Concerns raised 9 Failure to maintain accurate clinical notes View source Failure to prescribe and administer treatment for impacted faeces and constipation View source Failure to administer prescribed PABRINEX View source Failure to maintain complete and legible Medical Administration Records View source Delays in commencing antibiotics for patients requiring antimicrobial treatment View source Failure to communicate updated patient information during clinical handover View source Failure to provide adequate treatment for opioid withdrawal View source Lack of Senior Pharmacist review of Medical Administration Record charts View source Failure to refer patients to the Critical Care Outreach Team at required NEWS thresholds View source See 6 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
MARTIN ARNOLD HILL · 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
MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate clinical notes
Wider context from the report “(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given. In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking .
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe and administer treatment for impacted faeces and constipation
Wider context from the report “(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given . In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed PABRINEX
Wider context from the report “(3) Whilst it is noted that Mr. HILL was admitted at lunchtime on a Friday and the critical events took place over a weekend, nonetheless he was known to be an intravenous heroin user on a Methadone prescription and yet he was given no treatment for withdrawal treatment save for 2mg of Diazepam on the 28th March at 22:15 hours and another 2mg of Diazepam at 09:00 on the 30th March. Also on the 30th March PABRINEX was considered and he was written up for this, although this was not given . On the 30th March at 09:50 hours he was given 5ml of METHADONE and later at 13:00 on the 30th March he was given another 5ml of Methadone. (NB: His daily Methadone prescription was 50ml)
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete and legible Medical Administration Records
Wider context from the report “(5) There are serious omissions on the Medical Administration Record . I was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend. Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the Chief Pharmacist.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing antibiotics for patients requiring antimicrobial treatment
Wider context from the report “(1) Although this man arrived in A & E on the 28th March 2014 at approximately 12:30, having been suffering confusion, abdominal pain and vomiting for some three days with raised white cell count and markedly raised C-Reactive Protein. He was not commenced on antibiotics until over 48 hours later at 14:00 hours on the 30th March, 2014 . At Inquest I was told that he should have been commenced on Pragmatic antibiotics shortly after his arrival and assessment by a Doctor in A & E.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate updated patient information during clinical handover
Wider context from the report “(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given. In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate treatment for opioid withdrawal
Wider context from the report “(3) Whilst it is noted that Mr. HILL was admitted at lunchtime on a Friday and the critical events took place over a weekend, nonetheless he was known to be an intravenous heroin user on a Methadone prescription and yet he was given no treatment for withdrawal treatment save for 2mg of Diazepam on the 28th March at 22:15 hours and another 2mg of Diazepam at 09:00 on the 30th March. Also on the 30th March PABRINEX was considered and he was written up for this, although this was not given. On the 30th March at 09:50 hours he was given 5ml of METHADONE and later at 13:00 on the 30th March he was given another 5ml of Methadone . (NB: His daily Methadone prescription was 50ml )
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of Senior Pharmacist review of Medical Administration Record charts
Wider context from the report “(5) There are serious omissions on the Medical Administration Record. I was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend . Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the Chief Pharmacist.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer patients to the Critical Care Outreach Team at required NEWS thresholds
Wider context from the report “(2) At 20:00 hours on the 28th March 2014 after he had been admitted to The Royal Sussex County Hospital, Brighton his NEWS rose from 1 to 6. NEWS’ own Guidance and the Hospital’s Protocol require that Mr. HILL should have been referred to the Critical Care Outreach Team. He was not. His NEWS rose to 6 again on the 30th March 2014 at 00:20 hours. However, he was not referred then either. He was not referred to Critical Care Outreach until his NEWS rose to 10 at 07:00 hours on the 30th March 2014.
” Open source report
Concerns raised 8 Use of trial operators with limited on-site availability and experience View source Insufficient time for trial information review and informed consent before procedures View source Inaccurate terminology about the cause of procedural injury View source Failure to communicate trial involvement and suspected trial-related events to receiving clinicians View source Failure to ensure adequate information for trial clinicians View source Failure to notify the Coroner of a trial patient's death and trial involvement View source Conduct of trial procedures under competing time pressure View source Failure to record suspected trial-related causes in hospital notes View source See 5 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
John Henry ADAMS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Henry Adams died following multiple complications of an appropriate cardiac intervention after being recruited to a cardiac trial just before the procedure. Concerns included whether there was sufficient time for informed consent, the suitability and preparedness of the trial operator, and the recording and communication of the trial’s possible relevance to the cardiac tamponade and subsequent death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of trial operators with limited on-site availability and experience
Wider context from the report “(4) Is it appropriate for a visiting Cardiologist, only present at the Hospital for a few hours every fortnight to be the "operator" to take part in this trial ?
(5) Given that the Consultant Cardiologist in Mr. Adams' case does only visit Brighton once a fortnight for a few hours, and this was his first patient on the Trial, was he himself appropriately informed?
In evidence I was told that he was already late for a Clinic when he left the Hospital, believing that Mr. Adams was fine, and that involvement in the trial meant that the procedure took longer than normal - possibly about half an hour longer.
Does that sort of pressure result in the best outcome?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient time for trial information review and informed consent before procedures
Wider context from the report “(2) Was it appropriate that he should have been recruited within an hour or so prior to his procedure commencing ?
(3) Did this give him time to read the several page booklet which was provided to him and to absorb the information and give informed consent?
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate terminology about the cause of procedural injury
Wider context from the report “(7) The hospital notes in Brighton, the letter of referral to Kings College Hospital and the report to the Coroner all gave the impression, because of the wording used, that what had happened at the PCI was that the diagonal artery had dissected and this is what is believed to have caused the pericardial effusion and tamponade.
The Consultant Cardiologist is the only person to have used the expression "dissection" to describe the damage to the diagonal artery which occurred during the PCI.
Should more care be taken in terminology? In this case it seems to have lead to a great deal of confusion.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate trial involvement and suspected trial-related events to receiving clinicians
Wider context from the report “(8) One of the organisers of the Trial has written in Mr. Adams' notes that he has been notified of what has happened to Mr. Adams but he makes no mention of what is believed to have occurred as a result of the Trial . Why not?
Why was the Trial not mentioned to Kings College Hospital in the Referral letter dated the 1st February 2014?
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate information for trial clinicians
Wider context from the report “(4) Is it appropriate for a visiting Cardiologist, only present at the Hospital for a few hours every fortnight to be the "operator" to take part in this trial?
(5) Given that the Consultant Cardiologist in Mr. Adams' case does only visit Brighton once a fortnight for a few hours, and this was his first patient on the Trial, was he himself appropriately informed?
In evidence I was told that he was already late for a Clinic when he left the Hospital, believing that Mr. Adams was fine, and that involvement in the trial meant that the procedure took longer than normal - possibly about half an hour longer.
Does that sort of pressure result in the best outcome?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the Coroner of a trial patient's death and trial involvement
Wider context from the report “(9) Finally; surely the death of a patient while on a Trial is a matter of major concern to the Trial itself and yet no-one contacted the Coroner , either the original Coroner in South London or me, Coroner for Brighton and Hove when I took over jurisdiction pursuant to Section 2 of the Coroner’s and Justice Act, to let us know that this man had been on a Trial .
If I had known that, and in particular if I had been able to tell ████████ of that fact, she would have been able to ascertain precisely where the bleeding/haemorrhage originated and there would have been good clear helpful information for those managing the Trial and of course future patients who might have benefited from it.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Conduct of trial procedures under competing time pressure
Wider context from the report “(4) Is it appropriate for a visiting Cardiologist, only present at the Hospital for a few hours every fortnight to be the "operator" to take part in this trial?
(5) Given that the Consultant Cardiologist in Mr. Adams' case does only visit Brighton once a fortnight for a few hours, and this was his first patient on the Trial, was he himself appropriately informed?
In evidence I was told that he was already late for a Clinic when he left the Hospital , believing that Mr. Adams was fine, and that involvement in the trial meant that the procedure took longer than normal - possibly about half an hour longer .
Does that sort of pressure result in the best outcome?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record suspected trial-related causes in hospital notes
Wider context from the report “(6) The Hospital notes for Mr. Adams admission on the 30th do not mention the view (apparently formed within an hour or so of surgery), that it was the pacing wires; which was the extra requirement of the Trial; which caused the cardiac tamponade .
Why not? Why was this information effectively concealed?
” Open source report
2 Jun 2014 Denise PRIOR · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Inadequate record-keeping of oxygen levels and prescriptions View source Failure to apply or appropriately depart from the NEWS system View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Denise PRIOR · 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
Denise Prior died on 6 November 2013 following a cardiac arrest after a fall caused by her underlying medical condition. The report raised serious concerns about record-keeping at St Richards Hospital, including recording and prescribing oxygen and applying the National Early Warning Score system, with a stated risk of future deaths.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate record-keeping of oxygen levels and prescriptions
Wider context from the report “That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription , and in the application or departure from the ‘NEWS’ system.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply or appropriately depart from the NEWS system
Wider context from the report “That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription, and in the application or departure from the ‘NEWS’ system .
” 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 Roll out outreach-team review of ward PatientTrack data across both sites and feed findings back to ward sisters.
Verbatim wording from the response “Patient track data reporting – We are planning to roll out the wound care team of the outreach team onto both sites – reviewing individual ward data and feeding back to the sisters. This looks at timeliness of observations in relation to NEWS scores in escalation process. This will highlight wards who may need extra support and more education.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and improve NEWS content in AIMS and ALERT training programmes.
Verbatim wording from the response “Continue to ensure NEWS section on AIMS and ALERT course programme is adequate.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Re-audit oxygen-policy use and redistribute the updated Rapid Response report.
Verbatim wording from the response “There was Rapid Response alert issued by NPSA in 2009. This alerted all NHS organisations to assess and self-implement the issues identified but there is a case for refreshing the message after five years on.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 and highlight NEWS escalation issues through monthly Sisters’ meetings.
Verbatim wording from the response “Monthly agenda item at Sisters’ meetings to discuss and highlight sites to review the NEWS process; both sites to highlight low escalation.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Obtain online medical-gases training for nurses and establish a method for completing it.
Verbatim wording from the response “We are going to have access to online training packages for nurses in relation to medical gases including oxygen and should ensure that they understand their usefulness and a method to implement their completion.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Reinforce NEWS scoring and escalation during annual resuscitation training updates.
Verbatim wording from the response “NEWS is discussed at resuscitation training annual updates – ensure that scoring and escalation is reinforced at these sessions on both sites.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Obtain an online F1 training package containing oxygen-prescribing content and make completion mandatory during doctors’ first year.
Verbatim wording from the response “We are going to have access to an online training package (via HEKSS) for F1s – which a respiratory section of which should be included in oxygen prescribing. This should become mandatory training for doctors for completion during the first year.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Share the upgraded oxygen-device recording facility with other UK hospitals using PatientTrack.
Verbatim wording from the response “The team at WSHT are also in the process of upgrading this facility so that the actual oxygen device (e.g. nasal prongs, Venturi, non-invasive ventilation) can also be recorded in Patientrack, and this facility will also be shared with other hospitals in the UK using Patientrack.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 ward-based NEWS update and drop-in sessions.
Verbatim wording from the response “Action taken
Matron’s outreach to do update sessions on the wards to ensure all know the process, using Patient Safety paper version of ward meetings, ‘drop in’ update sessions.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 cardiac-arrest cases and provide feedback on inappropriate observation frequency through root-cause analysis.
Verbatim wording from the response “Cardiac arrest cases – all are currently reviewed, including frequency of observations. This will be fed back to teams if not appropriate as part of RCA.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Document NEWS discussions and assess whether the NEWS chart requires revision.
Verbatim wording from the response “Action taken
Document what has been discussed with NEWS and whether creating NEWS chart needs revising to allow better revising to allow better documentation on chart itself.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Apply the Trust oxygen-prescribing and monitoring policy in all settings.
Verbatim wording from the response “Action taken
There is a current and very robust Trust policy regarding prescribing and monitoring of oxygen – all requirements to be followed in all settings.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Upgrade PatientTrack to record the oxygen device delivered to patients.
Verbatim wording from the response “Oxygen concentration for mechanically ventilated patient monitored” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide laminated ward escalation sheets showing escalation thresholds and observation-recording requirements.
Verbatim wording from the response “Ensure all wards have:” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 Keep ward nursing-station computers available for high-flag screening and observation scheduling.
Verbatim wording from the response “Ensure all wards have:” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with the current drug chart and present outcomes to clinical governance groups.
Verbatim wording from the response “Compliance with the current drug chart, which was developed in line with oxygen prescribing policy and directs towards the identification of device and O2 saturation target.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Move inspired-oxygen recording from the electronic observation chart to the electronic prescribing screen.
Verbatim wording from the response “In contradiction to the evidence given to the Assistant Coroner at the inquest, PatientTrack does have the facility to record inspired oxygen concentration (FiO2) delivered to the patient and this is used within the Trust. The screenshot below is currently taken place on the electronic observation chart, but will move onto the electronic prescribing screen where it is a realtime facility for recording and not describing, hence the opposite gives a realtime assessment of the inspired oxygen.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 current Trust policy robustly governs oxygen prescribing and monitoring, with requirements to be followed in all settings.
Verbatim wording from the response “Matter of concern
(2) Lack of recording of oxygen prescription and concentration and accountability on patient track.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 PatientTrack already has, and the Trust uses, a facility to record inspired oxygen concentration delivered to patients.
Verbatim wording from the response “(4) Record of inspired Oxygen concentration on PatientTrack.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 PatientTrack appears accessible via desktop computers; intermittency was attributed to uncharged Android handheld devices rather than system unavailability.
Verbatim wording from the response “(3) Problems with intermittency of working of patient track paper as an alternative.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-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 PatientTrack is intended as the normal record, with paper charts reserved for significant information-technology problems.
Verbatim wording from the response “The issue appears to be that the Android handheld devices were not charged, as PatientTrack can be accessed at all times by desktop computers at the nurses station.” Source location 2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Open published response
29 Apr 2014 Janet BLACKMAN · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Failure to apply DVT avoidance policy to patients in psychiatric units View source Failure to provide seamless physical and mental healthcare including DVT prophylaxis within a single unit View source Failure to apply DVT prophylaxis policy and clerking to patients entering psychiatric units View source Failure of psychiatric units to deliver required physical healthcare 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
Janet BLACKMAN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janet Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply DVT avoidance policy to patients in psychiatric units
Wider context from the report “(3) By way of emphasis and duplication, that if anything, the NICE recommendations and policy for DVT avoidance is as relevant to patients being treated in psychiatric units as in any other units providing patient 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide seamless physical and mental healthcare including DVT prophylaxis within a single unit
Wider context from the report “(4) It should be possible to develop a system enabling a seamless delivery of care covering both the physical and mental health treatment including DVT Prophylaxis to a patient in a single unit without the need to move patients physically from one unit to another , even if different aspects of care are delivered by different trusts.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply DVT prophylaxis policy and clerking to patients entering psychiatric units
Wider context from the report “(2) It would seem that the logic of the DVT prophylactic policy as recommended by NICE is not applied to those patients coming into the psychiatric units – or if it were then Mrs Blackman would have been subject to the same clerking process on each of her admissions to the HKU and thereafter would have been able to receive the prophylaxis care that had been prescribed for her in the AMU.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of psychiatric units to deliver required physical healthcare
Wider context from the report “(1) The HKU like other units dedicated to the delivery of essentially psychiatric care are not able to deliver at least some of the elements required of the patient for her physical healthcare .
” Open source report
Concerns raised 4 Failure to communicate discharge information to receiving care providers and family View source Failure to ensure patients are medically fit for discharge View source Failure to complete discharge paperwork View source Failure to maintain an ongoing discharge process 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
Graham Harold WATTS · 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
Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate discharge information to receiving care providers and family
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure patients are medically fit for discharge
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete discharge paperwork
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an ongoing discharge process
Wider context from the report “(1) That the Discharge procedure followed in respect of Mr. Watts’ discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4th December 2014 was deeply flawed. There was no ongoing process of discharge.
(2) The discharge paperwork was effectively blank.
(3) There was no communication as to the discharge, either with regard to the anticipated date of discharge or with Nursing Home where expected to receive him back or with Graham Watts’ son. He was medically unfit for discharge arriving back at his Nursing Home hypothermic, hypotensive, oedematous and sleepy.
(4) It is acknowledged and accepted that a change of environment increases the risks of fall.
” 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 Start and evaluate a one-year multidisciplinary pilot for consistent management of frail elderly patients across three wards, with learning intended for wider Trust implementation.
Verbatim wording from the response “The Trust is aiming to start a one year pilot scheme to focus on consistent multi-disciplinary management of frail elderly patients, led by an individual from the discipline most relevant to the individual patient’s circumstances, in preparation for their discharge. Subject to successful recruitment, it is anticipated that the pilot will start in July 2014 on three wards. This pilot will be evaluated throughout the year as well as at its conclusion so that the learning from it can be extended throughout the Trust for the benefit of frail elderly patients.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.
Verbatim wording from the response “The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 Add a social worker to the ward’s daily multidisciplinary Board Round to support discharge planning.
Verbatim wording from the response “In order to reduce the risk of a recurrence, the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily “Board Round”, which staff of several disciplines are encouraged to attend. Recently a social worker has also started to attend these meetings, which also assists in patient discharge planning. The details held on the whiteboard have been adjusted to include more information relevant specifically to discharge planning. It appears that to some extent, some staff on the ward may have felt that the information on the Board had made it no longer necessary to include detailed discharge planning documentation in the individual patient record.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 Adjust Board Round whiteboard information to include discharge-planning details.
Verbatim wording from the response “In order to reduce the risk of a recurrence, the Trust has taken several steps, working closely with the Matron and ward manager responsible for the ward on these issues. It is the practice on this ward to hold a daily “Board Round”, which staff of several disciplines are encouraged to attend. Recently a social worker has also started to attend these meetings, which also assists in patient discharge planning. The details held on the whiteboard have been adjusted to include more information relevant specifically to discharge planning. It appears that to some extent, some staff on the ward may have felt that the information on the Board had made it no longer necessary to include detailed discharge planning documentation in the individual patient record.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.
Verbatim wording from the response “The ward nurses have all had refresher training on the processes they are expected to go through, including but not limited to the related documentation, before any patient is discharged from the ward. This has included a reminder of the correct procedure to be followed with any “Do Not Attempt Cardio-pulmonary Resuscitation” form. The Trust deeply regrets that this form did not accompany Mr Watts on his discharge as it should have done.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.
Verbatim wording from the response “Each month a snapshot audit is being done of 10 sets of medical records from the ward to ensure that they reflect an acceptable standard of discharge documentation. For this ward, the April review of discharge documentation showed 100% compliance with the requirement for documentation in the discharge planner, and also on the provision of information about discharge plans to relatives.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.
Verbatim wording from the response “The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 the forms used for discharge planning.
Verbatim wording from the response “The Trust has reviewed the forms currently used for discharge planning and is devising new paperwork which is intended to facilitate timely documentation, and to encourage daily consideration of each in-patient’s progress towards discharge.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 junior nurses’ shadowing of senior colleagues to strengthen discharge decision-making and communication skills.
Verbatim wording from the response “The senior nursing staff agree that it is essential that a nurse to nurse discharge summary is completed for any patient leaving the hospital to go to, or return to, residential or nursing home care. They have emphasized the importance of this to the ward nurses. As part of the programme for developing the skills of junior nurses, the ward is placing increased emphasis on shadowing senior colleagues, to equip these junior staff with the skills needed to make robust decisions and to give them role models to assist with their communication skills.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.
Verbatim wording from the response “The Trust acknowledges and apologises that there were significant shortcomings in the discharge planning process for Mr Watts, arising from failures by staff to complete thoroughly all the steps necessary to ensure safe and timely discharge for each patient. The Trust does not accept that the process itself was deeply flawed, but acknowledges that it was not implemented adequately on this occasion.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-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 patient was medically ready for discharge, with satisfactory observations and no reason to regard him as medically unready.
Verbatim wording from the response “There is increasing recognition among Trust staff that the nationally widely used term “Medically Fit for Discharge” (often abbreviated to MFFD) can be very misleading. There is a growing ground-swell of opinion that it would be less open to misinterpretation if the phrase “Medically Ready for Discharge” (MRFD) or some similar form of words were adopted. Mr Watts was already for discharge in as much as that he no longer required active medical treatment in an acute hospital at the time of his discharge. His last set of clinical observations taken during the afternoon immediately before he left the hospital were entirely satisfactory, with a National Early Warning Score of zero: there was therefore no reason to identify him as medically unready for discharge.” Source location 2014-0149-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published response
Concerns raised 7 Failure to cannulate patients appropriately View source Failure to provide appropriate care and supervision in AMU View source Failure to record the timing and reason for doctors' visits View source Failure to act on NEWS scores View source Failure to seek early senior review View source Failure to create a care plan and provide assistance View source Failure to record fluid charts correctly View source See 4 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
Herta Edith Maria WOODS · 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
Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to cannulate patients appropriately
Wider context from the report “(5) Failure to cannulate her appropriately . Her cannula had initially been inserted by the ambulance crew; this isued and needed to be replaced. The requirements concerning cannulation of patients are strict. They were not adhered to in Mrs. Wood's case. This should have been dealt with in A & E.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate care and supervision in AMU
Wider context from the report “(1) The apparent abandonment of this lady in AMU .
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the timing and reason for doctors' visits
Wider context from the report “(2) The failure to record the timing and reason for the Doctor's visit (the reason was only illicitied from evidence).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on NEWS scores
Wider context from the report “(4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her. This lady was very likely near the end of her life. However, from the evidence that I heard, it was clear that she would not have died when she did had she been given appropriate care and treatment.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to seek early senior review
Wider context from the report “(3) The failure to seek an early Senior Review for the failure to record the Fluid Chart correctly - this is important because it was fluid overload that was the immediate cause of Mrs. Wood's death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to create a care plan and provide assistance
Wider context from the report “(4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her . This lady was very likely near the end of her life. However, from the evidence that I heard, it was clear that she would not have died when she did had she been given appropriate care and treatment.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record fluid charts correctly
Wider context from the report “(3) The failure to seek an early Senior Review for the failure to record the Fluid Chart correctly - this is important because it was fluid overload that was the immediate cause of Mrs. Wood's death.
” Open source report
Concerns raised 11 Failure of the hospital CT scanning service View source Inadequate ward round documentation View source Inappropriate transfer to an Acute Medical Unit View source Failure to appreciate the dangers of an acute abdomen View source Failure to provide ongoing surgical assessment and response to deterioration View source Delays in surgical review after referral View source Failure to arrange an emergency theatre View source Delays in initial nursing and medical assessment in A & E View source Failure to prepare a patient for urgently needed surgery View source Failure to recognise patient deterioration View source Lack of early senior review View source See 8 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
Stephen John PALMER · 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
Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the hospital CT scanning service
Wider context from the report “(10) A complete failure of the CT scanning service at this Hospital. This led Mr. Palmer to be denied a CT scan which would certainly have diagnosed his condition. This failure arose because the CT scanning system at this Hospital is unfit for purpose.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate ward round documentation
Wider context from the report “(7) There was a completely inadequate Ward Round Note made at the hurried ward round between 08:30 and 08:40 hours. This left the Nursing Staff in the Acute Medical Unit unable to look after this surgical patient efficiently.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inappropriate transfer to an Acute Medical Unit
Wider context from the report “(3) Inappropriate transfer to an Acute Medical Unit when he should either have stayed in A & E or gone to a Surgical Unit. The concern was that he was effectively unsafe and in an inappropriate clinical environment.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appreciate the dangers of an acute abdomen
Wider context from the report “(5) Even though his acute abdomen had been diagnosed at 07:00 hours there was a failure to appreciate the dangers of his condition.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide ongoing surgical assessment and response to deterioration
Wider context from the report “(1) Delay in being seen both by Nursing Staff and Doctors in A & E.
Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013.
Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in surgical review after referral
Wider context from the report “(1) Delay in being seen both by Nursing Staff and Doctors in A & E.
Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013.
Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange an emergency theatre
Wider context from the report “(9) Failure to arrange an emergency theatre for him (CEPD).
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in initial nursing and medical assessment in A & E
Wider context from the report “(1) Delay in being seen both by Nursing Staff and Doctors in A & E.
Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013.
Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare a patient for urgently needed surgery
Wider context from the report “(8) Failure to prepare Mr. Palmer for surgery which it had been acknowledged he needed urgently.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise patient deterioration
Wider context from the report “(4) There was a failure to appreciate his deterioration largely because he was not seen by the Surgical Team in spite of requests that he should be seen.
” 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of early senior review
Wider context from the report “(2) No early senior review.
” Open source report
24 Jan 2014 Lucy Maria GOULDING · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 3 Lack of consultant supervision of emergency paediatric admissions by on-call trainees or sub-consultant paediatric doctors View source Lack of independent consultant assessment of paediatric admissions View source Lack of national guidelines for assessment and investigation of headaches 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
Lucy Maria GOULDING · 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
Lucy Goulding was admitted to hospital on 26 June 2013 with worsening headaches, later collapsed and suffered a cardiorespiratory arrest, and was confirmed dead on 27 June 2013 after emergency treatment for a brain tumour. The principal concerns were inadequate consultant supervision and independent assessment of paediatric admissions, and the lack of national guidelines for assessing and investigating headaches in children.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant supervision of emergency paediatric admissions by on-call trainees or sub-consultant paediatric doctors
Wider context from the report “1. Lack of consultant supervision of on-call paediatric trainees or sub-consultant paediatric doctors admitting paediatric patients as an emergency into Worthing Hospital
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of independent consultant assessment of paediatric admissions
Wider context from the report “2. Lack of independent consultant assessment of paediatric admissions into Worthing Hospital in and outside normal working hours
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for assessment and investigation of headaches in children
Wider context from the report “3. Lack of national guidelines for assessment and investigation of headaches in children
” Open source report
30 Jul 2013 Phillip Arthur Pratt · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Delays in discontinuing Tramadol after onset of confusion View source Failure to assess and reassess the need for alcohol detoxification View source Unavailability of additional nursing staff for high-risk patient monitoring View source Failure to complete medication reconciliation on admission and pre-assessment View source Delays in shoulder X-ray imaging 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
Phillip Arthur Pratt · 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
Phillip Arthur Pratt died on 2 November 2012 at St Richards Hospital after a fall-related fracture, surgery, and a sudden deterioration attributed to bronchopneumonia. The report raised concerns about incomplete medication information, delayed consideration of alcohol detoxification, delayed discontinuation of tramadol after confusion developed, delayed shoulder X-rays, and the unavailability of requested additional nursing staff for a high-risk patient.
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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in discontinuing Tramadol after onset of confusion
Wider context from the report “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken.
(1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication;
(2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed;
(3) The onset of agitation and confusion had been recognized, with a
(4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication ;
(5) There was a delay in x-raying the shoulder. The report comments
(6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and reassess the need for alcohol detoxification
Wider context from the report “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken.
(1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication;
(2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed ;
(3) The onset of agitation and confusion had been recognized, with a
(4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication;
(5) There was a delay in x-raying the shoulder. The report comments
(6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of additional nursing staff for high-risk patient monitoring
Wider context from the report “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken.
(1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication;
(2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed;
(3) The onset of agitation and confusion had been recognized, with a
(4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication;
(5) There was a delay in x-raying the shoulder. The report comments
(6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete medication reconciliation on admission and pre-assessment
Wider context from the report “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken.
(1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication ;
(2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed;
(3) The onset of agitation and confusion had been recognized, with a
(4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication;
(5) There was a delay in x-raying the shoulder. The report comments
(6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in shoulder X-ray imaging
Wider context from the report “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken.
(1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication;
(2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed;
(3) The onset of agitation and confusion had been recognized, with a
(4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication;
(5) There was a delay in x-raying the shoulder . The report comments
(6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not available.
” Open source report
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Addressed to Brighton and Sussex University Hospitals NHS Trust, now represented here by University Hospitals Sussex NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations