understand that the Medical Director and the Clinical Director for Neurosciences have reviewed ████████ job plan (July 2015) and a new job plan will be effective from 1 October 2015. In her new job plan, ████████ clinical sessions will be reduced to allow her to have better work life balance and since November 2014, Dr Summers does not travel to Cannock Hospital to undertake clinics and ward referrals and this has significantly reduced her travel requirements.” Source location 2015-0251-Response-by-University-Hospitals-of-North-Midlands-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 consultant’s job plan to address workload and work-life balance.
Verbatim wording from the response “Nevertheless, I understand that the Medical Director and the Clinical Director for Neurosciences have reviewed ████████ job plan (July 2015) and a new job plan will be effective from 1 October 2015. In her new job plan, ████████ clinical sessions will be reduced to allow her to have better work life balance and since November 2014, Dr Summers does not travel to Cannock Hospital to undertake clinics and ward referrals and this has significantly reduced her travel requirements.” Source location 2015-0251-Response-by-University-Hospitals-of-North-Midlands-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 Encourage the consultant to use available administrative support.
Verbatim wording from the response “In addition to this, ████████ is not currently working in isolation at the County Hospital and has the support of a second Consultant. She has also been encouraged to utilise the administrative support that is available to her. As a Neurosciences Directorate we are keen to provide the right working environment for ████████ and patient safety is very high on our priorities.” Source location 2015-0251-Response-by-University-Hospitals-of-North-Midlands-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 the consultant with support from a second consultant at County Hospital.
Verbatim wording from the response “In addition to this, ████████ is not currently working in isolation at the County Hospital and has the support of a second Consultant. She has also been encouraged to utilise the administrative support that is available to her. As a Neurosciences Directorate we are keen to provide the right working environment for ████████ and patient safety is very high on our priorities.” Source location 2015-0251-Response-by-University-Hospitals-of-North-Midlands-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 consultant’s working arrangements complied with applicable regulations through the compensatory-rest regime and her job plan.
Verbatim wording from the response “The EC Directive on Working Time for Consultants was introduced in October 1998 and from this time onwards, all consultants are covered by the entitlements afforded by the Directive. In 1998, the Central Consultants and Specialists Committee (CCSC) of the British Medical Association and the NHS Executive negotiated a collective agreement regarding the application of the Directive for senior hospital doctors, which applied derogations to inflexible hourly, daily and weekly limits under regulation 21 and in their place established the right of senior hospital doctors to take compensatory rest where the limits were exceeded. These derogations were applied to ensure that continuing responsibility to patients was maintained and the necessary protection for senior hospital doctors under the directive was retained.” Source location 2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Open published response
22 Apr 2014 Audrey Wakefield · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Failure to ensure effective communication of discharge information to GPs at practices outside the Stoke on Trent area View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Audrey Wakefield · 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
Audrey Wakefield suffered a stroke, later fell at a care home, deteriorated after hospital admission, and died at a hospice on 11 April 2013. The principal concern was inadequate communication of discharge information from the hospital to her GP, particularly for practices outside the usual local communication system.
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 North Midlands NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective communication of discharge information to GPs at practices outside the Stoke on Trent area
Wider context from the report “(1) At the Inquest I was greatly assisted by ████████ Consultant Stroke Physician at your hospital. He indicated that when Mrs Wakefield was discharged from UHNS on 16 January 2013 the communication of relevant discharge information to Mrs Wakefield’s GP was not good . The reason was that there is a good communication system from the hospital and GPs in the Stoke on Trent area but this did not apply to more distant practices (Mrs Wakefield’s practice was in Stone). ████████ indicated that steps were being taken to improve this. With Stafford Hospital moving to come under the control of your Trust the situation could be quite serious as a number of GPs practices are likely to be involved. It may be that this is being addressed in any event but I should be grateful if you could check that an effective system of discharge information will apply wherever a patient’s GP’s practice may be situated .
” 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 Continue negotiating annual funding arrangements with external GP practices and request confirmation of payment for electronic correspondence.
Verbatim wording from the response “In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with the system supplier to ‘switch on’ GP practices in South Staffordshire, Shropshire and Cheshire. UHNS funded the one-off development of the solution with the supplier however there is a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic correspondence. This is a matter requiring on-going negotiation although it is common practice nationally, for Clinical Commissioning Groups to fund this within their local area.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a supplier solution enabling electronic discharge correspondence for GP practices beyond Stoke and North Staffordshire.
Verbatim wording from the response “In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with the system supplier to ‘switch on’ GP practices in South Staffordshire, Shropshire and Cheshire. UHNS funded the one-off development of the solution with the supplier however there is a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic correspondence. This is a matter requiring on-going negotiation although it is common practice nationally, for Clinical Commissioning Groups to fund this within their local area.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
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 Switch on electronic discharge correspondence for GP practices in Stone, including the deceased’s practice.
Verbatim wording from the response “The GP practices in Stone were ‘switched on’ by 12 June 2014, including the GP practice which provided care to Mrs Wakefield. All of the remaining Stafford and Cannock GP practices (South Staffs) have committed to being switched on by the end of July; this allows some time prior to UHNS and Mid Staffs Hospital acquisition which is due to occur on 1 November 2014.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
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 Switch on electronic discharge correspondence for remaining Stafford and Cannock GP practices by the end of July 2014.
Verbatim wording from the response “The GP practices in Stone were ‘switched on’ by 12 June 2014, including the GP practice which provided care to Mrs Wakefield. All of the remaining Stafford and Cannock GP practices (South Staffs) have committed to being switched on by the end of July; this allows some time prior to UHNS and Mid Staffs Hospital acquisition which is due to occur on 1 November 2014.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
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 Electronic rollout beyond existing areas cannot be completed until participating areas confirm funding for annual practice charges.
Verbatim wording from the response “A total solution for all areas is proposed to be delivered in three separate phases based on geographical area; South Staffordshire, Shropshire and Cheshire and I wrote to them on 29 April 2014. This will include remote implementation and training where possible, and GP practices will also be supported by a dedicated IT trainer, telephone support during implementation and Standard Operating Procedures. We are still awaiting confirmation from Western Cheshire, South East Staffs and Seisdon, Shropshire and Vale Royal and South Cheshire who have not yet confirmed that they will pay the annual practice charge. I will write to them again to ask them to do this however it may be helpful for you to do the same given that the request came from you.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
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 Ongoing electronic correspondence costs are expected to be funded by GP practices or their local Clinical Commissioning Groups.
Verbatim wording from the response “In order to facilitate the timely electronic distribution of discharge letters beyond Stoke on Trent and North Staffs Clinical Commissioning Groups, a solution has been developed with the system supplier to ‘switch on’ GP practices in South Staffordshire, Shropshire and Cheshire. UHNS funded the one-off development of the solution with the supplier however there is a requirement for each GP practice to pay an annual fee for the on-going delivery of electronic correspondence. This is a matter requiring on-going negotiation although it is common practice nationally, for Clinical Commissioning Groups to fund this within their local area.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
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 Delivery of discharge-information improvements is a shared responsibility involving the Local Health Economy IM&T Group and Clinical Commissioning Groups.
Verbatim wording from the response “Action Taken
The University Hospital of North Staffordshire NHS Trust has considered the Coroner’s concerns and has outlined below the actions taken in conjunction with the wider Local Health Economy (LHE). UHNS does not have a unilateral obligation to resolve the issues and the Trust therefore continues to work in partnership with the LHE IM&T Group and the local Clinical Commissioning Groups.” Source location 2014-0186-Response-by-University-Hospital-of-North-Staffordshire
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations