Concerns raised 3 Failure to comply with Regulation 20 statutory duty of candour View source Failure to provide relevant documentation to the Coroner under Schedule 5 disclosure duties View source Failure to investigate incidents in accordance with Datix requirements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lee Kenneth Eustace · 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
Lee Kenneth Eustace was admitted for treatment of oesophageal cancer and underwent a gastro-oesophagectomy with jejunostomy feeding. He developed abdominal pain, but the feed was increased and continued, and he subsequently developed jejunostomy feeding syndrome and bowel ischaemia, dying in intensive care on 1 May 2022. The report raises concerns about an insufficient and partly un followed feeding protocol, and about failures to investigate the incident, comply with the Duty of Candour, and provide relevant information to the Coroner.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with Regulation 20 statutory duty of candour
Wider context from the report “I am concerned that the Trust has not complied with its statutory duty under Regulation 20 of the Regulations ; has not provided relevant documentation to the Coroner in accordance with its disclosure duties under Schedule 5 of the Coroners and Justice Act 2009 ("CJA"); and has not investigated this incident in accordance with the requirement to do so under Datix. I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide relevant documentation to the Coroner under Schedule 5 disclosure duties
Wider context from the report “I am concerned that the Trust has not complied with its statutory duty under Regulation 20 of the Regulations; has not provided relevant documentation to the Coroner in accordance with its disclosure duties under Schedule 5 of the Coroners and Justice Act 2009 ("CJA") ; and has not investigated this incident in accordance with the requirement to do so under Datix. I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate incidents in accordance with Datix requirements
Wider context from the report “I am concerned that the Trust has not complied with its statutory duty under Regulation 20 of the Regulations; has not provided relevant documentation to the Coroner in accordance with its disclosure duties under Schedule 5 of the Coroners and Justice Act 2009 ("CJA"); and has not investigated this incident in accordance with the requirement to do so under Datix . I am concerned that if such omissions exist in other cases that there is a risk of deaths occurring in the future due to a lack of proper incident investigation and adherence to statutory requirements relating to patient safety and investigation of deaths.
” 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 Report identified care concerns through the incident reporting system and provide Duty of Candour, investigation and learning.
Verbatim wording from the response “• If any triggers are identified, a Structured Judgement Review (SJR) is undertaken by an independent clinician.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
Concerns raised 1 Failure to provide adequate nursing care and treatment 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
DAVID ARTHUR SHARP BATEMAN · 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
David Arthur Sharp Bateman underwent elective surgery for high-risk cancerous colon polyps on 3 September 2023 and subsequently experienced complications, repeated admissions, deconditioning and cognitive impairment. He died from frailty syndrome on 22 July 2024. The principal concerns were poor nursing care, including inadequate nutritional support, weight monitoring and physiotherapy, and failures in personal and stoma care; the report states that these issues may have contributed to his death and that there was no evidence they had been addressed.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate nursing care and treatment
Wider context from the report “1. The finding of poor nursing care and treatment that was possibly causative of Dave’s death and the evidence of the treating consultant that such poor care raised a mortality risk for other patients .
2. There was no evidence before the court that these concerns have been addressed and remedied.
” Open source report
Concerns raised 3 Failure to learn from serious incidents and consider recommendations for future care View source Failure to assess and manage patients’ behavioural needs and provide enhanced observation of care View source Inadequate analysis of serious incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mary Margaret Pomeroy · 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 Margaret Pomeroy, an 89-year-old hospital inpatient, died after being pushed to the floor by a fellow patient on 3 March 2022, suffering bilateral humeral fractures and deteriorating before her death on 15 March 2022. The inquest found that inadequate assessment and management of the fellow patient’s psychiatric, behavioural and cognitive needs materially contributed to the incident and death. It also identified inadequate analysis of the incident in the hospital’s internal investigation, including failure to identify relevant prior incidents and consider appropriate learning and recommendations.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to learn from serious incidents and consider recommendations for future care
Wider context from the report “At the inquest, the author of UHP NHS’s investigation report (who was the Matron of the relevant ward) accepted, in evidence, that the patient who pushed Mary Pomeroy should, on 3 March 2022, have been subject to enhanced observations of care – this was on the basis that previous assessments in November 2021 and January 2022 had shown that this was required for him owing to his psychiatric and behavioural presentation (which had become more concerning by the end of February/beginning of March 2022) and also because of very recent and specific concerns regarding his behaviour which should have been obvious to ward staff following the incident on 1 March 2022.
The Matron accepted, in evidence, that had enhanced observation and care been in place for the patient (which could have taken a number of forms following assessment, depending on what would have been most clinically and therapeutically appropriate at the time) then he should have been prevented from being in a position where he was able to push Mary Pomeroy to the ground on 3 March 2022.
The Matron accepted, in evidence, that UHP NHS’s RCA report had been incorrect to conclude that the type of incident that occurred on 3 March 2022 could not have been foreseen. The Deputy Chief Nurse of UHP NHS accepted, in evidence, that the SI Panel Meeting should have interrogated the relevant facts and chronology more thoroughly.
The inquest determined that the incident on the ward on 3 March 2022 was foreseeable, based on the concerns about the patient’s behaviour, the likely triggers for him becoming distressed and aggressive and the almost identical incident that had occurred on 1 March 2022. The inquest also determined that the lack of assessment and management of this patient’s behaviour and needs materially contributed to the incident which led to Mary Pomeroy suffering injuries and led to her death.
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of UHP NHS’s RCA report, that there was inadequate analysis of this serious incident by UHP NHS, with concerning circumstances surrounding the care provided not being identified – therefore appropriate recommendations to inform future care provision were not given consideration as part of the RCA investigation/report .
If UHP NHS do not identify concerning matters when carrying out internal investigations and do not take steps to try and learn from serious incidents when they occur , then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and manage patients’ behavioural needs and provide enhanced observation of care
Wider context from the report “At the inquest, the author of UHP NHS’s investigation report (who was the Matron of the relevant ward) accepted, in evidence, that the patient who pushed Mary Pomeroy should, on 3 March 2022, have been subject to enhanced observations of care – this was on the basis that previous assessments in November 2021 and January 2022 had shown that this was required for him owing to his psychiatric and behavioural presentation (which had become more concerning by the end of February/beginning of March 2022) and also because of very recent and specific concerns regarding his behaviour which should have been obvious to ward staff following the incident on 1 March 2022.
The Matron accepted, in evidence, that had enhanced observation and care been in place for the patient (which could have taken a number of forms following assessment, depending on what would have been most clinically and therapeutically appropriate at the time) then he should have been prevented from being in a position where he was able to push Mary Pomeroy to the ground on 3 March 2022.
The Matron accepted, in evidence, that UHP NHS’s RCA report had been incorrect to conclude that the type of incident that occurred on 3 March 2022 could not have been foreseen. The Deputy Chief Nurse of UHP NHS accepted, in evidence, that the SI Panel Meeting should have interrogated the relevant facts and chronology more thoroughly.
The inquest determined that the incident on the ward on 3 March 2022 was foreseeable, based on the concerns about the patient’s behaviour, the likely triggers for him becoming distressed and aggressive and the almost identical incident that had occurred on 1 March 2022. The inquest also determined that the lack of assessment and management of this patient’s behaviour and needs materially contributed to the incident which led to Mary Pomeroy suffering injuries and led to her death.
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of UHP NHS’s RCA report, that there was inadequate analysis of this serious incident by UHP NHS, with concerning circumstances surrounding the care provided not being identified – therefore appropriate recommendations to inform future care provision were not given consideration as part of the RCA investigation/report.
If UHP NHS do not identify concerning matters when carrying out internal investigations and do not take steps to try and learn from serious incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate analysis of serious incidents
Wider context from the report “At the inquest, the author of UHP NHS’s investigation report (who was the Matron of the relevant ward) accepted, in evidence, that the patient who pushed Mary Pomeroy should, on 3 March 2022, have been subject to enhanced observations of care – this was on the basis that previous assessments in November 2021 and January 2022 had shown that this was required for him owing to his psychiatric and behavioural presentation (which had become more concerning by the end of February/beginning of March 2022) and also because of very recent and specific concerns regarding his behaviour which should have been obvious to ward staff following the incident on 1 March 2022.
The Matron accepted, in evidence, that had enhanced observation and care been in place for the patient (which could have taken a number of forms following assessment, depending on what would have been most clinically and therapeutically appropriate at the time) then he should have been prevented from being in a position where he was able to push Mary Pomeroy to the ground on 3 March 2022.
The Matron accepted, in evidence, that UHP NHS’s RCA report had been incorrect to conclude that the type of incident that occurred on 3 March 2022 could not have been foreseen. The Deputy Chief Nurse of UHP NHS accepted, in evidence, that the SI Panel Meeting should have interrogated the relevant facts and chronology more thoroughly .
The inquest determined that the incident on the ward on 3 March 2022 was foreseeable, based on the concerns about the patient’s behaviour, the likely triggers for him becoming distressed and aggressive and the almost identical incident that had occurred on 1 March 2022. The inquest also determined that the lack of assessment and management of this patient’s behaviour and needs materially contributed to the incident which led to Mary Pomeroy suffering injuries and led to her death.
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of UHP NHS’s RCA report, that there was inadequate analysis of this serious incident by UHP NHS , with concerning circumstances surrounding the care provided not being identified – therefore appropriate recommendations to inform future care provision were not given consideration as part of the RCA investigation/report.
If UHP NHS do not identify concerning matters when carrying out internal investigations and do not take steps to try and learn from serious incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided.
” 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 Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
Verbatim wording from the response “4. Recruitment to x2 Learning Response Lead posts.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
Verbatim wording from the response “In June 2024, in line with other NHS Organisations across England, University Hospitals Plymouth NHS Trust (UHP) transitioned to the use of the Patient Safety Incident Response Framework (PSIRF) and ceased the use of the Serious Incident Framework (SIF).” Source location Response from University Hospitals Plymouth 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 Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
Verbatim wording from the response “5. Recruitment of two Patient Safety Partners. The remit of the Patient Safety Partner role is set out in the National Patient Safety Strategy through the Framework for Involving Patients in Patient Safety. Patient Safety Partners are lay people, who have extensive experience of receiving care and on occasion, may have been involved in safety incidents. As such, they provide a different perspective on patient safety, removing the potential of influence by organisational bias or historical systems.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
Verbatim wording from the response “7. Redesigned our governance processes to further promote transparency and proactive multidisciplinary review of quality concerns and undertaking assurance work on any actions implemented as a result of those concerns. We have done this by ensuring:” Source location Response from University Hospitals Plymouth 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 Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
Verbatim wording from the response “6. Developed a new policy for the investigation of safety incidents, which includes new investigation methods” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
Concerns raised 2 Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site View source Failure to give sufficient weight to continuity of clinical care in transfer decisions 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
Norma Ann Patricia Tellam · 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
Norma Ann Patricia Tellam suffered a fall causing a proximal femoral fracture and underwent surgery, followed by rehabilitation and further surgery after problems developed with the metalwork. She later suffered an upper gastrointestinal bleed and died on 16 April 2023. Concerns included transfers between hospitals that did not give sufficient weight to continuity of clinical care and did not return her to the hospital responsible for her orthopaedic follow-up.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site
Wider context from the report “1. Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her .
2. When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery .
3. Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give sufficient weight to continuity of clinical care in transfer decisions
Wider context from the report “1. Although Mrs Tellam was under the care of Royal Cornwall Hospital and awaiting a post operation follow up, when clinical staff at Liskeard Community Hospital had concerns about a possible infection at the site of the surgery Mrs Tellam was taken to Derriford Hospital rather than to the orthopaedic team at the Royal Cornwall Hospital who had recently operated on her.
2. When Mrs Tellam had recovered from a chest infection she was transferred from Derriford to Liskeard Community Hospital for further rehabilitation rather than to the Royal Cornwall Hospital for follow up on the developing problems with the fixing metalwork at the site of the hip surgery.
3. Decisions relating to the transfer of Mrs Tellam between Liskeard Community Hospital and Derriford Hospital did not give sufficient weight to continuity of clinical care.
” Open source report
Concerns raised 4 Unavailability of neurological status information to surgical and anaesthetic teams View source Failure to record the full extent of significant critical incidents in hospital notes View source Failure to investigate unexplained omissions in critical incident records and handover View source Failure of handover from critical care to surgical teams to convey significant events and clinical status 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
Ian Jacka · 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
Ian Jacka suffered serious injuries after a fall from height on 3 June 2022 and later developed hypoxic brain injury following airway complications during spinal surgery. He died in intensive care on 15 June 2022. The principal concerns were omissions in record keeping and handover about a serious medical episode before surgery, and the absence of a formal written handover process for significant events involving complex patients.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of neurological status information to surgical and anaesthetic teams
Wider context from the report “(5) The surgical and anaesthetic team had no reason to suspect a secondary brain injury. The team had no information on Ian’s neurological status. Ian is likely to have suffered a hypoxic brain injury during the critical incident of 5th June. This will have undermined his resilience and ability to physically withstand the rigors of spinal surgery and airway exchange.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the full extent of significant critical incidents in hospital notes
Wider context from the report “(1) There was an error of omission in record keeping and in handover from critical care to surgery, and that this error likely contributed to Ian’s death.
(2) There was no entry in Ian’s hospital notes to indicate the full extent of the critical incident of 5 June 2022 .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate unexplained omissions in critical incident records and handover
Wider context from the report “(4) The error of omission was unexplained and has not been investigated by the NHS. The evidence regarding the error of omission came to light after the completion of the NHS investigation into Ian’s death. The Consultant Anaesthetist involved in Ian’s operation discovered the fact of the critical incident of 5 June 2022 on a later examination of ventilator data. The data indicated that Ian deteriorated significantly, that he was close to a cardiac arrest and the critical care team saved his life.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of handover from critical care to surgical teams to convey significant events and clinical status
Wider context from the report “(3) There was a lack of information on handover from critical care to the surgical team regarding the full extent of the critical incident of the 5 June 2022. There was a verbal handover which was brief and vague. There was no formal written handover process highlighting significant events.
” 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 Create a pre-operative handover checklist for complex intensive care patients, covering airway, allergies, medications, clotting, blood products and other relevant care information.
Verbatim wording from the response “decision makers, as well as improving the quality of information that is received. The Trust is committed to ensuring that the quality of handovers is as robust as possible given the well evidenced risks, and therefore the following actions have been agreed.” Source location Response from University Hospitals Plymouth 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 Review current intensive care-to-theatre transfer and handover practice.
Verbatim wording from the response “A review of the current practice for reviewing and handing over patients who require transfer from the Intensive Care Unit to the operating theatre has been undertaken. Currently patients are reviewed by the surgical and anaesthetic teams pre-operatively and information is collected and documented by the anaesthetic team using a structured Pre-operative Anaesthetic Assessment chart in keeping with standard procedures across the Trust. The anaesthetic team assess the patient and examine/record relevant information relating to the patient’s history, airway assessment, cardiorespiratory system, and any diagnostic tests and results. The pre-operative assessment is undertaken to formulate a clear anaesthetic plan, but also provides an opportunity to seek additional information, optimise the patient if required, and consider if the surgery is safe to proceed.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing pre-operative assessment, intensive-care access and theatre briefing arrangements address relevant information-sharing needs, alongside a narrower new checklist.
Verbatim wording from the response “A review of the current practice for reviewing and handing over patients who require transfer from the Intensive Care Unit to the operating theatre has been undertaken. Currently patients are reviewed by the surgical and anaesthetic teams pre-operatively and information is collected and documented by the anaesthetic team using a structured Pre-operative Anaesthetic Assessment chart in keeping with standard procedures across the Trust. The anaesthetic team assess the patient and examine/record relevant information relating to the patient’s history, airway assessment, cardiorespiratory system, and any diagnostic tests and results. The pre-operative assessment is undertaken to formulate a clear anaesthetic plan, but also provides an opportunity to seek additional information, optimise the patient if required, and consider if the surgery is safe to proceed.” Source location Response from University Hospitals Plymouth 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 No further pre-operative investigations were considered necessary because neurological assessment showed no change after intubation.
Verbatim wording from the response “The decision to progress to surgical fixation of Mr Jacka’s thoracic spinal injuries was made by the surgical team in consultation with the Intensive Care team and in the knowledge that he had been intubated for respiratory failure early on the 5th June. He had an appropriate clinical neurological assessment during the daytime on the 5th June and was demonstrated to be unchanged following intubation. No other investigations were deemed necessary pre-operatively by the surgical or Intensive Care teams.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The clinical record comprehensively documented the critical incident, and there was no omission in record keeping or handover.
Verbatim wording from the response “The documentation in relation to the critical incident is both comprehensive and appropriate. Mr Jacka deteriorated, requiring intubation and ventilation as a result of type 2 respiratory failure caused by his significant chest and spinal injuries. His blood oxygen saturations and blood pressure fell significantly but were rapidly restored to normal upon the arrival of the ICU registrar with simple interventions after a relatively short period of time. The lowest oxygen saturations and blood pressure values were recorded in the notes by the ICU nurse at the time. Mr Jacka was anaesthetised and intubated – this was technically challenging and represented a difficult airway, but Mr Jacka remained stable throughout this process with no further drop in oxygen levels.” Source location Response from University Hospitals Plymouth NHS Trust
Open published response
Concerns raised 1 Significant under-resourcing of the Pathology Department View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
David Anthony Hulme · 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
David Anthony Hulme had chest symptoms and a right pulmonary abscess, and underwent a right thoracotomy for pneumonectomy on 12 June 2020. After differing pathology opinions identified lymphoma, his condition deteriorated while he remained in intensive care, and he died on 6 March 2021. The concern was that the Pathology Department was significantly under-resourced, including insufficient consultant staffing for thoracic work, affecting timely and accurate diagnosis.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Significant under-resourcing of the Pathology Department
Wider context from the report “I am concerned that the Pathology Department remains significantly under resourced .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with Devon system partners to assess histopathology resources and explore a system solution.
Verbatim wording from the response “Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.” Source location Response from NHS University Hospitals Plymouth
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 Recruit four funded Consultant Pathologists.
Verbatim wording from the response “I can confirm that UHP have approved the funding for 4 x Consultant Pathologist posts and whilst we cannot guarantee a date that these posts will be filled, we hope to recruit into these posts as soon as possible and are in an active recruitment phase.” Source location Response from NHS University Hospitals Plymouth
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use governed outsourcing to strengthen pathology capacity.
Verbatim wording from the response “Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.” Source location Response from NHS University Hospitals Plymouth
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 Work with the Pathology network to develop additional workforce resilience across Devon and Cornwall.
Verbatim wording from the response “Due to this, I would like to assure you that we have taken additional action and are still reviewing mitigating processes we can take to improve the system within which we operate to further reduce the risk of harm occurring to patients. This is as outlined within the evidence already submitted as part of the inquest process, with governed outsourcing and working with system partners across Devon to look at all histopathology resource in our respective organisations to understand if a system solution is possible. We are also working with the Pathology network to try and find additional workforce resilience across Devon and Cornwall.” Source location Response from NHS University Hospitals Plymouth
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 Approve funding for four Consultant Pathologist posts.
Verbatim wording from the response “The evidence submitted both within the RCA and via a further report, authored by the Pathology Operations Manager, confirmed that the business case to appoint further Consultants into the Pathology Department had been approved with funding allocated to this end. It was stated that the recruitment process would commence as soon as possible.” Source location Response from NHS University Hospitals Plymouth
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 national shortage of suitably qualified clinical staff may prevent timely recruitment to the approved Consultant Pathologist posts.
Verbatim wording from the response “I can confirm that UHP have approved the funding for 4 x Consultant Pathologist posts and whilst we cannot guarantee a date that these posts will be filled, we hope to recruit into these posts as soon as possible and are in an active recruitment phase.” Source location Response from NHS University Hospitals Plymouth
Open published response
Concerns raised 6 Failure to perform a sip test to exclude aspiration View source Failure to properly transfer records View source Failure to keep appropriate records View source Failure to identify or remedy the absent aspiration-exclusion test View source Inconsistent consenting procedures for identical endoscopy treatment View source Failure to act on an endoscopy report indicating a possible dangerous complication View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Name not published · 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
The deceased had significant comorbidities, including ischaemic heart disease, and was admitted to hospital for a blood transfusion following a diagnosis of anaemia. An endoscopy to investigate blood loss was abandoned, and on the balance of probability her oesophagus was perforated during the procedure; she developed surgical emphysema, deteriorated and died at Derriford Hospital on 11 December 2017. Concerns included discrepancies in consent for endoscopy, failure to perform or address a ‘sip test’ to exclude aspiration, failure to act on a report indicating a possible dangerous complication, and inadequate record-keeping or transfer of records by senior staff.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform a sip test to exclude aspiration
Wider context from the report “(2) A ‘sip test’ to exclude aspiration was not performed , and there has been no evidence that this had been noted or remedied at the Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly transfer records
Wider context from the report “(4) Appropriate records were not kept, or were not properly transferred , by senior staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep appropriate records
Wider context from the report “(4) Appropriate records were not kept , or were not properly transferred, by senior staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify or remedy the absent aspiration-exclusion test
Wider context from the report “(2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent consenting procedures for identical endoscopy treatment
Wider context from the report “(1) There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on an endoscopy report indicating a possible dangerous complication
Wider context from the report “(3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication .
” 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 Move toward procedure-specific consent information and engage external providers to support standardised information for each procedure.
Verbatim wording from the response “Currently the plan of the organisation is to move to procedure specific consent where possible and appropriate. We are looking to engage with external providers who produce consent and procedural information that are specific to particular procedures. In that way, rather than individual clinicians using their clinical discretion as to what to discuss with patients, standardised information is given each time a patient consents, ensuring all material information is given. For those undergoing elective surgery, it also allows more time for patients to read at their leisure the information provided, so they have time to digest and absorb the relevant information before signing to say they would wish to proceed.” Source location 2021-0211-University-Hospitals-Plymouth_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the revised SIRI process to address similar record-keeping issues immediately when they arise.
Verbatim wording from the response “The Trust accepts that poor record keeping should have been discussed with the individuals at the time of the event to ensure reflective learning. The revised SIRI process will ensure that any similar issues that may arise in the future would be addressed immediately.” Source location 2021-0211-University-Hospitals-Plymouth_Published
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 Responsibility for documenting clinical records to the required standard lies with individual practitioners, under professional and Trust requirements.
Verbatim wording from the response “The Trust accepts that elements of the record keeping were poor in this case. All professional bodies have an expectation that individual practitioners will document in the clinical records to an accepted standard. The Trust also has a policy that reflects this expectation. This highlights that responsibility lies with the individual professional and the Trust expects that each individual documents in the health records in accordance with the Trust’s policy and in line with codes of practice set by professional standards. Nevertheless, the Trust recognises that documentation may suffer during intense working periods and therefore we regularly remind staff at induction and through mandatory training the importance of proper documentation.” Source location 2021-0211-University-Hospitals-Plymouth_Published
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 Sip checking is basic post-recovery care, not a diagnostic test for perforation, and its small fluid volume would not cause mediastinitis.
Verbatim wording from the response “The use of ‘sip’ checking, i.e. ‘drinking a small amount of water post-oesophago-gastro-duodenoscopy (OGD) is to indicate that patients are able to swallow and do not aspirate liquid into the lungs before being allowed to eat. This is part of basic care and doesn’t constitute a diagnostic procedure, merely an aid to support post recovery after an OGD. The sip check is not a test to exclude perforation and the small volume of fluid would not result in mediastinitis.” Source location 2021-0211-University-Hospitals-Plymouth_Published
Open published response
Concerns raised 1 Lack of assurance that recommendations are being followed 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
Euan David Brinley ELLIS · 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
Euan David Brinley ELLIS, who had Marfan’s Syndrome and cardiac vulnerability, attended hospital with chest pains on 19 November 2017 and his GP the following day. He suffered a fatal haemopericardium at home on 23 November 2017. Concerns included limited access to his medical records and assurance that recommendations from a multidisciplinary investigation were being followed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance that recommendations are being followed
Wider context from the report “At the Inquest the Coroner received evidence from ████████ who referred to a multi disciplinary investigation which contained recommendations. The Coroner is concerned to be assured that the recommendations are being followed .
” Open source report
Concerns raised 1 Failure to provide confirmation of fulfilment of Root Cause Analysis recommendations 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
Roger Albert NEAVES · 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
Roger Albert Neaves fell in his bedroom on 16 October 2018, fractured his left femur, was taken to hospital, deteriorated and died on 18 October 2018. The Coroner was concerned to receive confirmation that recommendations from the Hospital Trust’s Root Cause Analysis had been fulfilled.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide confirmation of fulfilment of Root Cause Analysis recommendations
Wider context from the report “The Coroner received evidence from ████████ the author of a Root Cause Analysis conducted by the Hospital Trust following Mr Neaves’s death. That Root Cause Analysis made various recommendations which required action by the Hospital Trust.
The Coroner is concerned to receive confirmation that the recommendations have been fulfilled.
” Open source report
Concerns raised 4 Insufficient radiology clinician staffing View source Failure to transfer prescribed medication to the community hospital View source Failure to transfer complete discharge documentation to the community hospital View source Lack of medical cover at the community hospital during out-of-hours admissions 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
Terence Douglas Thornton · 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
Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient radiology clinician staffing
Wider context from the report “(1) At the Inquest I heard evidence from ████████ Clinical Director for Radiology at Derriford Hospital. He told me that, currently, there are 44 radiologists working within the Trust. He told me that he believed there was a need for up to a further 16 clinicians across a range of specialities .
(2) I also heard evidence from ████████ who felt that work pressures may have caused or contributed to the error that occurred in this instance .
(3) It is not the first time that shortages of radiology clinicians has been brought to my attention at Inquest. I am aware that there are difficulties in this regard nationally but I am concerned that the problems in Derriford appear to be worsening with the consequent risk that similar fatalities may occur in the future. In the circumstances, it is my duty to report this situation to you so that you may consider what action needs to be taken to address the situation.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer prescribed medication to the community hospital
Wider context from the report “BRIEF SUMMARY OF MATTERS OF CONCERN
(1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication . As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.”
(2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication . He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm.
(3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication . You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to transfer complete discharge documentation to the community hospital
Wider context from the report “BRIEF SUMMARY OF MATTERS OF CONCERN
(1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.”
(2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication . He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm.
(3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of medical cover at the community hospital during out-of-hours admissions
Wider context from the report “BRIEF SUMMARY OF MATTERS OF CONCERN
(1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties . The out of hours service had to be contacted for a doctor to attend . In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.”
(2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm.
(3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place.
” 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 Review estimated radiology demand against capacity through business planning.
Verbatim wording from the response “You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.” Source location 2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the radiology establishment by four posts and further expand it.
Verbatim wording from the response “You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.” Source location 2019-0114-Response-by-University-Hospitals-Plymouth-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 vacant neuroradiologist post was not a contributory factor in the incident.
Verbatim wording from the response “You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.” Source location 2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
Open published response
Concerns raised 6 Failure to provide stress-dose steroids View source Failure to prescribe intravenous hydrocortisone when vomiting prevents oral steroid administration View source Failure to administer prescribed steroids View source Lack of a policy for steroid administration and use with multiple comorbidities View source Inadequate staff training and awareness on Nil by Mouth management for patients requiring regular medication View source Inadequate staff awareness and training on steroid management 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
Terence Bradfield · 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
Terence Bradfield entered Derriford Hospital on 1 December 2013 with gastric bleeding and died on 17 December 2013, primarily from the consequences of his gastrointestinal bleed. The report raised concerns that his long-term steroid medication was not given or adequately managed, including when he was vomiting, and about staff training and the absence of policies for steroid management and “Nil by Mouth” patients with co-morbidities.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide stress-dose steroids
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe intravenous hydrocortisone when vomiting prevents oral steroid administration
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed steroids
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for steroid administration and use with multiple comorbidities
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training and awareness on Nil by Mouth management for patients requiring regular medication
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff awareness and training on steroid management
Wider context from the report “(1) They are :
1. Mr. Bradfield was not given his steroids on 2.12.13
2. Mr. Bradfield was not prescribed intravenous hydrocortisone on 4th and 5th December 2013 when Mr. Bradfield had reported vomiting
3. Mr. Bradfield was not put on a stress dose of steroids whilst in Derriford hospital
4. The awareness and training of staff on the issue of steroid management.
5. The lack of a policy on the administration of steroids generally and their use in situations where a number of co – morbidities are present despite this death having arisen in 2013.
6. The training and awareness of staff on the meaning of “Nil by Mouth “ in patients who are suffering from a number of co –morbidities and are on important prescribed medication which needs to be taken regularly notwithstanding any planned necessary procedures .
” Open source report
Concerns raised 2 Lack of an internal radiology major incident response policy View source Lack of available CT imaging resource during simultaneous emergencies 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
Patricia Cragg · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Cragg underwent a high-risk percutaneous intervention and subsequently developed extensive haemorrhage after suspected bleeding from the arterial entry point. Her CT scan was delayed for hours because other patients were also awaiting imaging following an unrelated road traffic collision, and she deteriorated and died before surgery. The principal concerns were insufficient CT capacity during simultaneous emergencies and the absence of an internal radiology major incident policy.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an internal radiology major incident response policy
Wider context from the report “(2) I was told that the radiology department did not have its own internal major incident policy setting out how to respond to situations like that involving Mrs Cragg. ████████ informed me that this was a piece of work he was trying to complete but that he would need input and assistance from his consultant colleagues before being able to do so.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of available CT imaging resource during simultaneous emergencies
Wider context from the report “(1) There was a lack of available CT resource to deal with the two simultaneous sets of emergencies. The inquest heard from ████████ who accepted this had been recognised weakness for a considerable period of time . I was advised that there were two potential courses of action that could be adopted to overcome this difficulty. First, there could be a second on-call consultant radiologist available to assist the first on-call consultant at times of particularly high demand. Secondly, there could be a facility to open up and run a second CT scanner. This would require the presence of the whole range of staff to include radiographers, porters, et cetera. I was told this was the second time in recent years where there had been simultaneous emergencies that inevitably meant there was a delay in reporting a patient's condition . It seems a decision is required as to whether it is appropriate to allocate additional resource to CT imaging and if so how that additional resource should be deployed in times of unexpected high demand.
” Open source report
Concerns raised 3 Inability to weigh patients reliably View source Failure to prescribe Clexane in accordance with Derriford Protocol View source Failure of Pharmacy reviews to identify prescription errors View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harry Glibbery · 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
Harry Glibbery had a chronically infected left hip replacement and underwent a Girdlestone procedure before developing pulmonary emboli. He died on 7 April 2016 after a catastrophic intracerebral haemorrhage while receiving Clexane. The principal concerns were that the Clexane prescription exceeded the Derriford Protocol dose, the error was not identified during pharmacy reviews, and difficulties weighing him may have prevented a dose review as he lost weight.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inability to weigh patients reliably
Wider context from the report “(3) I was advised that during Mr Glibbery’s admission he lost a substantial amount of weight estimated at between 6 – 10 kilograms. ████████ (who gave evidence) expressed their difficulties in having patients weighed . This is particularly difficult for patients who have undergone hip replacements where, I was told, a hoist that is available is not high enough to return patients back to their beds . The importance of this is obvious in patients whose medication is weight-dependent. It is believed that Mr Glibbery was on the cusp of requiring a downward review of the amount of Clexane prescribed to him.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe Clexane in accordance with Derriford Protocol
Wider context from the report “(1) The doctor who originally prescribed the Clexane did not do so in accordance with Derriford Protocol ;
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Pharmacy reviews to identify prescription errors
Wider context from the report “(2) The doctor’s prescription error was not identified during Pharmacy reviews intended to pick up precisely this sort of shortcoming ;
” 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 Monitor postoperative patient weighing with Senior Nurses.
Verbatim wording from the response “measurements being taken, even if there are considerable technical issues. We will monitor this with the Senior Nurses. This does represent significant challenges, both as a result of the patient’s condition and the various mechanisms which are common to patients in this particular.” Source location 2016-0292-Response-by-Plymouth-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ePMA order sets linked to diagnosis, with weight-based dose calculation and time-limited weight updates.
Verbatim wording from the response “Furthermore, the Trust will be investing in the implementation of an electronic prescribing and medicines administration (ePMA) system during 2017. This system will include the use of “order sets” linked to diagnosis, which will ensure that the correct protocol is chosen. For weight specific dosing the patient’s weight will have to be entered in to the system and the dose will be automatically calculated. It will be possible for this functionality to be time limited, such that a new weight would have to be entered at a defined point in time (e.g. every 7 days) and a new dose calculated.” Source location 2016-0292-Response-by-Plymouth-Hospital-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 three therapeutic Clexane protocols through the Thrombosis Committee.
Verbatim wording from the response “There are currently three protocols for the use of “therapeutic” Clexane (i.e. not prophylactic use) – DVT / PE protocol; “Bridging therapy” protocol for patients that are routinely prescribed warfarin prior to admission; protocol for the management of Acute Coronary Syndrome.
In response to this incident, these protocols will be reviewed by the Thrombosis Committee and clear guidance disseminated across the Trust.” Source location 2016-0292-Response-by-Plymouth-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a pharmacist learning package covering therapeutic Clexane dosing, weight dependence and weight-loss-related dose changes.
Verbatim wording from the response “In response to this incident we have developed a learning package which is being delivered by the Deputy Senior Pharmacist to all pharmacists within the department emphasising the following points:” Source location 2016-0292-Response-by-Plymouth-Hospital-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 Disseminate clear therapeutic Clexane protocol guidance across the Trust.
Verbatim wording from the response “There are currently three protocols for the use of “therapeutic” Clexane (i.e. not prophylactic use) – DVT / PE protocol; “Bridging therapy” protocol for patients that are routinely prescribed warfarin prior to admission; protocol for the management of Acute Coronary Syndrome.
In response to this incident, these protocols will be reviewed by the Thrombosis Committee and clear guidance disseminated across the Trust.” Source location 2016-0292-Response-by-Plymouth-Hospital-NHS-Trust
Open published response
Concerns raised 4 Failure to document headache assessment and clinical reasoning View source Inadequate and incomplete recording of clinical events View source Failure to apply updated Neurology referral criteria for reported weakness View source Delays in processing incoming clinical consultation records View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Thomas Alexander Burchell · 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
Thomas Alexander Burchell had a brain tumour and developed progressive seizures after transfer for neurosurgical treatment; the post-mortem medical cause of death was brain swelling and infarction associated with glioblastoma. Concerns included incomplete records of the seizures and inadequate documentation and assessment of earlier headaches and weakness, including delays in processing prior medical records and uncertainty about referral guidance.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document headache assessment and clinical reasoning
Wider context from the report “(1) There is nothing in the records to explain how ████████ came to the view that Thomas was suffering from stress related headaches. Further, there is nothing in the notes to confirm whether or not he asked Thomas any questions at all about his headaches . In his evidence, ████████ had to accept that it was possible he did not do so.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incomplete recording of clinical events
Wider context from the report “(1) Inadequate and incomplete record keeping . This is in respect of both medical and nursing records . In particular, the seizure chart stated late and finished early . It is far from an accurate or complete record of what happened to Thomas .
(2) In a neurosurgical unit I understand there will be patients having seizures on a regular basis. I further understand that it is extremely rare for those seizures to progress as befell Thomas and then prove resistant to treatment. Where a patient does develop seizures, however, I consider that there should be a far more robust and complete record of the relevant events .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply updated Neurology referral criteria for reported weakness
Wider context from the report “(3) In his preparation for a subsequent significant events meeting, ████████ identified that the basis for referring a patient to Neurology had changed. He had previously been under the impression that he needed not only to have a complaint of weakness but also objectively to identify and confirm this weakness. He accepted that the guidance had changed so that a complaint of weakness alone was sufficient to warrant referral.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in processing incoming clinical consultation records
Wider context from the report “(2) ████████ also accepted in evidence that had he seen the notes and records from the Exeter consultation (which red flagged the headache entry) he would have treated Thomas differently and perhaps taken his concerns more seriously.. It was not completely clear when the records from the Exeter consultation arrived at the Borchardt practice. It was, however, before Thomas’ appointment with ████████ and there may have been several days (perhaps as much as a week) between the arrival of the notes and their “processing” by administrative staff . Such a delay is undesirable.
” Open source report
Concerns raised 5 Delays in determining patients’ mental health state View source Lack of resources for dealing with challenging and vulnerable patients View source Delays in recognising patients for whom usual discharge options are unavailable View source Lack of guidelines or protocols for discharging challenging patients View source Delays in approaching nursing homes able to accommodate patients View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
William John Charles Harnell · 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
William John Charles Harnell suffered a fractured left hip while attempting to mobilise from his wheelchair on 22 October 2014, remained in hospital, developed hospital-acquired pneumonia and died on 15 December 2014. Concerns included delays in recognising the difficulties surrounding his discharge, assessing his mental health, approaching suitable nursing homes, and a lack of resources and guidance for managing challenging and vulnerable patients.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in determining patients’ mental health state
Wider context from the report “(2) There appears to have been delay in determining Mr Harnell’s state of mental health
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of resources for dealing with challenging and vulnerable patients
Wider context from the report “(4) There appears to be a lack of resources available for dealing with challenging (and vulnerable) patients like Mr Harnell.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in recognising patients for whom usual discharge options are unavailable
Wider context from the report “(1) There was delay in recognising that Mr Harnell was a most challenging patient for whom the usual means of discharge would not all be available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of guidelines or protocols for discharging challenging patients
Wider context from the report “(5) There appears to be no guideline or protocol to assist staff on how best to deal with the discharge of patients like Mr Harnell .
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in approaching nursing homes able to accommodate patients
Wider context from the report “(3) There appears to have been delay in approaching the Nursing Homes that may have been able to accommodate him .
” Open source report
Concerns raised 1 Failure of newly qualified clinicians to identify sepsis deaths in children 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
Ella Rose Block · 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
Ella Rose Block was admitted to Derriford Hospital on 1 March 2013, unwell and feverish, deteriorated overnight, and died on 2 March 2013. The concerns identified were that an opportunity may have been missed to provide suitable treatment and that newly qualified clinicians may not readily identify deaths of children resulting from sepsis.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of newly qualified clinicians to identify sepsis deaths in children
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
An opportunity may have been missed to provide suitable treatment. Deaths of children as a result of Sepsis are fortunately rare but as a result new qualified clinicians are not readily identifying such deaths
” Open source report
Concerns raised 5 Failure to hand over outstanding investigations and required result checks during staff shift changes View source Failure to identify and address prolonged delays in urgent investigations View source Failure to order an indicated chest X-ray promptly on emergency department admission View source Delays in performing urgent investigations View source Delays in medical review of investigation results View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Audrey Christine DAWS · 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 Christine Daws was admitted to Derriford Hospital with chest pain and other symptoms, but her chest X-ray was delayed and its result was not identified promptly. The X-ray eventually showed air under the diaphragm indicating a perforation; she underwent surgery, deteriorated and died. The principal concerns were inadequate handover of outstanding investigations and delays in ordering, performing and reviewing the X-ray.
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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over outstanding investigations and required result checks during staff shift changes
Wider context from the report “1. Handover of Information. The need for Mrs Daws to undergo a chest X-ray and for the result to be checked appears to have been lost as medical staff have changed at the end/start of consecutive shifts. You may wish to consider whether there needs to be a formal handover in respect of every patient where outstanding investigations are highlighted.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address prolonged delays in urgent investigations
Wider context from the report “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department.
One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue.
Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to order an indicated chest X-ray promptly on emergency department admission
Wider context from the report “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department.
One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue.
Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in performing urgent investigations
Wider context from the report “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department.
One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue.
Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred.
” 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 Plymouth NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in medical review of investigation results
Wider context from the report “2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department.
One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue.
Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish radiography performance standards for MAU and ward requests and monitor compliance monthly.
Verbatim wording from the response “Within the last 18 months, we have established strict standards which define a level of expectation for the performance of tests requested by various services. In relation to the MAU, there is a 4 hour standard which is monitored monthly – this shows that there is currently a median delay of 2 hours between request and performance of the examination. It is also worth noting that a significant number of tests are performed in less than an hour, with very few at 4 hours and no extreme outliers over the last year. In relation to patients on the ward, there is a 24 hour standard. Irrespective of either of these standards, any patient can be identified as urgent and the examination expedited by telephone or personal communication with the inpatient radiographic team.” Source location 2014-0318-Plymouth-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use ward patient plans and boards to track investigations, tests and urgent treatment, with daily nursing and medical review.
Verbatim wording from the response “• Each ward has a plan for every patient (this involves a whiteboard with a clear plan of daily investigations together with the tests ordered and expected for each patient, which can be tracked by nursing and medical staff). A second board, which includes tests or treatment which are urgent for the on-call doctors is evident by the nurses station. The plans for each patient are discussed on a daily basis with nursing and medical staff.” Source location 2014-0318-Plymouth-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require review of outstanding tests and verbal and written handover before transferring MAU patients to wards.
Verbatim wording from the response “• There is a full handover of every patient on the MAU with outstanding tests – no patient is transferred until all tests have been reviewed and there has been a verbal and written handover to the receiving team on the ward.” Source location 2014-0318-Plymouth-Hospital-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request overnight radiographs for relevant patients regardless of whether they are asleep.
Verbatim wording from the response “As indicated previously, many of the patients have their radiographs in transition between the Emergency Department and MAU. There is no delay in these patients receiving their radiograph whatsoever and these patients have been excluded from the data, which would in effect reduce the median time, were they to be included. With regard to patients being requested for radiograph that might have their examinations overnight I have asked that these examinations be performed irrespective of whether or not the patient is sleeping, on account of the fact that these patients may have been administered opiates.” Source location 2014-0318-Plymouth-Hospital-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 Radiograph patients with chest pain during transfer from the Emergency Department to the MAU.
Verbatim wording from the response “• All patients with chest pain are now radiographed on the way to the MAU, rather than the test being requested on the MAU and the patient having to return to the Emergency Department for the test.” Source location 2014-0318-Plymouth-Hospital-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 Conduct formal handovers for every on-call team to transfer information and identify outstanding tests and concerns.
Verbatim wording from the response “• There are now formal shift handovers for every on-call team, both within the week and weekend, which manage the transfer of information between shifts and identify outstanding tests and cases of concern.” Source location 2014-0318-Plymouth-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Radiography delays are within established standards, and patients transferred from the Emergency Department to the MAU receive radiographs without delay.
Verbatim wording from the response “Within the last 18 months, we have established strict standards which define a level of expectation for the performance of tests requested by various services. In relation to the MAU, there is a 4 hour standard which is monitored monthly – this shows that there is currently a median delay of 2 hours between request and performance of the examination. It is also worth noting that a significant number of tests are performed in less than an hour, with very few at 4 hours and no extreme outliers over the last year. In relation to patients on the ward, there is a 24 hour standard. Irrespective of either of these standards, any patient can be identified as urgent and the examination expedited by telephone or personal communication with the inpatient radiographic team.” Source location 2014-0318-Plymouth-Hospital-NHS-Trust
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations