28 Oct 2025 Lewis Aubrey GARFIELD · Prevention of Future Deaths report Northamptonshire
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Concerns raised 7 Delays in transferring patients from the Emergency Department into wards View source Failure to provide interim safety guidance while awaiting ambulance arrival View source Delays in ambulance-to-hospital handover View source Delays in medically trained clinician review of ambulance call information View source Delays in transferring ambulance patients into the Emergency Department View source Failure to adequately record and accurately and completely convey symptom information View source Failure to base triage category changes on evidence of clinical change or deterioration View source See 4 more concerns
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AI-generated summary
Lewis Aubrey GARFIELD · 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
Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring patients from the Emergency Department into wards
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards , causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide interim safety guidance while awaiting ambulance arrival
Wider context from the report “c) The family complained of not being given any guidance on how to deal with the patient pending the arrival of an ambulance e.g. not to move him given the fall down the stairs .
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance-to-hospital handover
Wider context from the report “d) I understand that nationally, the target time for handover from ambulance to hospital staff is 15 minutes. In the present case, the handover from ambulance to nursing staff at John Radcliffe Hospital took 25 minutes. However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours . The Trust lost 115 hours waiting to handover at Northampton over 121 hours at Kettering.
e) I heard evidence that steps are being taken to mitigate the impact of pressures in the healthcare system. University Hospitals of Northamptonshire have adopted the ‘45-minute handover’ approach. Despite this, on the day of the inquest on 27 October 2025, average handover times at Northampton General Hospital were 1 hour 11 minutes and I suspect that this will get worse during the full onset of winter pressures.
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Delays in medically trained clinician review of ambulance call information
Wider context from the report “b) The first call was at around 00:44 hours but it was not until over 4 hours later at 05:05 hrs that a medically trained clinician first reviewed the facts , immediately escalating it to category 1.
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring ambulance patients into the Emergency Department
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED , and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record and accurately and completely convey symptom information
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Failure to base triage category changes on evidence of clinical change or deterioration
Wider context from the report “a) It was not clear if information about the symptoms taken by SCAS was adequate or if it had been recorded or conveyed by them accurately/completely. It was odd that the call was upgraded to category 2, just 14 minutes after being designated a category 3, without any evidence that there had been a change or deterioration.
” 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 Hold twice-weekly system-partner escalation calls to support complex discharges.
Verbatim wording from the response “| Improved discharge planning and boardround documentation.
May 2025 | Release to Respond Go live NGH. | Implement release to respond model with key escalation triggers to balance clinical risk across the organisation.
June 2025 | NyeBevan move to medicine specialty only and address backflow of patients with GIRFT. | Reduced LoS on NyeBevan with reduced medical outliers in surgical wards.
July 2025 | Use of Siren to review patient identifiable information from EMAS pre arrival. | Reduce delays associated with registration of patients into EPR.
Sept 2025 | Twice weekly system partner escalation calls for complex discharge support. | Improvement in super stranded position across UHN.
Oct 2025 | Cardiology Virtual Ward launched at NGH. | Reduce length of stay through virtual monitoring of heart failure patients who would otherwise meet criteria to reside.” Source location Response from University Hospitals of Northamptonshire
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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 Reopen Sir Thomas Moore Ward as a 24/7 discharge lounge, adding 14 bed spaces and eight chairs.
Verbatim wording from the response “Date | Action Implemented | Impact
Mar 2025 | Implementation of a standardised Transfer of Care (TOC) form across UHN. | Improve quality and reduce delays associated with TOC referrals into the discharge hub.
Mar 2025 | Frailty SDEC go live KGH. | Dedicated capacity for Frailty SDEC service.
Mar 2025 | Agreement of Internal Professional Standards across UHN. | Expectations on timeliness of specialty support and escalation.
Apr 2025 | Sir Thomas Moore Ward (KGH) reopened to adult patients for 24/7 discharge lounge. | 14 additional bed spaces and 8 chairs for patients planned discharge to reduce length of stay.
Apr 2025 | Formalised direct to SDEC pathways for EMAS and extended operating hours. | 15% increase in SDEC activity to reduce ED attendance and overcrowding.
Apr-May 2025 | Boardround test for change and Boardround SOP (NGH).” Source location Response from University Hospitals of Northamptonshire
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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 standardised Transfer of Care form across the organisation to improve discharge-hub referrals.
Verbatim wording from the response “Date | Action Implemented | Impact
Mar 2025 | Implementation of a standardised Transfer of Care (TOC) form across UHN. | Improve quality and reduce delays associated with TOC referrals into the discharge hub.
Mar 2025 | Frailty SDEC go live KGH. | Dedicated capacity for Frailty SDEC service.
Mar 2025 | Agreement of Internal Professional Standards across UHN. | Expectations on timeliness of specialty support and escalation.
Apr 2025 | Sir Thomas Moore Ward (KGH) reopened to adult patients for 24/7 discharge lounge. | 14 additional bed spaces and 8 chairs for patients planned discharge to reduce length of stay.
Apr 2025 | Formalised direct to SDEC pathways for EMAS and extended operating hours. | 15% increase in SDEC activity to reduce ED attendance and overcrowding.
Apr-May 2025 | Boardround test for change and Boardround SOP (NGH).” Source location Response from University Hospitals of Northamptonshire
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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 Formalise direct ambulance pathways to Same Day Emergency Care and extend operating hours.
Verbatim wording from the response “Date | Action Implemented | Impact
Mar 2025 | Implementation of a standardised Transfer of Care (TOC) form across UHN. | Improve quality and reduce delays associated with TOC referrals into the discharge hub.
Mar 2025 | Frailty SDEC go live KGH. | Dedicated capacity for Frailty SDEC service.
Mar 2025 | Agreement of Internal Professional Standards across UHN. | Expectations on timeliness of specialty support and escalation.
Apr 2025 | Sir Thomas Moore Ward (KGH) reopened to adult patients for 24/7 discharge lounge. | 14 additional bed spaces and 8 chairs for patients planned discharge to reduce length of stay.
Apr 2025 | Formalised direct to SDEC pathways for EMAS and extended operating hours. | 15% increase in SDEC activity to reduce ED attendance and overcrowding.
Apr-May 2025 | Boardround test for change and Boardround SOP (NGH).” Source location Response from University Hospitals of Northamptonshire
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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 Launch Rapid Assessment and Acute Assessment Units to expand ambulance handover capacity and stream patients directly into acute assessment.
Verbatim wording from the response “Oct 2025 | Frailty SDEC go live NGH. | Frailty team based in medical SDEC for specialty assessment.
Oct 2025 | Trusted Assessor introduced at NGH. | Reduce discharge delays for patients returning to care homes.
Nov 2025 | Rapid Assessment Unit (RAU) and Acute Assessment Unit (AAU) go live. | Increase in capacity of ambulance handover space and medical pathway directly into AAU reducing ED demand.
Dec 2025 | Introduction of nerve centre pre arrivals screen | Improvement in <15min handovers as EMAS Siren clinical history added as pre arrival ready for handover once ambulance arrives to site.” Source location Response from University Hospitals of Northamptonshire
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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 a NerveCentre pre-arrival screen using ambulance clinical histories to prepare handovers before arrival.
Verbatim wording from the response “Oct 2025 | Frailty SDEC go live NGH. | Frailty team based in medical SDEC for specialty assessment.
Oct 2025 | Trusted Assessor introduced at NGH. | Reduce discharge delays for patients returning to care homes.
Nov 2025 | Rapid Assessment Unit (RAU) and Acute Assessment Unit (AAU) go live. | Increase in capacity of ambulance handover space and medical pathway directly into AAU reducing ED demand.
Dec 2025 | Introduction of nerve centre pre arrivals screen | Improvement in <15min handovers as EMAS Siren clinical history added as pre arrival ready for handover once ambulance arrives to site.” Source location Response from University Hospitals of Northamptonshire
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 Use Siren to review ambulance pre-arrival patient information and reduce registration delays.
Verbatim wording from the response “| Improved discharge planning and boardround documentation.
May 2025 | Release to Respond Go live NGH. | Implement release to respond model with key escalation triggers to balance clinical risk across the organisation.
June 2025 | NyeBevan move to medicine specialty only and address backflow of patients with GIRFT. | Reduced LoS on NyeBevan with reduced medical outliers in surgical wards.
July 2025 | Use of Siren to review patient identifiable information from EMAS pre arrival. | Reduce delays associated with registration of patients into EPR.
Sept 2025 | Twice weekly system partner escalation calls for complex discharge support. | Improvement in super stranded position across UHN.
Oct 2025 | Cardiology Virtual Ward launched at NGH. | Reduce length of stay through virtual monitoring of heart failure patients who would otherwise meet criteria to reside.” Source location Response from University Hospitals of Northamptonshire
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 Commission eight additional Rapid Assessment Unit trolley spaces at Northampton General Hospital for primary assessment and faster handover.
Verbatim wording from the response “As of Monday 3rd November at NGH, a new purpose built Rapid Assessment Unit (RAU) was commissioned providing 8 additional trolley spaces aimed at handover within 15mins into a dedicated space for primary assessment of patients. This forms a key part of strategic planning that will see a new Urgent Treatment Centre open from July 2026 with works already having commenced.” Source location Response from University Hospitals of Northamptonshire
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with system partners to reduce delay impacts and implement the national 45-minute maximum ambulance handover standard.
Verbatim wording from the response “Overcrowding in the Emergency Department is well recognised as impacting on quality and safety, increasing risk of harm to patients if unable to handover from ambulances. This risk is actively monitored through the Trust Accountability Framework with performance and actions reviewed through Divisional Accountability meetings, Clinical Quality and Safety Committee in Common, Trust Board and ICB UEC Board. In line with this year’s 2025/26 planning guidance and Urgent and Emergency Care Recovery plan a 45min handover ceiling has been worked towards in close collaboration with EMAS colleagues both at Directorate and Director level.” Source location Response from University Hospitals of Northamptonshire
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14 Mar 2025 Dominic Martin PHILIP · Prevention of Future Deaths report Northamptonshire
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Concerns raised 3 Unexplained exposure to Lidocaine, including for people allergic to Lidocaine View source Lack of pre-injection identification of potential allergy to iodinated contrast agents View source Failure to maintain accountable removal and stock counts for Lidocaine 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
Dominic Martin PHILIP · 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
Dominic Martin Philip died at Kettering General Hospital on 3 February 2023 from an anaphylactic reaction to contrast medium injected for an abdominal CT scan. Concerns included whether potential allergies to contrast medium could be identified before injection, the unexplained presence of Lidocaine in his blood despite his disclosed Lidocaine allergy, and controls over the storage and removal of Lidocaine.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals of Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Unexplained exposure to Lidocaine, including for people allergic to Lidocaine
Wider context from the report “b) Mr Philip did disclose an allergy to Lidocaine. The toxicology report records that Lidocaine was detected in Mr Philip’s blood post-mortem. Despite the hospital conducting a comprehensive review of the care provided, it has not been possible to ascertain why Lidocaine was present in Mr Philip’s system . Aside from the contrast medium, the only medication that Mr Philip received at hospital was IV Tazocin, IV paracetamol, Oramorph and IV saline. The toxicologist has also ruled out any possibility of contamination of the blood sample during testing. The toxicologist adds “I note that Mr Philip described as healthy so I would not expect its use outside a hospital setting”. There was no other source identified at inquest . I am therefore concerned that Mr Philip has come into contact with Lidocaine without any explanation – could there be a contaminated supply of medication? Have there been any similar unexplained occurrences anywhere else in the country? This is of course of particular concern to those who, like Mr Philip, are allergic to Lidocaine .
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Lack of pre-injection identification of potential allergy to iodinated contrast agents
Wider context from the report “a) It was stated in evidence that - an X-Ray is no longer preferred as it is not sensitive enough and a smaller obstruction might be missed; anaphylactic type reactions to iodinated contrast agents are rare accounting for 0.6% of cases with only 0.04% considered aggressive; and almost all contrast reactions that are life threatening occur within 20 minutes of intravenous injection. The current policy appears to be that a patient referred for a CT scan by the Emergency Department is to be accompanied by a doctor trained in advanced life support (ALS). In Mr Philip’s case, he was accompanied by a Core Trainee Year 2 who had ALS training. The policy for planned/outpatient interventions was not fully explored at inquest, but there was a suggestion that there might be some possibility testing for an allergic reaction to the contrast medium in advance of such an appointment? My concern is that if a patient has never before had contrast medium (as was the case with Mr Philip) they cannot possibly know if they have an allergy to it . Making arrangements for ALS after the event seems reactionary and I wondered if any other options might be available which would flag a potential allergy before the contrast is injected .
” 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 Northamptonshire NHS Group; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accountable removal and stock counts for Lidocaine
Wider context from the report “c) It has also been brought to my attention in a different case currently under investigation within my jurisdiction that as Lidocaine is a prescription only medication, it needs to be stored in a locked cupboard. However, Lidocaine is not a Controlled Drug which means that clinicians do not need a double signature to remove the medication from the stock and it is not subject to a count of the stock each time an ampoule is used . The Hospital has stated that “The use of Lidocaine will vary within each area dependant on the patients being seen within each department and treatments given. Stock levels are reviewed by pharmacy to ascertain stock required. Unless a large amount of stock was removed from a single clinical area there would be no alert to indicate that Lidocaine was being removed for reasons other than patient treatment ”.
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No reliable standardised test can currently predict contrast reactions in patients without prior adverse symptoms.
Verbatim wording from the response “It should further be noted that there is currently no reliable or standardised test to predict patients that may have a reaction to contrast without any history of adverse symptoms.” Source location Response from University Hospitals of Northamptonshire NHS Group
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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 relevant MHRA alerts makes manufacturer-contaminated medication an unlikely source of the lidocaine.
Verbatim wording from the response “A review of the MHRA alerts revealed one alert nationally relating to product contamination and this involved a tablet of loperamide. There were no incidences concerning Lidocaine. Therefore, it is unlikely that the patient was given contaminated medication from a manufacturer.” Source location Response from University Hospitals of Northamptonshire NHS Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine allergy testing is not viable because services lack capacity and testing could delay diagnostic and cancer-treatment pathways.
Verbatim wording from the response “This immunology testing is not available at either of the hospitals within the University Hospitals of Northamptonshire (UHN) and patients would need to be referred to tertiary centres such as Leicester, Oxford or Addenbrooke’s to obtain this test. This process would have a potential significant impact on patients in the Northamptonshire area in terms of time, travel and cost.” Source location Response from University Hospitals of Northamptonshire NHS Group
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations