Concerns raised 12 Failure to monitor Trust staff after training View source Failure to encourage reporting of suboptimal and dangerous practices View source Failure to disseminate near-miss events View source Failure to control provision of hazardous substances to agency staff View source Failure to communicate important practices and protocols View source Failure to maintain separation of cleaner and food-and-water handling roles View source Failure to identify near-miss events View source Failure to provide effective training for Trust and agency staff View source Failure of Housekeeping supervisors to adhere to required practices View source Failure to learn from previous mistakes View source Lack of control over hazardous-substance training for agency staff View source Failure to comply with COSHH requirements View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 13
Action
Separate Host, Catering Assistant and Housekeeper roles, with dedicated Catering Assistants, differentiated uniforms and a Trust-wide rollout.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024. View source
Action
Secure cleaning cupboards with swipe-card access, restrict access to authorised trained staff and retain access records.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Deliver and disseminate an inquest-learning presentation that explains system failures and instructs staff to report COSHH and patient-safety concerns.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Update COSHH training and use anonymised inquest learning to strengthen staff understanding of hazardous-substance risks.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Remove opaque coloured patient jugs and require clear jugs exclusively for patients’ drinking water.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Appraise the Trust incident-reporting system and develop preliminary recommendations for improving incident data capture and analysis.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024. View source
Action
Move Catering Assistants into the Food Safety Manager’s reporting line and provide refresher training when staff transfer, with training records securely maintained and reviewed.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Recruit permanent Facilities and Estates staff, avoid agency Housekeepers and Catering Assistants, and require Trust induction and statutory and mandatory training for new staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024. View source
Action
Record and formally investigate COSHH breaches, remove involved staff from duty during investigations, provide retraining and monitor resulting actions and learning.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Conduct scheduled and unscheduled hospital environmental checks on COSHH storage and use.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Discuss the incident at Board and Executive Committee meetings and continue promoting an open culture of learning across the Trust.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 February 2024. View source
Action
Maintain revised COSHH folders in every ward and department, including product listings, usage guidance, risk assessments and guidelines.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source
Action
Embed COSHH management in operational meetings and safety huddles, with Food Improvement Group monitoring, governance escalation and organisation-wide communication of learning.
Stated completedThe respondent said that this action was complete when they made their response on 23 February 2024. View source See 10 more actions
×
AI-generated summary
Mrs. Joan Catherine BLABER · 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 report concerns the death of Mrs. Joan Catherine BLABER, with the circumstances referred to in the Record of Inquest. The principal concerns included failures to comply with COSHH requirements, inadequate training and supervision, confusion over staff roles, poor communication of practices, and failures to report and learn from dangerous or near-miss events.
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 monitor Trust staff after training
Wider context from the report “(5) Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances.
” 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 encourage reporting of suboptimal and dangerous practices
Wider context from the report “(7) Failure to encourage reporting of suboptimal and dangerous practices within the 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 Failure to disseminate near-miss events
Wider context from the report “(8) Failure to identify "near miss" events, to disseminate these and to learn from previous mistakes.
” 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 control provision of hazardous substances to agency staff
Wider context from the report “(6) Failures in supervisory staff in the Housekeeping department (particularly those on the fourth floor of the Thomas Kemp Tower) to adhere to their own practices and requirements eg. Giving Agency Staff a container of Flash to take away . Blatant breach of COSHH
” 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 important practices and protocols
Wider context from the report “(4) Failure to communicate important practices/protocols eg. water jug 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 maintain separation of cleaner and food-and-water handling roles
Wider context from the report “(3) Confusion in roles . Mixing the roles of the cleaners with those members of staff who should only be dealing with food and water .
” 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 identify near-miss events
Wider context from the report “(8) Failure to identify "near miss" events , to disseminate these and to learn from previous mistakes.
” 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 effective training for Trust and agency staff
Wider context from the report “(2) Failures in training (both Trust and Agency Staff) and in particular to ensure that training has been understood and retained .
” 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 Housekeeping supervisors to adhere to required practices
Wider context from the report “(6) Failures in supervisory staff in the Housekeeping department (particularly those on the fourth floor of the Thomas Kemp Tower) to adhere to their own practices and requirements eg. Giving Agency Staff a container of Flash to take away. Blatant breach of COSHH
” 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 learn from previous mistakes
Wider context from the report “(8) Failure to identify "near miss" events, to disseminate these and to learn from previous mistakes .
” 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 control over hazardous-substance training for agency staff
Wider context from the report “(5) Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances .
” 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 comply with COSHH requirements
Wider context from the report “(1) Historic and ongoing failure to comply with Control of Substances Hazardous to Health Regulations (COSHH)
” 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 Separate Host, Catering Assistant and Housekeeper roles, with dedicated Catering Assistants, differentiated uniforms and a Trust-wide rollout.
Verbatim wording from the response “I am pleased to say the roles of Hosts and Housekeepers has been split and clarified as recommended by you at the inquest. We now have dedicated Catering Assistants who have no cleaning duties outside the kitchen. Housekeepers are now tasked with cleaning duties and do not deal with patients’ food or water. These new clearer roles have started in the Barry Building, Sussex Eye Hospital and the Nursery and there is a roll out programme in progress so the whole of the Trust will be incorporated by the end of March 2019. To” Source location Response from Brighton and Sussex University Hospitals
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 Secure cleaning cupboards with swipe-card access, restrict access to authorised trained staff and retain access records.
Verbatim wording from the response “The Trust’s cleaning cupboards have been modified now to swipe card access only to guarantee they are secure at all times and we have a record of who has accessed the cupboards and when. Only with permission from ████████ can staff have their ID cards updated to include access to a cleaning cupboard. The introduction of swipe card access has meant we have significantly reduced the number of staff who have access to COSHH products and the staff who do have access have all received the appropriate COSHH training. This alone has made our hospitals much safer for patients, visitors and staff.” Source location Response from Brighton and Sussex University Hospitals
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 and disseminate an inquest-learning presentation that explains system failures and instructs staff to report COSHH and patient-safety concerns.
Verbatim wording from the response “████████ also designed a presentation using the learning from Mrs Blaber’s inquest which she has delivered to her teams and a wider audience, being open and frank about what happened, the system failures and our organisational learning. This presentation encourages staff to report any concerns about patient safety / COSHH management immediately to their line manager and to report it as an incident on Datix.” Source location Response from Brighton and Sussex University Hospitals
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 Update COSHH training and use anonymised inquest learning to strengthen staff understanding of hazardous-substance risks.
Verbatim wording from the response “████████, Clinical Director for Facilities and Estates has confirmed that our COSHH training has been reviewed and updated. Our training includes anonymised extracts from evidence given at Mrs Blaber’s inquest to ensure our staff can actually relate to the content and are aware of the seriousness of COSHH products in our hospitals.” Source location Response from Brighton and Sussex University Hospitals
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 Remove opaque coloured patient jugs and require clear jugs exclusively for patients’ drinking water.
Verbatim wording from the response “All patient jugs are now clear so the contents can be easily seen. All opaque coloured jugs have been removed from use. The training our staff have received confirms that clear jugs are the only jugs to be used, and they are only to be used for patients’ drinking water.” Source location Response from Brighton and Sussex University Hospitals
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 Appraise the Trust incident-reporting system and develop preliminary recommendations for improving incident data capture and analysis.
Verbatim wording from the response “Following the inquest, ████████, our Deputy Chief of Safety has commenced a wide ranging appraisal of the Trust’s Incident Reporting system. This piece of work is still in progress, the preliminary recommendations include:” Source location Response from Brighton and Sussex University Hospitals
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 Catering Assistants into the Food Safety Manager’s reporting line and provide refresher training when staff transfer, with training records securely maintained and reviewed.
Verbatim wording from the response “make these distinct roles clearer for patients, families, visitors and staff, new uniforms have been ordered so the uniforms of the two distinct roles are not confused and are well differentiated. Furthermore, the management structure has been updated. Catering Assistants (Hosts) are now managed by the Food Safety Manager so they are not under the same managerial line as the Housekeepers. When each member of staff has moved across to the new management structure, there has been a review of the training they have received, they have received refresher training whether they were due this or not, under their new management structure. The training records are securely stored and regularly reviewed to ensure training is up to date.” Source location Response from Brighton and Sussex University Hospitals
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 permanent Facilities and Estates staff, avoid agency Housekeepers and Catering Assistants, and require Trust induction and statutory and mandatory training for new staff.
Verbatim wording from the response “Following Mrs Blaber’s inquest we have not employed any Agency Housekeepers or Catering Assistants. It is our intention to remain in this position as there is a full recruitment programme in place to recruit permanent members of staff to any vacancies. Any new members of staff will attend Trust Induction (no matter what role they undertake) and undertake the Trust's programme of statutory and mandatory training (this portfolio includes Health and Safety Training). All Facilities and Estates staff training is monitored by the Facilities and Estates Learning and Development Manager and kept in date.” Source location Response from Brighton and Sussex University Hospitals
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 Record and formally investigate COSHH breaches, remove involved staff from duty during investigations, provide retraining and monitor resulting actions and learning.
Verbatim wording from the response “I have been assured that any breaches (however minor they may seem) are recorded on Datix and investigated formally by the Facilities and Estates Directorate and our HR team; staff involved are removed from duty immediately and receive retraining during the investigation process. Any actions identified as necessary from the investigation are put in place and monitored by the Senior Management team in Facilities and Estates who report actions and learning to the Health and Safety Committee.” Source location Response from Brighton and Sussex University Hospitals
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 scheduled and unscheduled hospital environmental checks on COSHH storage and use.
Verbatim wording from the response “████████ undertakes scheduled walks around the hospitals to conduct environmental checks and non scheduled checks too so she, and I, can be assured that the correct safety standards are adhered to in relation to the safe storage and use of COSHH products throughout our hospitals.” Source location Response from Brighton and Sussex University Hospitals
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 Discuss the incident at Board and Executive Committee meetings and continue promoting an open culture of learning across the Trust.
Verbatim wording from the response “As you have said, it is unlikely that we will ever know how Flash cleaning fluid got into Mrs Blaber’s water jug, and I agree. However, I wish to reassure that we have discussed the tragic incident at very high level meetings, including our Board Meetings and Trust Executive Committee meetings, to ensure we have learnt and to embed this learning from the top down, as well as from the ‘hands on’ Housekeepers and Catering Assistants up, and we continue to encourage an open culture of learning at all levels.” Source location Response from Brighton and Sussex University Hospitals
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 revised COSHH folders in every ward and department, including product listings, usage guidance, risk assessments and guidelines.
Verbatim wording from the response “Every ward and department has a revised and up to date COSHH folder listing all COSHH products, their proper usage, risk assessments, and the COSHH guidelines. The CQC at their recent inspection confirmed they were impressed with our COSHH folders and staff knowledge and compliance in relation to COSHH.” Source location Response from Brighton and Sussex University Hospitals
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Embed COSHH management in operational meetings and safety huddles, with Food Improvement Group monitoring, governance escalation and organisation-wide communication of learning.
Verbatim wording from the response “Owing to the culture change brought about by Mrs Blaber’s experience, COSHH management is a regular agenda item on many of our meeting agendas. For example, it is now routinely discussed at the Patient Led Assessments of the Care Environment (PLACE) meetings, the Weekly Operational Look Forward Meeting and teams’ safety huddles. Terence Walters is the Chair of the Food Improvement Group and Ms Walters has ensured the group monitor and maintain the systems and processes we have put in place and there is a clear governance reporting escalation channel up to the Executives and the Board, for any concerns. The Head of Nursing for Practice Development has become a member of this Group, to ensure that learning is spread across the organisation and any new initiatives are widely communicated to all groups of staff.” Source location Response from Brighton and Sussex University Hospitals
Open published response
Concerns raised 2 Suboptimal care at Ne whaven Downs View source Failure to adhere to the transfer policy 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
Ronald Thomas HARMAN · 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
Ronald Thomas HARMAN was transferred to Newhaven Downs, where his condition deteriorated before he returned to Royal Sussex County Hospital with aspiration pneumonia and died eight days later. Concerns included the Brighton & Sussex University Hospitals NHS Trust’s transfer policy being ignored and care at Newhaven Downs being described as suboptimal.
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 Suboptimal care at Ne whaven Downs
Wider context from the report “(1) Brighton & Sussex University Hospitals NHS Trust’s Transfer Policy once again ignored.
(2) No transfer should take place unless and until it is adhered to.
(3) Care at Ne whaven Downs suboptimal .
Patient deteriorated
Returned to Royal Sussex County Hospital with aspiration pneumonia. Died of aspiration pneumonia (unable to respond to/benefit from anti biotics) 8 days later.
” 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 adhere to the transfer policy
Wider context from the report “(1) Brighton & Sussex University Hospitals NHS Trust’s Transfer Policy once again ignored .
(2) No transfer should take place unless and until it is adhered to.
(3) Care at Ne whaven Downs suboptimal.
Patient deteriorated
Returned to Royal Sussex County Hospital with aspiration pneumonia. Died of aspiration pneumonia (unable to respond to/benefit from anti biotics) 8 days later.
” Open source report
Concerns raised 7 Failure to recognise the urgency of treatment for septic patients View source Delays in endoscopic retrograde cholangiopancreatography View source Insufficient ERCP capacity for urgent requirements View source Failure to arrange early transfer to an appropriate specialist hospital View source Failure to adhere to the Trust’s Transfer Policy View source Lack of supporting paperwork for patient transfers View source Unnecessary transfers to and from the Princess Royal Hospital 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
Rita Elizabeth GILES · 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
Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.
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 recognise the urgency of treatment for septic patients
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement.
There was a failure to appreciate that as she was already septic when she came in the matter was urgent .
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” 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 endoscopic retrograde cholangiopancreatography
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement.
There was a failure to appreciate that as she was already septic when she came in the matter was urgent.
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” 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 ERCP capacity for urgent requirements
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays . The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement .
There was a failure to appreciate that as she was already septic when she came in the matter was urgent.
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” 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 early transfer to an appropriate specialist hospital
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement.
There was a failure to appreciate that as she was already septic when she came in the matter was urgent.
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be , there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” 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 adhere to the Trust’s Transfer Policy
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect .
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement.
There was a failure to appreciate that as she was already septic when she came in the matter was urgent.
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” 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 supporting paperwork for patient transfers
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork .
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement.
There was a failure to appreciate that as she was already septic when she came in the matter was urgent.
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” 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 Unnecessary transfers to and from the Princess Royal Hospital
Wider context from the report “(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork.
(2) The Trust’s own Transfer Policy not adhered too in any respect.
(3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later.
(4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement.
There was a failure to appreciate that as she was already septic when she came in the matter was urgent.
From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round.
” Open source report
Concerns raised 8 Failure to provide enhanced recovery paperwork View source Failure to provide the enhanced recovery cystectomy leaflet View source Inadequate continuity and completeness of hospital notes View source Unavailability of senior urology input during admission View source Unavailability of enhanced recovery nurse specialist support during admission View source Lack of a coherent urology enhanced recovery discharge planning protocol View source Lack of pre-operative preparation View source Failure of the system for recalling discharged urology patients by ambulance 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
Barry John TUCKER · 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 supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.
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 provide enhanced recovery paperwork
Wider context from the report “(3) The Enhanced Recovery Nurse Specialist was also away during his admission. He never met her or received any paperwork from her
” 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 the enhanced recovery cystectomy leaflet
Wider context from the report “(4) He never received a copy of the leaflet “Enhanced Recovery after having a Cystectomy” .
” 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 continuity and completeness of hospital notes
Wider context from the report “(5) Mr. Tucker’s hospital notes from arriving on Michelham Ward were suboptimal, lacking continuity, incomplete and unhelpful .
” 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 senior urology input during admission
Wider context from the report “(2) The Urology Consultant Surgeon was away during his admission and he had no senior input .
” 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 enhanced recovery nurse specialist support during admission
Wider context from the report “(3) The Enhanced Recovery Nurse Specialist was also away during his admission . He never met her or received any paperwork from her
” 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 a coherent urology enhanced recovery discharge planning protocol
Wider context from the report “(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients .
” 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 pre-operative preparation
Wider context from the report “(1) Mr. Tucker received no pre-op preparation .
” 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 the system for recalling discharged urology patients by ambulance
Wider context from the report “(6) Eastbourne District General Hospital’s system for recalling patients to the Urology ward following discharge, if they need to go in by ambulance, is flawed .
” Open source report
Concerns raised 7 Insufficient discussion with patients about their care View source Unstructured discussions about patients’ subsequent care View source Failure to consider patients’ best interests before repeat hub-to-hub transfers View source Delays in decisions to transfer patients between vascular hubs View source Delays in starting thrombolysis after arrival at a receiving vascular hub View source Failure to provide urgent clinical decision-making and care View source Failure of a vascular hub to maintain required staffing and resources 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
Roger Albert Saxby · 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 Saxby died from natural causes, to which delay in treatment and lack of urgency contributed. Concerns included inadequate staffing and resources at Royal Sussex County Hospital, delays in transfer and thrombolysis, and an unstructured discussion about his subsequent care, including two hub-to-hub transfers within 36 hours.
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 Insufficient discussion with patients about their care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 Unstructured discussions about patients’ subsequent care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured .
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 consider patients’ best interests before repeat hub-to-hub transfers
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest .
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 decisions to transfer patients between vascular hubs
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 starting thrombolysis after arrival at a receiving vascular hub
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed .
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 urgent clinical decision-making and care
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” 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 a vascular hub to maintain required staffing and resources
Wider context from the report “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements.
As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources.
I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available.
Resources may be reduced but that is not an excuse for providing unsafe services.
In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed.
After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured.
None of those involved in his case demonstrated any sense of urgency.
There was insufficient discussion with Mr Saxby.
Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest.
The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence.
There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other.
” Open source report
Concerns raised 1 Failure to provide authorised personnel with access to electronic records across hospital departments during weekends and out-of-hours periods 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
Paul Eric GANDER · 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
Paul Eric GANDER’s death was investigated, with the inquest concluding on 27 November 2017 with a narrative conclusion. The principal concern was that, during weekends and out-of-hours, the Consultant Orthopaedic and Trauma Surgeon could not access other departments’ electronic hospital records, and that authorised personnel should have full access to all hospital records.
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 provide authorised personnel with access to electronic records across hospital departments during weekends and out-of-hours periods
Wider context from the report “That at a weekend and out of hours the Consultant Orthopaedic and Trauma Surgeon involved was not able to access the electronic records of other departments within the hospital .
This is completely unacceptable.
This information is imperative.
Arrangements must be made to ensure that full access is given to properly authorised personnel to all hospital records.
” Open source report
Concerns raised 8 Failure to provide enhanced observation during periods of increased falls vulnerability View source Failure to provide meaningful activity during periods of patient vulnerability View source Delays in discharge of MRFD patients View source Failure of handover documentation to communicate individual patient needs View source Unavailability of safe, appropriately fitting non-slip footwear View source Lack of specialist nursing for patients at high risk of falls View source Insufficient staffing for patients in side rooms and balcony areas View source Reliance on reactive rather than proactive falls prevention 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
Patricia Margherita WEBB · 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 Margherita WEBB was an 86-year-old woman who was admitted to hospital after which she experienced six falls, fracturing her hip in the sixth fall. The report raised concerns about fall prevention, observation and meaningful activity, footwear and mobility, staffing and ward layout, handover arrangements, resources, and delays in discharge.
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 provide enhanced observation during periods of increased falls vulnerability
Wider context from the report “(2) There was a plan in mid-September put in place by the Dementia Nurse for Mrs Webb to have increased levels of observation, for her to be engaged in meaningful activity and for allowing her to be more mobile using non slip footwear and a mobility aid.
With regard to the observations I really could not see any evidence that this was giving her enhanced protection. When analysing the falls and their timing it was clear that they always happened early in the morning and often round about the end of the night shift and the start of the day shift when clearly this particular lady was more vulnerable because I suppose she was more active, possibly also if she had been in bed for most of the night she might have been less safely mobile. It’s a shame that this pattern was not observed and arrangements put in place to keep a particular eye on her around this period of time.
With regard to meaningful activity it never appeared in the notes following the mid-September plan and since it wasn’t in the notes I found no evidence that it happened. I would suggest that on each change of shift the meaningful activity which the patient has engaged in is recorded and noted so that if there is something that he or she finds particularly absorbing this activity can be offered at times of particular vulnerability.
With regard to mobilising, I fully appreciate that the wandering patient who is mobile is at particular risk and I also appreciate the difficulty that might be encountered when trying to persuade such a patient to use a mobility aid. Non slip footwear however, is surely much easier to provide. I know that the hospital footwear comprises ‘short socklets’ in different sizes (thus the right size is always difficult to obtain) with non-slip soles. I was told that these can shift round on the foot so that the sole perhaps rides round to the top of the foot meaning the socklet then becomes dangerous.
Wouldn’t it be an idea to see whether proper slippers can be sourced. Perhaps there is a local firm who would like to provide these – it would be a challenge to make them reusable or alternatively if they are cheap enough to be disposed of after use by one patient.
Is it worthwhile liaising with South East Coast Ambulance asking them to encourage patients being bought to hospital to bring their own slippers in exactly the same way as they bring their own medications. Whilst I appreciate many of the slippers bought in by patients will be unsuitable by the same token many will be perfectly acceptable.
” 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 meaningful activity during periods of patient vulnerability
Wider context from the report “(2) There was a plan in mid-September put in place by the Dementia Nurse for Mrs Webb to have increased levels of observation, for her to be engaged in meaningful activity and for allowing her to be more mobile using non slip footwear and a mobility aid.
With regard to the observations I really could not see any evidence that this was giving her enhanced protection. When analysing the falls and their timing it was clear that they always happened early in the morning and often round about the end of the night shift and the start of the day shift when clearly this particular lady was more vulnerable because I suppose she was more active, possibly also if she had been in bed for most of the night she might have been less safely mobile. It’s a shame that this pattern was not observed and arrangements put in place to keep a particular eye on her around this period of time.
With regard to meaningful activity it never appeared in the notes following the mid-September plan and since it wasn’t in the notes I found no evidence that it happened. I would suggest that on each change of shift the meaningful activity which the patient has engaged in is recorded and noted so that if there is something that he or she finds particularly absorbing this activity can be offered at times of particular vulnerability.
With regard to mobilising, I fully appreciate that the wandering patient who is mobile is at particular risk and I also appreciate the difficulty that might be encountered when trying to persuade such a patient to use a mobility aid. Non slip footwear however, is surely much easier to provide. I know that the hospital footwear comprises ‘short socklets’ in different sizes (thus the right size is always difficult to obtain) with non-slip soles. I was told that these can shift round on the foot so that the sole perhaps rides round to the top of the foot meaning the socklet then becomes dangerous.
Wouldn’t it be an idea to see whether proper slippers can be sourced. Perhaps there is a local firm who would like to provide these – it would be a challenge to make them reusable or alternatively if they are cheap enough to be disposed of after use by one patient.
Is it worthwhile liaising with South East Coast Ambulance asking them to encourage patients being bought to hospital to bring their own slippers in exactly the same way as they bring their own medications. Whilst I appreciate many of the slippers bought in by patients will be unsuitable by the same token many will be perfectly acceptable.
” 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 discharge of MRFD patients
Wider context from the report “(7) Discharge itself in the MRFD patient must be speeded up.
” 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 handover documentation to communicate individual patient needs
Wider context from the report “(5) The final area which concerns me is handover. It is such an important time for exchange of information so that appropriate care can be given to each individual patient and from what I heard at Mrs Webb’s Inquest the handover relies more and more on the notes and the notes are relying more and more on tick boxes which are simply not adequate to deal with the individualities of each patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of safe, appropriately fitting non-slip footwear
Wider context from the report “(2) There was a plan in mid-September put in place by the Dementia Nurse for Mrs Webb to have increased levels of observation, for her to be engaged in meaningful activity and for allowing her to be more mobile using non slip footwear and a mobility aid.
With regard to the observations I really could not see any evidence that this was giving her enhanced protection. When analysing the falls and their timing it was clear that they always happened early in the morning and often round about the end of the night shift and the start of the day shift when clearly this particular lady was more vulnerable because I suppose she was more active, possibly also if she had been in bed for most of the night she might have been less safely mobile. It’s a shame that this pattern was not observed and arrangements put in place to keep a particular eye on her around this period of time.
With regard to meaningful activity it never appeared in the notes following the mid-September plan and since it wasn’t in the notes I found no evidence that it happened. I would suggest that on each change of shift the meaningful activity which the patient has engaged in is recorded and noted so that if there is something that he or she finds particularly absorbing this activity can be offered at times of particular vulnerability.
With regard to mobilising, I fully appreciate that the wandering patient who is mobile is at particular risk and I also appreciate the difficulty that might be encountered when trying to persuade such a patient to use a mobility aid. Non slip footwear however, is surely much easier to provide. I know that the hospital footwear comprises ‘short socklets’ in different sizes (thus the right size is always difficult to obtain ) with non-slip soles. I was told that these can shift round on the foot so that the sole perhaps rides round to the top of the foot meaning the socklet then becomes dangerous.
Wouldn’t it be an idea to see whether proper slippers can be sourced. Perhaps there is a local firm who would like to provide these – it would be a challenge to make them reusable or alternatively if they are cheap enough to be disposed of after use by one patient.
Is it worthwhile liaising with South East Coast Ambulance asking them to encourage patients being bought to hospital to bring their own slippers in exactly the same way as they bring their own medications. Whilst I appreciate many of the slippers bought in by patients will be unsuitable by the same token many will be perfectly acceptable.
” 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 specialist nursing for patients at high risk of falls
Wider context from the report “(1) At the Inquest I was told that on Emerald Ward the Nursing staff have a higher awareness of the risk of falls because so many of their patients are at high risk. However, they provide no specialising. Presumably the rationale for this is that they are extremely good at their job and are able to take care of their patients without specialising. Demonstrably in Mrs Webb’s case this did not happen.
” 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 staffing for patients in side rooms and balcony areas
Wider context from the report “(4) I was also told that patients being nursed in side rooms and in the balcony area can produce problems for the nursing staff as I understand it are sometimes short staffed . It may be that when the new building is completed there will be less hidden areas but how many falls will take place between now and 2021 when it is hoped that the building may be open?
” 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 Reliance on reactive rather than proactive falls prevention
Wider context from the report “(3) In the Royal Sussex County Hospital, I understand there is to be or already taking place a trial of ‘buzzer alerts’ for Nurses – I am sure this is an extremely good idea but feel that it may be more profitable to be proactive rather than reactive.
” Open source report
Concerns raised 2 Lack of hospital bed availability delaying patient admission View source Failure to complete hospital handovers within the 30-minute national standard View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ronald William Bennett · 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
Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute to his 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 Lack of hospital bed availability delaying patient admission
Wider context from the report “(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day).
(2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate.
(3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds .
(4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death.
(5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH.
” 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 hospital handovers within the 30-minute national standard
Wider context from the report “(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes . I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes . The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day).
(2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate.
(3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds.
(4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death.
(5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a £31 million capital scheme expanding the emergency floor, Urgent Care Centre, Emergency Department GP input and ambulatory emergency care at Royal Sussex County Hospital.
Verbatim wording from the response “(3) We now have a £31m capital scheme in development to expand the emergency floor, including an expanded Urgent Care Centre at the Royal Sussex County Hospital, more GP input to the Emergency Department and an ambulatory emergency care facility in advance of next winter.” Source location 2017-0097-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 Commission an observational audit of the ambulance handover process to identify further improvements.
Verbatim wording from the response “As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.” Source location 2017-0097-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 Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-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 Implement a joint clinical handover protocol and escalation triggers at 15, 30 and 60 minutes after patient arrival.
Verbatim wording from the response “As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.” Source location 2017-0097-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 Expand Newhaven Downs Community Hospital to create additional discharge capacity.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-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 Implement the SAFER care bundle to improve patient flow and support earlier discharge.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-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 Fund a joint Hospital Ambulance Liaison Officer appointment.
Verbatim wording from the response “As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.” Source location 2017-0097-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 Review service provision at Princess Royal Hospital to relieve pressure on Royal Sussex County Hospital bed capacity.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-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 Work more closely with South East Coast Ambulance Service to improve ambulance handover processes.
Verbatim wording from the response “Since January 2017, there have been significant efforts to work more closely with South East Coast Ambulance Service NHS Foundation Trust (SECAMB) and this has been reflected in improved ambulance handover performance. In March 2017 the ambulance handover performance was the best for two years.” Source location 2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Open published response
Concerns raised 2 Delays in reporting important microbiology results to clinicians View source Failure to send microbiology samples in the correct containers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul William BARBER · 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
Paul William BARBER had recently diagnosed aggressive lung cancer and developed pericarditis with fluid around his heart. Samples of the fluid were sent to microbiology in the wrong containers, causing a potential delay, and the identification of two organisms was not reported to clinicians until shortly after his death. The report identified these as failings, while stating that, on the balance of probabilities, they did not affect the outcome in this case.
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 reporting important microbiology results to clinicians
Wider context from the report “(2) Delay in reporting important results to clinicians . On the 22nd July bacterial growth was detected in the bottles and gram staining showed gram positive cocci – this information was passed to the medical team looking after Mr Barber. On the next day, Saturday 23rd July, the laboratory found the same sample growing two organisms. This indicated that Mr Barber had a bacterial pericarditis – this was a very unusual situation and the identification of the organisms ought to have been given on the Saturday as soon as it was known to the medical team . For some reason the organisms were not reported until Tuesday 26th July shortly after Mr Barber’s death.
Had these results been given appropriately on the 23rd July appropriate steps could have been taken to treat the patient with antibiotics.
It is right to say that in this particular case on the balance of probabilities the two failings mentioned above did not affect the outcome – however it is right to report this so that these mistakes are highlighted and do not occur again either in this Hospital Trust or any other.
” 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 send microbiology samples in the correct containers
Wider context from the report “(1) Samples being sent to microbiology in the wrong containers and to elaborate on that Mr Barber had a recently diagnosed aggressive lung cancer on the back of which he developed pericarditis. By the 21st July 2016 it was clear that there was a collection of fluid around his heart which was susceptible to draining. This was done and sampling of the fluid was sent to the microbiologists for analysis. However, it was sent in the wrong container , this meant that it needed incubation before it could be dealt with giving a potential delay for results of between 24 – 48 hours . If it had been sent in the correct pot there is a good chance that full results would have been available the same day it was sent as the laboratory is open and testing until 7 p.m.
” 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 Discuss the delayed laboratory-result notification at a microbiology and infection clinical governance meeting as training for registrars prioritising urgent follow-up.
Verbatim wording from the response “Concerning the delay in updating the clinicians caring for the patient about the new laboratory findings, the microbiology and infection department have discussed Mr Barber’s case in detail at their clinical governance meeting, as part of training for microbiology registrars to help them discriminate effectively in prioritising urgent follow up for appropriate specimens.” Source location Paul-Barber-Response
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 Circulate Trust-wide guidance on submitting normally sterile body fluids in sterile white-capped containers rather than blood culture bottles.
Verbatim wording from the response “In order to ensure that as many staff as possible learn from these events, a message has been circulated to all Trust staff reminding them that normally sterile body fluids, such as pericardial or ascitic fluid, should only be submitted to the laboratory in a sterile white capped container and not in a blood culture bottle. The same message made it clear that only blood and peritoneal dialysis fluid should be inoculated into blood culture bottles at the bedside. Secondly, the standard operating procedure within the laboratory has been altered so that, if such a specimen is received in the wrong container, an educational message is now sent advising on the correct container to be used in such circumstances so that the staff learn from this.” Source location Paul-Barber-Response
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 Alter the laboratory standard operating procedure to send educational advice when specimens arrive in incorrect containers.
Verbatim wording from the response “In order to ensure that as many staff as possible learn from these events, a message has been circulated to all Trust staff reminding them that normally sterile body fluids, such as pericardial or ascitic fluid, should only be submitted to the laboratory in a sterile white capped container and not in a blood culture bottle. The same message made it clear that only blood and peritoneal dialysis fluid should be inoculated into blood culture bottles at the bedside. Secondly, the standard operating procedure within the laboratory has been altered so that, if such a specimen is received in the wrong container, an educational message is now sent advising on the correct container to be used in such circumstances so that the staff learn from this.” Source location Paul-Barber-Response
Open published response
Concerns raised 2 Failure to medically review suitability for discharge View source Poorly informed discharge decision-making View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Raymond Frank POLLARD · 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
Mr Raymond Frank Pollard was admitted to hospital with community-acquired pneumonia and respiratory and renal problems, including metabolic acidosis and high potassium levels. He was discharged to a rehabilitation nursing home without further arterial blood gas checks, a further doctor review, or reassessment before discharge, but became extremely unwell and required urgent hospital treatment. The principal concerns were that the discharge decision was poorly informed, that he was not reviewed for suitability for discharge, and that the failed discharge seriously compromised him.
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 medically review suitability for discharge
Wider context from the report “(1) A poorly informed decision to discharge made for a patient with no real improvement in his condition.
(2) The patient was not seen again by a doctor or reviewed as to suitability for discharge .
(3) As a result the discharge failed and this failure seriously compromised Mr Pollard.
” 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 Poorly informed discharge decision-making
Wider context from the report “(1) A poorly informed decision to discharge made for a patient with no real improvement in his condition .
(2) The patient was not seen again by a doctor or reviewed as to suitability for discharge.
(3) As a result the discharge failed and this failure seriously compromised Mr Pollard.
” 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 Raise the discharge-related events through Directorate clinical governance meetings and staff training and awareness sessions.
Verbatim wording from the response “Events surrounding Mr Pollard’s discharge are being raised with nursing and medical staff through the Directorate clinical governance meetings and training/awareness sessions for staff which will continue this year, as a means of ensuring learning. These will focus on ensuring adherence to existing policies in respect of:” Source location 2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
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 identified care concerns to identify required improvements and share learning with Respiratory Medicine staff.
Verbatim wording from the response “I am very sorry to read about the circumstances of Mr Pollard’s death and the concerns which you have highlighted. These issues have been reviewed by senior medical and nursing staff, including the Trust’s Head of Nursing, Discharge and Partnerships, to identify improvements required within the Directorate and to ensure that learning from this case is shared with staff in Respiratory Medicine.” Source location 2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
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 Automatic medical review after discharge decisions is unnecessary because board rounds, nurse escalation and existing discharge policies provide sufficient safeguards.
Verbatim wording from the response “I do understand your concern about continuing medical review of complex patients following a decision that they are ready for discharge. The Trust is committed to ensuring that all available medical resources are used as effectively as possible; this includes prioritising those patients who will most benefit from direct medical input, rather than providing automatic medical review of all patients. The medical team does review the progress of all MRFD patients on the daily “board round” and will follow up any issues identified either as a result of that process, or arising from any request from clinical colleagues, including nurses. It is very important, therefore, that existing Trust policies are followed from the point when the patient’s discharge becomes nurse-led, in responding to changes in patients’ symptoms and appropriately requesting medical input.” Source location 2017-0023-Response-by-Brighton-and-West-Sussex-University-Hospital-NHSTrust
Open published response
Concerns raised 1 Unavailability of intensive care beds for time-critical specialist neurosurgical transfers 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
Mary Patricia MULDOWNEY · 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 Patricia Muldowney suffered a spontaneous subarachnoid haemorrhage caused by a ruptured artery and was admitted to East Surrey Hospital on 20 July 2016. Several hospitals refused urgent transfer to specialist neurosurgical care because intensive care beds were unavailable; she was eventually transferred and underwent surgery, but died after her condition deteriorated during transfer. The principal concern was that the lack of an immediately available intensive care bed delayed time-critical surgery, which the report states she probably would have survived if performed promptly.
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 Unavailability of intensive care beds for time-critical specialist neurosurgical transfers
Wider context from the report “In the light of the gravity of Ms Muldowney’s situation, with the only definitive treatment being surgery, she required immediate transfer to a specialist neurosurgical unit, yet she was refused transfer by at least three hospitals who said they had no intensive care beds.
She could have been transferred, undergone surgery, spent time in recovery, and then an intensive care bed procured, perhaps even by transferring out a non neurosurgical patient.
If such a bed was still unavailable, she could then have been transferred to a different hospital , at least having undergone the time critical clot evacuation and aneurysm clipping.
With prompt transfer and surgery, Ms Muldowney would probably have survived.
” Open source report
Concerns raised 18 Failure to assess and investigate reported respiratory deterioration View source Delays in providing pain relief after hospital arrival View source Inadequate patient and ward instructions for fractured-shoulder care View source Failure of orthopaedic staff to see the patient View source Delays in physiotherapy referral View source Delays in recognising dying patients and initiating end-of-life care View source Failure to communicate and document specialist treatment instructions View source Failure to organise orthopaedic review View source Failure to provide proper handover during ward transfer View source Failure to follow the hospital discharge protocol View source Failure to ensure competent selection and application of slings View source Failure to recognise harm from an incorrectly applied sling View source Lack of continuity and active care View source Failure to provide analgesia at discharge View source Failure to complete senior review before discharge View source Failure of senior clinicians to examine patients and specify required treatment View source Failure to provide appropriate positioning and personal care View source Failure to balance medication effects and pain control View source See 15 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
Leslie Isaac LERNER · 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
Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.
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 assess and investigate reported respiratory deterioration
Wider context from the report “17th May – 22nd May 2016
There is no evidence of any continuity of care.
There is good evidence of “hands off” care and nursing.
In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering.
No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics.
In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing, because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing.
” 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 providing pain relief after hospital arrival
Wider context from the report “15th May 2016
(1) Mr Lerner was back at the RSCH, by ambulance at 1006 hrs in considerable pain and discomfort. He was seen by the Consultant in Elderly Medicine at 1645 and was given analgesia at 1700 hrs – ie almost 7 hours after he arrived at the hospital .
This is completely unacceptable, this man was in pain from the fracture and he should have been given pain relief .
At that stage he should also have been reviewed by the Orthopaedic Team, no such review was organised.
” 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 patient and ward instructions for fractured-shoulder care
Wider context from the report “16th May 2016
(1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made.
(2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover.
There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists.
Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder , however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward .
” 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 orthopaedic staff to see the patient
Wider context from the report “16th May 2016
(1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made.
(2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover.
There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists.
Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward.
” 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 physiotherapy referral
Wider context from the report “16th May 2016
(1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made.
(2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover.
There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists .
Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward.
” 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 recognising dying patients and initiating end-of-life care
Wider context from the report “22nd May 2016
(1) This was the day (nine days after its application) that hospital staff realised that the sling was incorrectly tied, and of the wrong type, and had caused a long deep Grade 2 pressure sore and necrotic ulcerated area where it had been pressing into the back of Mr Lerner’s neck. Every time he was moved and repositioned this wound will have chaffed and given him extra pain.
With regard to his medications: these were either given at a level at which he was completely unable to communicate and co-operate and unable to realise that his family were visiting him, or left him in such pain that he was quite unable to manage it, as a result of this, his dementia and confusion worsened.
A wound care nurse referral was made on the 22nd May and he was seen on the 23rd May at 2 p.m.
It was not possible now to apply any sling and it wasn’t until a few days after that, that any careful thought was given to supporting his arm and shoulder in such a way as to minimise the pain.
From the notes, once the sling had been removed Mr Lerner himself appeared brighter and less confused, however this improvement was short lived.
He deteriorated but end of life care was not initiated until the 31st May and he died at 0835 hrs on the morning of the 3rd June. In Court the Elderly Care Consultant accepted that there had been delay in recognising Mr Lerner as a dying patient .
This case showed evidence of lack of communication, lack of care, lack of continuity of care, too much use of ‘virtual’ clinics and a general “hands off” attitude towards this patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate and document specialist treatment instructions
Wider context from the report “16th May 2016
(1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made.
(2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover.
There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists.
Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward.
” 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 organise orthopaedic review
Wider context from the report “15th May 2016
(1) Mr Lerner was back at the RSCH, by ambulance at 1006 hrs in considerable pain and discomfort. He was seen by the Consultant in Elderly Medicine at 1645 and was given analgesia at 1700 hrs – ie almost 7 hours after he arrived at the hospital.
This is completely unacceptable, this man was in pain from the fracture and he should have been given pain relief.
At that stage he should also have been reviewed by the Orthopaedic Team, no such review was organised .
” 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 proper handover during ward transfer
Wider context from the report “16th May 2016
(1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made.
(2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover .
There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists.
Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward.
” 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 follow the hospital discharge protocol
Wider context from the report “14th May 2016
(1) Mr Lerner was kept in the Royal Sussex County Hospital overnight and towards the middle of the day he was discharged without a Senior Review.
I was told that before he was discharged he should have been seen by a Senior Doctor and it may well have been that the inappropriately applied sling would have been recognised.
He was sent home with no analgesia. He should have been given analgesia. It became clear from the evidence that the pain that he suffered was very much part of his overall deterioration and an exacerbating factor with his dementia.
The Hospital’s own Discharge Protocol was not followed , it should have been.
” 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 competent selection and application of slings
Wider context from the report “13th May 2016
(1) Junior Doctor applied wrong sling with wrong knot for Mr Lerner after she had learned that he had had a fractured shoulder which was to be treated conservatively.
I heard that a Nurse should have applied the sling because the chances are that he or she would have known which sling to use and how to apply it .
(2) Although the Junior Doctor discussed Mr Lerner with her Senior, the Senior did not actually see him nor specifically state which type of sling (should have been a collar and cuff) should be applied.
I was told that the Senior should always see the Patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise harm from an incorrectly applied sling
Wider context from the report “17th May – 22nd May 2016
There is no evidence of any continuity of care.
There is good evidence of “hands off” care and nursing.
In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering.
No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics.
In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing, because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing.
” 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 continuity and active care
Wider context from the report “17th May – 22nd May 2016
There is no evidence of any continuity of care.
There is good evidence of “hands off” care and nursing.
In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering.
No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics.
In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing, because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing.
” 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 analgesia at discharge
Wider context from the report “14th May 2016
(1) Mr Lerner was kept in the Royal Sussex County Hospital overnight and towards the middle of the day he was discharged without a Senior Review.
I was told that before he was discharged he should have been seen by a Senior Doctor and it may well have been that the inappropriately applied sling would have been recognised.
He was sent home with no analgesia. He should have been given analgesia. It became clear from the evidence that the pain that he suffered was very much part of his overall deterioration and an exacerbating factor with his dementia.
The Hospital’s own Discharge Protocol was not followed, it should have been.
” 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 senior review before discharge
Wider context from the report “14th May 2016
(1) Mr Lerner was kept in the Royal Sussex County Hospital overnight and towards the middle of the day he was discharged without a Senior Review .
I was told that before he was discharged he should have been seen by a Senior Doctor and it may well have been that the inappropriately applied sling would have been recognised.
He was sent home with no analgesia. He should have been given analgesia. It became clear from the evidence that the pain that he suffered was very much part of his overall deterioration and an exacerbating factor with his dementia.
The Hospital’s own Discharge Protocol was not followed, it should have been.
” 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 senior clinicians to examine patients and specify required treatment
Wider context from the report “13th May 2016
(1) Junior Doctor applied wrong sling with wrong knot for Mr Lerner after she had learned that he had had a fractured shoulder which was to be treated conservatively.
I heard that a Nurse should have applied the sling because the chances are that he or she would have known which sling to use and how to apply it.
(2) Although the Junior Doctor discussed Mr Lerner with her Senior, the Senior did not actually see him nor specifically state which type of sling (should have been a collar and cuff) should be applied .
I was told that the Senior should always see the Patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate positioning and personal care
Wider context from the report “17th May – 22nd May 2016
There is no evidence of any continuity of care.
There is good evidence of “hands off” care and nursing.
In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering.
No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics.
In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing , because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing.
” 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 balance medication effects and pain control
Wider context from the report “22nd May 2016
(1) This was the day (nine days after its application) that hospital staff realised that the sling was incorrectly tied, and of the wrong type, and had caused a long deep Grade 2 pressure sore and necrotic ulcerated area where it had been pressing into the back of Mr Lerner’s neck. Every time he was moved and repositioned this wound will have chaffed and given him extra pain.
With regard to his medications: these were either given at a level at which he was completely unable to communicate and co-operate and unable to realise that his family were visiting him, or left him in such pain that he was quite unable to manage it , as a result of this, his dementia and confusion worsened.
A wound care nurse referral was made on the 22nd May and he was seen on the 23rd May at 2 p.m.
It was not possible now to apply any sling and it wasn’t until a few days after that, that any careful thought was given to supporting his arm and shoulder in such a way as to minimise the pain.
From the notes, once the sling had been removed Mr Lerner himself appeared brighter and less confused, however this improvement was short lived.
He deteriorated but end of life care was not initiated until the 31st May and he died at 0835 hrs on the morning of the 3rd June. In Court the Elderly Care Consultant accepted that there had been delay in recognising Mr Lerner as a dying patient.
This case showed evidence of lack of communication, lack of care, lack of continuity of care, too much use of ‘virtual’ clinics and a general “hands off” attitude towards this patient.
” Open source report
Concerns raised 5 Failure to use NEWS properly View source Inaccurate NEWS scoring View source Failure to report raised NEWS scores to doctors or critical care outreach View source Failure to increase observation frequency during clinical deterioration View source Potential inaccurate timing of recorded observations View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Diana Maxine RITCHIE · 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
Diana Maxine Ritchie was recovering from major surgery when she deteriorated overnight on 5–6 March and suffered a cardiac arrest at around 12.20 hrs on 6 March. Concerns included missed opportunities to escalate care in response to raised NEWS scores, inaccurate or potentially delayed observations, and failures in the use of NEWS across the Trust.
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 use NEWS properly
Wider context from the report “(6) Finally this is not the first time I have had to write a Regulation 28 Report to this Trust which involves abuse of or failure to use NEWS properly at all . It is in my view necessary for there to be substantial and immediate training on proper use of NEWS throughout the Trust.
I am told that there are electronic hand-held ‘smart’ pieces of equipment which can be used to take and record NEWS and which then omit a warning signal if the NEWS is raised. This should be considered at this hospital. I understand that Worthing Hospital (recently rated excellent by the CQC) has this handheld equipment and uses it to good effect.
” 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 NEWS scoring
Wider context from the report “(2) That there were missed opportunities to escalate Mrs Ritchie's treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team. There were eight different NEWS scores taken between 06.30 on the 6th and 11.15 on the 6th.
On two of them the scoring was inaccurate (one was scored 2 points too high and the other was scored 2 points too low ). One of them scored at 4 but the remainder scored at 5 and above. As I say, none of them resulted in a call to critical care outreach or to the ward SHO.
” 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 report raised NEWS scores to doctors or critical care outreach
Wider context from the report “(2) That there were missed opportunities to escalate Mrs Ritchie's treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team . There were eight different NEWS scores taken between 06.30 on the 6th and 11.15 on the 6th.
On two of them the scoring was inaccurate (one was scored 2 points too high and the other was scored 2 points too low). One of them scored at 4 but the remainder scored at 5 and above. As I say, none of them resulted in a call to critical care outreach or to the ward SHO .
” 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 increase observation frequency during clinical deterioration
Wider context from the report “(4) The other area of concern I have is that the observations were not taken more regularly during the night of the 5th/6th March when it was clear that Mrs Ritchie's condition was deteriorating – it should not have needed any form of direction from the doctors attending for these observations to be taken more regularly .
The Nurse in charge of the ward should have been informed and should have made a direction for the appropriate timing of these observations.
” 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 Potential inaccurate timing of recorded observations
Wider context from the report “(5) It was also suggested to me that the observations taken at 11 o’clock, 11.05, 11.10 and 11.15 were not in fact taken at those times but were taken later , after the first relatively short lived loss of consciousness which occurred at around 11.15. If this is correct then this is really an extremely worrying use of this assessment tool.
” 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 Circulate a monthly patient-safety bulletin highlighting recognition and escalation of care for deteriorating patients.
Verbatim wording from the response “The Trust's Patient Safety team sends a “Patients 1st” bulletin each month to all staff. This uses a fictionalized story to draw attention to things that may go wrong and sets out good practice. Since the death of Mrs Ritchie, such a bulletin has been circulated, which focused on the recognition and appropriate escalation of care for a deteriorating patient.” Source location 2016-0296-Response-by-Brighton-and-Sussex-University-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 the detailed business case for investment in an electronic National Early Warning System.
Verbatim wording from the response “The Trust is considering carefully the series of actions which are essential before any electronic NEWS system can be introduced. The Trust provides clinical services in a wide range of buildings - some extremely old - across several sites. As an essential preliminary step, WIFI cover is being extended to cover the whole Trust. It is anticipated that this will be in place in 2017, enabling the Trust to make further progress in automating observations. The Trust Senior Management Team has given support in principle to the introduction of an electronic NEWS system, and the detailed business case required for such an investment is actively being taken forward.” Source location 2016-0296-Response-by-Brighton-and-Sussex-University-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 National Early Warning System safety guidance to all staff through the weekly Spotlight on Safety message and Patient Observation Policy link.
Verbatim wording from the response “In order to extend this learning more widely, I used the Spotlight on Safety, in my weekly message to all staff, to focus on NEWS, saying - among other things - “it is vital that NEWS scores are calculated correctly and acted on appropriately if we are to provide safe care for our patients” and providing a direct link to the Trust's Patient Observation Policy.” Source location 2016-0296-Response-by-Brighton-and-Sussex-University-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 Improve ward staff familiarity with National Early Warning observations, scoring and escalation through reflection and additional training.
Verbatim wording from the response “I recognise, as does the Trust's Interim Chief Nurse, that accurate completion and scoring of observations on the National Early Warning charts, and appropriate escalation, is very important. In the light of these events, considerable action has been taken on the ward concerned (in conjunction with their matron) to ensure that the individuals directly caring for Mrs Ritchie, as well as the rest of the ward team, are fully familiar with what is expected of them. They have reflected carefully on this, as well as attending specific additional training since these sad events to improve their knowledge and skills. The ward action plan is being presented to the monthly adult meeting for women's services, as well as feedback being taken to the safety and quality meeting for wider learning.” Source location 2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
Open published response
15 Jul 2016 Leilani Chute · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 5 Failure to perform cervical replacement in accordance with standard training View source Failure to take steps to address identified care and service delivery issues View source Failure of Root Cause Analysis investigations to identify care and service delivery problems View source Failure to ensure consultant knowledge of manual cervical replacement View source Failure to provide balanced relevant facts for informed consent 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
Leilani Chute · 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
Leilani Chute was delivered by Caesarean section after an unsuccessful trial of instrumental delivery and was in a moribund condition, with terminal bradycardia and no other signs of life. The inquest concluded that she died shortly after birth from hypoxic brain injury and umbilical cord occlusion. The principal concerns were the use of an unendorsed practice of manually pushing back the cervix and inadequate disclosure of relevant risks when obtaining consent for instrumental delivery rather than proceeding directly to Caesarean section.
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 perform cervical replacement in accordance with standard training
Wider context from the report “(1) That the practice of manually pushing back the cervix was one adopted by two junior doctors. This practice was not in accordance with standard training and was conducted without the knowledge of the consultant;
” 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 take steps to address identified care and service delivery issues
Wider context from the report “(3) That neither of the above matters had been identified as a “Care and Service Delivery problem” by the Trust’s Root Cause Analysis investigation and hence no steps had been taken by the Trust to address these issues .
” 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 Root Cause Analysis investigations to identify care and service delivery problems
Wider context from the report “(3) That neither of the above matters had been identified as a “Care and Service Delivery problem” by the Trust’s Root Cause Analysis investigation and hence no steps had been taken by the Trust to address these issues.
” 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 consultant knowledge of manual cervical replacement
Wider context from the report “(1) That the practice of manually pushing back the cervix was one adopted by two junior doctors. This practice was not in accordance with standard training and was conducted without the knowledge of the consultant ;
” 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 balanced relevant facts for informed consent
Wider context from the report “(2) That the manner in which consent was sought from women in labour when there was a choice to be made between attempted instrumental delivery and going straight to a CS did not appear to provide them with the relevant facts in order to come to an informed choice , but presented those facts that favoured the doctor’s preferred approach to management .
” 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 Provide departmental and individual feedback on the audit findings.
Verbatim wording from the response “Feedback from the audit will now take place at both departmental level and for the individuals concerned.” Source location 2016-0251-Response-by-Western-Sussex-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 obstetric and gynaecological medical staff to complete the introduced obstetric consent module every three years.
Verbatim wording from the response “The service has introduced a more in depth online training module for obstetric staff alongside the existing Trust mandatory annual online e-learning on consent. The recently introduced EIDO Healthcare online learning contains a specific module on consent in obstetrics and all obstetric and gynaecological medical staff are now required to undertake this training every three years. The uptake of training will be monitored by the Division and a link to the training is shown below.
http://www.beinformedplus.com/” Source location 2016-0251-Response-by-Western-Sussex-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 Trust and specialty guidance on consent for informed patient choice.
Verbatim wording from the response “i. Policy and guidance” Source location 2016-0251-Response-by-Western-Sussex-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 processes for investigating perinatal deaths using RCOG and CQC best-practice models.
Verbatim wording from the response “i. Processes for planning investigations when perinatal deaths have occurred” Source location 2016-0251-Response-by-Western-Sussex-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 Audit instrumental deliveries to assess whether manually pushing back the cervix formed part of clinical practice.
Verbatim wording from the response “i. Audit of current practice” Source location 2016-0251-Response-by-Western-Sussex-Hospital-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 Share concerns about the cervical practice with the deanery to support wider learning.
Verbatim wording from the response “Initial feedback with the supervising consultants has taken place for both the trainee doctors who used this procedure prior to them leaving the Trust. Further formal meetings are scheduled to take place that include their educational supervisors from their time at WSHT and their new supervisors. Your concerns will also be shared with the deanery to ensure there is wider learning.” Source location 2016-0251-Response-by-Western-Sussex-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 Obtain Trust governance-team support to make Serious Incident root-cause analyses rigorous and objective.
Verbatim wording from the response “A review of existing processes for these investigations is underway using existing models of best practice from the RCOG and CQC with a half day governance meeting scheduled for October to consider any emerging proposals. The Trust governance team has also been asked to provide support for the division to ensure that RCA’s undertaken for Serious Incidents are rigorous and objective.” Source location 2016-0251-Response-by-Western-Sussex-Hospital-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 Strengthen specialty guidance on instrumental delivery and caesarean section to reflect RCOG consent guidance and informed patient choice.
Verbatim wording from the response “Work is underway to strengthen the Trust’s specialty guidance on instrumental delivery and caesarean section to fully reflect Royal College of Obstetrics and Gynaecology (RCOG) guidelines on consent in these specific circumstances and place appropriate emphasis on informed patient choice.” Source location 2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the NHS England/Department of Health National Perinatal Mortality tool at the Trust when available from late 2017.
Verbatim wording from the response “From late 2017 it is anticipated the planned NHS England/Department of Health National Perinatal Mortality tool will become available and will be implemented at the Trust. The newly developed tool adopts a standardised approach for the investigation of perinatal deaths and will incorporate national reporting and learning.” Source location 2016-0251-Response-by-Western-Sussex-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 trainee feedback meetings and senior-staff appraisal to support reflection and learning about the consent process.
Verbatim wording from the response “iii. Feedback and learning for the individuals involved in the consent process” Source location 2016-0251-Response-by-Western-Sussex-Hospital-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 Hold formal feedback meetings involving the trainee doctors and their former and new educational supervisors.
Verbatim wording from the response “Initial feedback with the supervising consultants has taken place for both the trainee doctors who used this procedure prior to them leaving the Trust. Further formal meetings are scheduled to take place that include their educational supervisors from their time at WSHT and their new supervisors. Your concerns will also be shared with the deanery to ensure there is wider learning.” Source location 2016-0251-Response-by-Western-Sussex-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 Provide initial supervisory feedback to the two trainee doctors involved in the delivery.
Verbatim wording from the response “ii. Feedback for the two individuals involved in baby LC’s delivery who used the practice of manually pushing back the cervix” Source location 2016-0251-Response-by-Western-Sussex-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 Monitor uptake of the obstetric consent training.
Verbatim wording from the response “The service has introduced a more in depth online training module for obstetric staff alongside the existing Trust mandatory annual online e-learning on consent. The recently introduced EIDO Healthcare online learning contains a specific module on consent in obstetrics and all obstetric and gynaecological medical staff are now required to undertake this training every three years. The uptake of training will be monitored by the Division and a link to the training is shown below.
http://www.beinformedplus.com/” Source location 2016-0251-Response-by-Western-Sussex-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 the Trust position that manually pushing back the cervix is unacceptable through staff email and maternity safety huddles.
Verbatim wording from the response “A statement has been circulated by email to the medical and midwifery staff highlighting the Trust position that manually pushing back the cervix is not an acceptable practice.” Source location 2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend local guidelines to state that manually pushing back the cervix is unacceptable practice.
Verbatim wording from the response “In addition, local guidelines have been amended to state clearly that pushing back the cervix is not acceptable practice.” Source location 2016-0251-Response-by-Western-Sussex-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 Existing Trust-wide consent guidance is considered clear and compliant with Montgomery, although specialty guidance is being strengthened.
Verbatim wording from the response “In view of your concerns the Trust has reviewed both the overall Trust guidance and the relevant specialty guidance on consent. The existing overall Trust guidance gives clear guidance on informed patient choice and fully reflects the implications of the recent Montgomery judgment.” Source location 2016-0251-Response-by-Western-Sussex-Hospital-NHS-Trust
Open published response
16 Jun 2016 Valerie Margaret Ellis · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 7 Lack of a policy for discharge counselling and warning cards for Apixaban View source Failure to consult clinical advisors in complex KMSS 111 cases View source Inadequate training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions View source Imprecision and unresolved improvement of the NHS Pathways clinical algorithm View source Failure of IC24 case management to keep telephone referrals open until planned callbacks occur View source Poorly organised training for IC24 clinical staff in use of the computer system View source Failure to arrange a joint RCA of KMSS 111 and IC24 investigations View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Valerie Margaret 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
Valerie Margaret Ellis, an 83-year-old woman, died at home on 6 September 2015 after a massive gastrointestinal bleed associated with Apixaban. The report identified concerns about inadequate counselling on the medication, communication and call-handling problems in NHS 111, premature closure of an IC24 case, and aspects of ambulance triage.
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 a policy for discharge counselling and warning cards for Apixaban
Wider context from the report “1) On discharge from the hospital the use of Apixaban in an elderly confused patient being cared for by a carer with hearing loss should have merited careful counselling by the clinicians and the use of a warning card.
Whilst the hospital is taking steps to assess this area, my understanding is that no policy has been adopted and I feel it should be made a matter of urgency.
” 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 consult clinical advisors in complex KMSS 111 cases
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February.
” 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 training of KMSS 111 health advisors to recognise potentially fatal illnesses and deteriorating conditions
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor . I am concerned about the training schedule, particularly for those with little or no background medical knowledge . Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February.
” 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 Imprecision and unresolved improvement of the NHS Pathways clinical algorithm
Wider context from the report “2) KMSS 111 provides a valuable lifeline for many patients and although health advisors are trained to follow algorithms they only have 4 weeks training followed by 2 weeks of sitting in with an experienced advisor. I am concerned about the training schedule, particularly for those with little or no background medical knowledge. Whilst reliant on algorithms, advisors must be able to recognise potentially fatal illnesses and deteriorating conditions as thousands of patients rely on this service for medical help. Clinical advisors on duty were not consulted in this complex case. The senior manager for Quality and Clinical Governance at KMSS 111 expressed concern at the algorithm used in the case of Mrs Ellis. The clinical algorithm called NHS Pathways is owned by the Department of Health and was felt to be imprecise but despite representations to the Department of Health by KMSS 111 for changes and improvement there has been no positive communication since February .
” 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 IC24 case management to keep telephone referrals open until planned callbacks occur
Wider context from the report “3) A disposition from 111 was made to IC24 for a telephone consultation by an on call clinician. This was received and logged and a call was made within one hour. There was no response by the carer and a note was made to call back within 5 minutes. Apparently the case was closed before this could occur ; no explanation could be given as to why this happened . Training for clinical staff in the use of the computer system used by IC24 is essential but did not appear well organised and should be rectified.
” 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 Poorly organised training for IC24 clinical staff in use of the computer system
Wider context from the report “3) A disposition from 111 was made to IC24 for a telephone consultation by an on call clinician. This was received and logged and a call was made within one hour. There was no response by the carer and a note was made to call back within 5 minutes. Apparently the case was closed before this could occur; no explanation could be given as to why this happened. Training for clinical staff in the use of the computer system used by IC24 is essential but did not appear well organised and should be rectified.
” 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 a joint RCA of KMSS 111 and IC24 investigations
Wider context from the report “4) The results of investigations by both KMSS 111 and IC24 should result in a joint RCA. This has not occurred as yet and no date has apparently been arranged .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a pharmacy standard operating procedure supporting NOAC alert-card distribution.
Verbatim wording from the response “As you will be aware, the Trust launched the NOAC alert card in October 2015 and introduced a Standard Operating Procedure to enable pharmacy staff to be fully appraised of the new system and to support the distribution of the warning card. In addition, daily reminders generated by the electronic prescribing software ensure that new patients are identified. It is hoped to strengthen the system still further by placing a further NOAC card in the medication bag given to patients on discharge and to ensure that all discussions with relatives and carers regarding the new drug are documented.” Source location 2016-0252-Response-by-Western-Sussex-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 Revise the anticoagulant prescribing and administration policy to capture NOAC counselling, consent and written-information standards.
Verbatim wording from the response “The Patient First initiative sits at the very heart of the Western Sussex NHS Foundation Trust’s vision of continuous improvement and provides a framework for reviewing each stage of a patient care process. While the above actions seek to address the former inadequacies of the counselling process, it is intended to adopt this methodology to review the entire NOAC process. The standards are being captured in the revised policy for prescribing and administration of anti-coagulants. The policy includes that newly initiated patients are consented by the medical staff as treatment is initiated and receive written information and counselling during the stay and at discharge from nursing and pharmacy staff.” Source location 2016-0252-Response-by-Western-Sussex-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 Formalize electronic recording of NOAC counselling discussions.
Verbatim wording from the response “Concurrently plans are underway for the establishment of a multi-disciplinary group to design and introduce mechanisms to ensure the policy is embedded in practice including actions to formalize electronic recording of counselling discussions, an initiation checklist for use by prescribers and patient leaflets to support the NOAC card. Mrs Ellis’s family has been invited to be part of this group and we very much hope that, in time, they will wish to be involved. The Trust’s incident reporting system will provide an invaluable tool to assist future audits to measure the effectiveness of these new initiatives.” Source location 2016-0252-Response-by-Western-Sussex-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 Establish a multidisciplinary group to design and introduce mechanisms embedding the revised NOAC policy in practice.
Verbatim wording from the response “Concurrently plans are underway for the establishment of a multi-disciplinary group to design and introduce mechanisms to ensure the policy is embedded in practice including actions to formalize electronic recording of counselling discussions, an initiation checklist for use by prescribers and patient leaflets to support the NOAC card. Mrs Ellis’s family has been invited to be part of this group and we very much hope that, in time, they will wish to be involved. The Trust’s incident reporting system will provide an invaluable tool to assist future audits to measure the effectiveness of these new initiatives.” Source location 2016-0252-Response-by-Western-Sussex-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 Adopt the Patient First methodology to review the entire NOAC care process.
Verbatim wording from the response “The Patient First initiative sits at the very heart of the Western Sussex NHS Foundation Trust’s vision of continuous improvement and provides a framework for reviewing each stage of a patient care process. While the above actions seek to address the former inadequacies of the counselling process, it is intended to adopt this methodology to review the entire NOAC process. The standards are being captured in the revised policy for prescribing and administration of anti-coagulants. The policy includes that newly initiated patients are consented by the medical staff as treatment is initiated and receive written information and counselling during the stay and at discharge from nursing and pharmacy staff.” Source location 2016-0252-Response-by-Western-Sussex-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 Introduce patient leaflets supporting the NOAC alert card.
Verbatim wording from the response “Concurrently plans are underway for the establishment of a multi-disciplinary group to design and introduce mechanisms to ensure the policy is embedded in practice including actions to formalize electronic recording of counselling discussions, an initiation checklist for use by prescribers and patient leaflets to support the NOAC card. Mrs Ellis’s family has been invited to be part of this group and we very much hope that, in time, they will wish to be involved. The Trust’s incident reporting system will provide an invaluable tool to assist future audits to measure the effectiveness of these new initiatives.” Source location 2016-0252-Response-by-Western-Sussex-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 Launch and maintain a NOAC alert card for patients prescribed apixaban and other new oral anticoagulants.
Verbatim wording from the response “The Trust has welcomed the opportunity to build upon the work already in place to ensure that patients prescribed Apixaban receive the very best information about the potential side-effects. Despite the absence of national guidance, the Trust has continued to strive to develop a system to ensure that both counselling and a warning card provide patients and their carers with a firm understanding of the risks, as well as the benefits, of this and other new oral anticoagulants (NOAC).” Source location 2016-0252-Response-by-Western-Sussex-Hospital-NHS-Trust
Open published response
Concerns raised 8 Failure to recognise and appropriately manage the dying patient View source Failure to maintain required arm’s length observation View source Inaccurate handover documentation View source Failure to complete admission and fall documentation View source Lack of assurance that bank staff are trained to Trust standards View source Failure to record nurses’ observations adequately View source Failure to document specialling and observations View source Failure to record doctors’ visits adequately View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Christine Valerie STREET · 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
Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying 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 Failure to recognise and appropriately manage the dying patient
Wider context from the report “(3) From the 12th September 2015 the recording of doctor's visits, of nurses observations and the processes around the recognition of the dying patient were utterly flawed, unprofessional and unacceptable.
I do not propose to rehearse all the things that went wrong since I am quite sure that there should now be a full investigation into what happened by the hospital. This is not the first Regulation 2 report that I have had to write recently (in the last few months) following Inquests and concerning the hospital's failure to recognise the dying patient and act appropriately and in accordance with their own and national guidance. This is a matter which exercises everyone these days particularly following the discussion which arose following the Liverpool Care Pathway AND IT MUST be addressed by this hospital Trust.
This abject failure did not, the Jury accepted from the evidence, affect the care that Mrs. Street was given following her fall and head injury. The lack of recognition and the lack of procedures did not affect her and therefore did not either cause or more than minimally contribute to her death, which is why this Regulation 28 Report is so important. These failings did however have a huge impact on her large and loving family who were denied all the support that they should have been given as set out in the End of Life Care Protocols for this Hospital 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain required arm’s length observation
Wider context from the report “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall , the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed.
The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA.
The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all.
This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy.
There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust.
The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately.
” 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 handover documentation
Wider context from the report “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed.
The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA.
The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all.
This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy.
There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust.
The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately.
” 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 admission and fall documentation
Wider context from the report “(1) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11th September 2015 (was not completed) . The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs. Street’s notes.
” 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 assurance that bank staff are trained to Trust standards
Wider context from the report “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed.
The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA.
The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all.
This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy.
There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust.
The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately.
” 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 nurses’ observations adequately
Wider context from the report “(3) From the 12th September 2015 the recording of doctor's visits, of nurses observations and the processes around the recognition of the dying patient were utterly flawed, unprofessional and unacceptable .
I do not propose to rehearse all the things that went wrong since I am quite sure that there should now be a full investigation into what happened by the hospital. This is not the first Regulation 2 report that I have had to write recently (in the last few months) following Inquests and concerning the hospital's failure to recognise the dying patient and act appropriately and in accordance with their own and national guidance. This is a matter which exercises everyone these days particularly following the discussion which arose following the Liverpool Care Pathway AND IT MUST be addressed by this hospital Trust.
This abject failure did not, the Jury accepted from the evidence, affect the care that Mrs. Street was given following her fall and head injury. The lack of recognition and the lack of procedures did not affect her and therefore did not either cause or more than minimally contribute to her death, which is why this Regulation 28 Report is so important. These failings did however have a huge impact on her large and loving family who were denied all the support that they should have been given as set out in the End of Life Care Protocols for this Hospital 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document specialling and observations
Wider context from the report “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed.
The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA.
The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all.
This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations , i.e., the national policy.
There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust.
The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately.
” 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 doctors’ visits adequately
Wider context from the report “(3) From the 12th September 2015 the recording of doctor's visits , of nurses observations and the processes around the recognition of the dying patient were utterly flawed, unprofessional and unacceptable .
I do not propose to rehearse all the things that went wrong since I am quite sure that there should now be a full investigation into what happened by the hospital. This is not the first Regulation 2 report that I have had to write recently (in the last few months) following Inquests and concerning the hospital's failure to recognise the dying patient and act appropriately and in accordance with their own and national guidance. This is a matter which exercises everyone these days particularly following the discussion which arose following the Liverpool Care Pathway AND IT MUST be addressed by this hospital Trust.
This abject failure did not, the Jury accepted from the evidence, affect the care that Mrs. Street was given following her fall and head injury. The lack of recognition and the lack of procedures did not affect her and therefore did not either cause or more than minimally contribute to her death, which is why this Regulation 28 Report is so important. These failings did however have a huge impact on her large and loving family who were denied all the support that they should have been given as set out in the End of Life Care Protocols for this Hospital Trust.
” 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 Audit every patient requiring constant observation and collate the findings for subsequent learning and action.
Verbatim wording from the response “Furthermore an audit has been carried out very recently of every patient being specialised. The findings are now being collated and action will be taken, including if necessary revision of the current policy, in the light of any learning points that emerge from this audit.” Source location 2016-0177-Response-by-Brighton-and-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 Establish a ward practice educator role providing neuro-competency and general nursing training.
Verbatim wording from the response “A series of study days has been held for the nurses on L8AW, to help them understand fully their responsibilities and obligations. Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year, who provides training both on specific neuro-competencies for nurses and also on more general nursing skills.” Source location 2016-0177-Response-by-Brighton-and-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 Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.
Verbatim wording from the response “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.” Source location 2016-0177-Response-by-Brighton-and-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 Organise a monthly neurosurgical records audit to improve documentation quality.
Verbatim wording from the response “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.” Source location 2016-0177-Response-by-Brighton-and-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 Correct staff understanding that the specialist care record applies to patients requiring constant observation, including neurological patients.
Verbatim wording from the response “I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.” Source location 2016-0177-Response-by-Brighton-and-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 Inform bank staff about observation policy and documentation requirements for one-to-one care.
Verbatim wording from the response “Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient.” Source location 2016-0177-Response-by-Brighton-and-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 Hold L8AW nursing study days covering deprivation of liberty, falls prevention, one-to-one care, end-of-life care and documentation.
Verbatim wording from the response “A series of study days has been held for the nurses on L8AW, to help them understand fully their responsibilities and obligations. Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year, who provides training both on specific neuro-competencies for nurses and also on more general nursing skills.” Source location 2016-0177-Response-by-Brighton-and-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 Follow up poor documentation with nursing and medical staff.
Verbatim wording from the response “I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.” Source location 2016-0177-Response-by-Brighton-and-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 Run refresher teaching for healthcare assistants on one-to-one care requirements.
Verbatim wording from the response “Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient.” Source location 2016-0177-Response-by-Brighton-and-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 Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.
Verbatim wording from the response “It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has” Source location 2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
Concerns raised 7 Failure to monitor nutritional status and refer for dietary support View source Failure to support mobility View source Failure to support psychological wellbeing View source Failure to provide mouth and denture care View source Failure to consider a Deprivation of Liberty Safeguards authorisation for a patient lacking capacity View source Failure to provide adequate personal hygiene care View source Failure to provide meaningful stimulation 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
Jack MOLYNEUX · 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
Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.
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 monitor nutritional status and refer for dietary support
Wider context from the report “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above.
Mobility
He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month.
His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth.
His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it.
With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged.
At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death.
I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed.
Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death.
When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content.
Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016.
” 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 support mobility
Wider context from the report “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above.
Mobility
He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month.
His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth.
His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it.
With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged.
At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death.
I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed.
Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death.
When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content.
Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016.
” 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 support psychological wellbeing
Wider context from the report “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above.
Mobility
He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month.
His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth.
His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it.
With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged.
At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death.
I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed.
Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death.
When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content.
Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016.
” 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 mouth and denture care
Wider context from the report “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above.
Mobility
He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month.
His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth.
His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it.
With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged.
At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death.
I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed.
Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death.
When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content.
Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016.
” 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 consider a Deprivation of Liberty Safeguards authorisation for a patient lacking capacity
Wider context from the report “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above.
Mobility
He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month.
His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth.
His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it.
With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged.
At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death.
I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed.
Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death.
When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content.
Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016.
” 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 personal hygiene care
Wider context from the report “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above.
Mobility
He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month.
His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth.
His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it.
With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged.
At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death.
I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed.
Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death.
When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content.
Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016.
” 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 meaningful stimulation
Wider context from the report “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above.
Mobility
He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month.
His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth.
His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it.
With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged.
At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death.
I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed.
Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death.
When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content.
Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016.
” Open source report
Concerns raised 3 Delays in referral to appropriate specialist services View source Failure to transmit private-sector diagnostic results into the local NHS system View source Failure to recognise and use available expedited referral routes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Geoffrey John MOYSE · 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
Geoffrey John MOYSE’s death was the subject of an inquest that concluded with a finding of Medical Misadventure. The report raised concerns about an eight-month delay in referral, poor communication between providers, and failures to transfer investigation results into the NHS system, leaving him unwell, undiagnosed and untreated for too long.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to appropriate specialist services
Wider context from the report “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.
Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.
It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that .
There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?
Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve?
Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked.
One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity.
It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.
In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own.
” 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 transmit private-sector diagnostic results into the local NHS system
Wider context from the report “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.
Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.
It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that.
There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?
Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve?
Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked.
One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system . Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity .
It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.
In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own.
” 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 and use available expedited referral routes
Wider context from the report “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.
Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.
It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that.
There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them . For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?
Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve?
Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked.
One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity.
It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.
In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own.
” 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 Implement changes to improve the effectiveness of abdominal surgery and medicine services.
Verbatim wording from the response “The Trust has been very conscious of the considerable difficulties in providing timely abdominal surgery appointments. A new Clinical Director of Abdominal Surgery and Medicine took up post in December 2015, and has already implemented several changes to improve the effectiveness of this service. Since the death of Mr Moyse, three new surgical consultants have taken up posts in the department and another Colorectal/Emergency surgeon is due to start in June 2016. We anticipate there will no requirement for Locum Consultants from June 2016.” Source location Moyse-Response
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 Appoint an additional colorectal and emergency surgeon.
Verbatim wording from the response “The Trust has been very conscious of the considerable difficulties in providing timely abdominal surgery appointments. A new Clinical Director of Abdominal Surgery and Medicine took up post in December 2015, and has already implemented several changes to improve the effectiveness of this service. Since the death of Mr Moyse, three new surgical consultants have taken up posts in the department and another Colorectal/Emergency surgeon is due to start in June 2016. We anticipate there will no requirement for Locum Consultants from June 2016.” Source location Moyse-Response
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 abdominal surgery staffing by appointing three surgical consultants.
Verbatim wording from the response “The Trust has been very conscious of the considerable difficulties in providing timely abdominal surgery appointments. A new Clinical Director of Abdominal Surgery and Medicine took up post in December 2015, and has already implemented several changes to improve the effectiveness of this service. Since the death of Mr Moyse, three new surgical consultants have taken up posts in the department and another Colorectal/Emergency surgeon is due to start in June 2016. We anticipate there will no requirement for Locum Consultants from June 2016.” Source location Moyse-Response
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 Referral locations and access to relevant imaging or histology are determined by Clinical Commissioning Groups, not the Trust.
Verbatim wording from the response “The Trust recognises that fragmentation of healthcare increases the opportunities for delays, breakdown in communication and potential compromise of effective patient care. However, the local NHS health economy is bound by the decisions of Clinical Commissioning Groups as to where patients may be referred for investigations and treatment, and how any imaging or histology which may be relevant to multidisciplinary team discussion is made readily available. Private providers of services are at liberty to choose to which laboratory specimens are submitted for reporting. This fragmentation is increasing. It is extremely disappointing that since January 2016, some histology work which used to be sent to the laboratory of this Trust from a local private hospital is now being sent elsewhere, and other privately run organisations were already doing this.” Source location Moyse-Response
Open published response
Concerns raised 11 Failure to provide patients with discharge-summary copies and an understanding of their significance View source Failure to send hospital discharge summaries electronically to GPs on the day of discharge View source Unavailability of complex-care guidance at weekends and bank holidays View source Failure to recognise when a patient is dying View source Failure to identify recent failed discharges during discharge planning View source Failure to apply discharge policy and begin discharge documentation at the start of the care journey View source Failure to ensure timely patient notification of cancer-diagnosis and specialist appointments View source Failure to conduct required multidisciplinary and multi-agency care discussions View source Failure to identify complex patients for management under complex-care guidance View source Lack of accountable coordination and continuity of patient care View source Failure to ensure referral to appropriate services 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.
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AI-generated summary
Marion Rose HOWES · 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
Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable 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 Failure to provide patients with discharge-summary copies and an understanding of their significance
Wider context from the report “(1) Discharge summaries from the hospital
These need to be sent electronically to the GP on the day of discharge for continuity of care and full handover to the community from the acute hospital.
In addition, the patient must understand the significance and be given his or her copy so that if by any chance there is a delay or a sudden readmission the patient understands the significance of keeping his copy with him for a few days after discharge.
” 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 send hospital discharge summaries electronically to GPs on the day of discharge
Wider context from the report “(1) Discharge summaries from the hospital
These need to be sent electronically to the GP on the day of discharge for continuity of care and full handover to the community from the acute hospital.
In addition, the patient must understand the significance and be given his or her copy so that if by any chance there is a delay or a sudden readmission the patient understands the significance of keeping his copy with him for a few days after discharge.
” 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 complex-care guidance at weekends and bank holidays
Wider context from the report “(4) In Mrs. Howes’ case there were two failed discharges.
The Trust's discharge policy is excellent on paper, but unfortunately does not appear to be practiced, or wasn't in Mrs. Howes case.
I am told that there are new principles entitled 'Right care, Right place Every time'. This is all well and good but frankly if the Trust and those working in it followed their own guidance they would not need to constantly revisit perfectly good policies.
It was clear from the Inquest that the discharge form should begin to be completed from the very beginning of the patient's 'journey'. Here it wasn't. It seems to me that this form should include two extra sections. First – ask whether there has been a failed discharge within the last X days and secondly address the question of whether this patient is a complex patient who should be dealt with under the complex guidance. I understand that that is not available at weekends , and so presumably complex patients should not be discharged at weekends or bank holidays.
” 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 when a patient is dying
Wider context from the report “(5) There was a failure to recognise the fact that Mrs. Howes was dying . Those looking after her over the last two or three days of her life may have felt under pressure from a demanding family, but families have a right to be demanding as do patients, and doctors and nurses should be able to manage their expectations. The failure to recognise that Mrs. Howes was dying resulted in an undignified and uncomfortable death for her and an enduring and sad memory for her family.
” 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 identify recent failed discharges during discharge planning
Wider context from the report “(4) In Mrs. Howes’ case there were two failed discharges.
The Trust's discharge policy is excellent on paper, but unfortunately does not appear to be practiced, or wasn't in Mrs. Howes case.
I am told that there are new principles entitled 'Right care, Right place Every time'. This is all well and good but frankly if the Trust and those working in it followed their own guidance they would not need to constantly revisit perfectly good policies.
It was clear from the Inquest that the discharge form should begin to be completed from the very beginning of the patient's 'journey'. Here it wasn't. It seems to me that this form should include two extra sections. First – ask whether there has been a failed discharge within the last X days and secondly address the question of whether this patient is a complex patient who should be dealt with under the complex guidance. I understand that that is not available at weekends, and so presumably complex patients should not be discharged at weekends or bank holidays.
” 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 discharge policy and begin discharge documentation at the start of the care journey
Wider context from the report “(4) In Mrs. Howes’ case there were two failed discharges.
The Trust's discharge policy is excellent on paper, but unfortunately does not appear to be practiced , or wasn't in Mrs. Howes case.
I am told that there are new principles entitled 'Right care, Right place Every time'. This is all well and good but frankly if the Trust and those working in it followed their own guidance they would not need to constantly revisit perfectly good policies.
It was clear from the Inquest that the discharge form should begin to be completed from the very beginning of the patient's 'journey'. Here it wasn't . It seems to me that this form should include two extra sections. First – ask whether there has been a failed discharge within the last X days and secondly address the question of whether this patient is a complex patient who should be dealt with under the complex guidance. I understand that that is not available at weekends, and so presumably complex patients should not be discharged at weekends or bank holidays.
” 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 timely patient notification of cancer-diagnosis and specialist appointments
Wider context from the report “(2) At this Inquest I was told that hospital was not considered the best place to impart the difficult news of a cancer and that this is dealt with by a Outpatients appointment being sent for the patient to meet the surgeon and the specialist nurse.
In this particular case the patient died and in fact never knew the date of the appointment allocated , but the appointment of the specialist nurse, when the diagnosis is made, would be helpful and timeous and enable the patient to understand and prepare for what is to come. It seems to me that it would be a very much kinder way to proceed and would also mean that the sensible patient would be preparing him or herself for the surgery which is likely to follow.
” 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 conduct required multidisciplinary and multi-agency care discussions
Wider context from the report “(3) In Mrs. Howes’ case there was a complete lack of co-ordination and continuity of care for her. Nobody took charge of her. Nobody was responsible and responsible for liaising with all the relevant firms so that she was dealt with comprehensively and by the appropriate people. It is suggested that consideration be given to the patient being appointed a named Consultant (not one who is just about to go on holiday) from the day of first admission and this Consultant should understand his or her duties with regard to the managing of the patient and ensuring that they are referred on to the appropriate forms and that the multi-disciplinary and multi-agency discussions take 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify complex patients for management under complex-care guidance
Wider context from the report “(4) In Mrs. Howes’ case there were two failed discharges.
The Trust's discharge policy is excellent on paper, but unfortunately does not appear to be practiced, or wasn't in Mrs. Howes case.
I am told that there are new principles entitled 'Right care, Right place Every time'. This is all well and good but frankly if the Trust and those working in it followed their own guidance they would not need to constantly revisit perfectly good policies.
It was clear from the Inquest that the discharge form should begin to be completed from the very beginning of the patient's 'journey'. Here it wasn't. It seems to me that this form should include two extra sections. First – ask whether there has been a failed discharge within the last X days and secondly address the question of whether this patient is a complex patient who should be dealt with under the complex guidance . I understand that that is not available at weekends, and so presumably complex patients should not be discharged at weekends or bank holidays.
” 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 accountable coordination and continuity of patient care
Wider context from the report “(3) In Mrs. Howes’ case there was a complete lack of co-ordination and continuity of care for her. Nobody took charge of her. Nobody was responsible and responsible for liaising with all the relevant firms so that she was dealt with comprehensively and by the appropriate people. It is suggested that consideration be given to the patient being appointed a named Consultant (not one who is just about to go on holiday) from the day of first admission and this Consultant should understand his or her duties with regard to the managing of the patient and ensuring that they are referred on to the appropriate forms and that the multi-disciplinary and multi-agency discussions take 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure referral to appropriate services
Wider context from the report “(3) In Mrs. Howes’ case there was a complete lack of co-ordination and continuity of care for her. Nobody took charge of her. Nobody was responsible and responsible for liaising with all the relevant firms so that she was dealt with comprehensively and by the appropriate people. It is suggested that consideration be given to the patient being appointed a named Consultant (not one who is just about to go on holiday) from the day of first admission and this Consultant should understand his or her duties with regard to the managing of the patient and ensuring that they are referred on to the appropriate forms and that the multi-disciplinary and multi-agency discussions take place.
” Open source report
Concerns raised 2 Lack of joined-up care and discharge planning in the Acute Medical Unit View source Failure to complete National Early Warning System scoring after acute deterioration View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thelma Patricia JONES · 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
Thelma Patricia JONES was admitted to the Acute Medical Unit from 16 to 23 February 2015, became acutely unwell, and was moved to intensive therapy after being intubated on the unit. The concerns were limited evidence of coordinated care planning and incomplete National Early Warning System scoring after her acute deterioration and a medical emergency team call on 23 February 2015.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of joined-up care and discharge planning in the Acute Medical Unit
Wider context from the report “This report once again, concerns the Acute Medical Unit (AMU) where Mrs. JONES was admitted from the 16th - 23rd February 2015 when she became acutely unwell and was moved to ITU having been intubated on AMU.
• firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU and I would certainly like to have seen that.
• The second matter is once again the question of the National Early Warning System (NEWS), which had been reasonably well completed until we come to the day of her acute deterioration, when after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23rd February 2015, the scoring is not completed. This is extremely poor; it is a matter that I have raised before and it must, please, be addressed.
” 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 National Early Warning System scoring after acute deterioration
Wider context from the report “This report once again, concerns the Acute Medical Unit (AMU) where Mrs. JONES was admitted from the 16th - 23rd February 2015 when she became acutely unwell and was moved to ITU having been intubated on AMU.
• firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU and I would certainly like to have seen that.
• The second matter is once again the question of the National Early Warning System (NEWS), which had been reasonably well completed until we come to the day of her acute deterioration, when after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23rd February 2015, the scoring is not completed . This is extremely poor; it is a matter that I have raised before and it must, please, be addressed.
” Open source report
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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 NEWS scores were not expected during the medical emergency because the early warning system had already fulfilled its function.
Verbatim wording from the response “In summary it would not be expected that NEWS scores would be calculated from the observations during a medical emergency response as the focus is on rapidly treating and managing the patient. The NEWS is an early warning system and it had fulfilled its function at the point a MET call was made.” Source location 2015-0318-Response-by-Brighton-and-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 No remedial action was considered necessary because the medical records contained appropriate detail about AMU care and NEWS scores.
Verbatim wording from the response “As with all cases we have carefully reflected on the issues in this situation and are open and committed to learning from such events. In this particular case, the Trust believes that the medical notes contain appropriate detailed information on the care and treatment given within AMU and in relation to the NEWS scores. To that end we do not believe that remedial action is necessary on the part of the Trust in this respect.” Source location 2015-0318-Response-by-Brighton-and-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 records show suitable care and treatment were provided, with discharge arrangements planned and coordinated.
Verbatim wording from the response “Having reviewed the medical records we consider that there is evidence that suitable care and treatment were provided and that discharge arrangements were planned and coordinated.” Source location 2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
Concerns raised 19 Failure to involve patients and families in discharge decisions View source Failure to complete clinical notes View source Failure to communicate adequately with patients and families View source Failure to complete requested blood tests View source Inadequate discharge planning View source Failure to provide rehabilitation on a rehabilitation ward View source Failure to provide accurate discharge lounge information View source Failure to manage trials without catheter safely View source Failure to follow and document ward transfer procedures View source Failure to communicate patients' care needs during ward transfers View source Failure to refer and plan for urinary incontinence View source Failure to address patients' mental health needs and anxieties View source Failure to document rehabilitation exercise View source Failure to complete bowel monitoring charts View source Failure to provide senior review and follow up suspected infection View source Insufficient physiotherapy staffing for rehabilitation patients View source Failure to document and adhere to fluid restrictions View source Failure to record nursing observations and NEWS View source Failure to maintain a physiotherapy plan View source See 16 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
MR. ANTHONY GEERTS · 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
Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to involve patients and families in discharge decisions
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th .
Neither Mr. GEERTS nor his family were involved in this decision .
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 clinical notes
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed .
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 adequately with patients and families
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 requested blood tests
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 discharge planning
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 rehabilitation on a rehabilitation ward
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th . Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 accurate discharge lounge information
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect .
” 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 manage trials without catheter safely
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 follow and document ward transfer procedures
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th . Transfer procedure not followed . Transfer not documented .
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 patients' care needs during ward transfers
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs . He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 and plan for urinary incontinence
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 address patients' mental health needs and anxieties
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital . His anxieties were not addressed in any meaningful way . He was given no assistance after the 6th .
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 document rehabilitation exercise
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented .
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 bowel monitoring charts
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 senior review and follow up suspected infection
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014 ; possibility of chest infection not followed up .
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 physiotherapy staffing for rehabilitation patients
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 document and adhere to fluid restrictions
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed . Fluid restriction not properly documented . Fluid restriction effectively disregarded .
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 nursing observations and NEWS
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 a physiotherapy plan
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan . I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” 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 Educate ward nurses on patient moves, site-manager information requirements and transfer documentation.
Verbatim wording from the response “g) educational sessions with ward nurses to explore the rationale for moving patients. This will include both emphasis on the need to provide adequate information to the clinical site manager if consideration is being given to moving a patient (especially late at night), and teaching on the documentation requirements (including completion of the transfer document), should it be unavoidable for a patient to be moved from one ward to another. This will help ensure that adequate information accompanies any patient who, for whatever reason, has to be moved from one ward to another.” Source location 2015-0240-Response-by-Brighton-and-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 Recruit a Clinical Nurse Practice Educator based on Twineham ward to support staff, including communication training.
Verbatim wording from the response “a) the recruitment of a new Clinical Nurse Practice Educator based on Twineham ward. This postholder is able to assist staff with a range of issues, including providing training on all aspects of communication (written and verbal)” Source location 2015-0240-Response-by-Brighton-and-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 Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.
Verbatim wording from the response “c) joint development of a training package for all the staff based on Twineham ward, by the senior physiotherapy and nursing staff, to assist with accurate and detailed documentation. This includes a specific focus on the potential consequences of poor documentation” Source location 2015-0240-Response-by-Brighton-and-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 Discuss avoiding late-night patient moves with clinical site managers responsible for bed allocation.
Verbatim wording from the response “In addition, there have been discussions with the clinical site managers, who are the senior nurses on duty 24 hours a day on each site, with responsibility for allocating beds for patients. These staff are well aware that it is undesirable to move any patient late at night, even though this may be unavoidable in order to accommodate patients admitted through the Emergency Department.” Source location 2015-0240-Response-by-Brighton-and-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 Strengthen senior medical review requirements, including consultant reviews, daily review of sick patients, junior attendance and documentation of discussions.
Verbatim wording from the response “h) review of senior medical input on Twineham ward. The Clinical Director for the musculoskeletal service has emphasized that every patient on Twineham ward should normally be seen by a consultant orthopaedic surgeon or orthogeriatrician at least four times a week (including one day at the weekend), including a conversation with the patient and review of their progress with them. Any patient who is sick should be seen daily by a consultant. The junior medical staff have been reminded that they must attend with the consultant, and should record every such discussion in the notes, if the consultant does not do this themselves” Source location 2015-0240-Response-by-Brighton-and-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 trained and therapy-support physiotherapy staffing to reduce missed planned physiotherapy and prioritise patients missed the previous day.
Verbatim wording from the response “d) increased physiotherapy staffing (both trained and therapy support staff), reducing the occasions when it is not possible for a patient to have physiotherapy as planned, with recognition that any patient that is not seen on one day must become one of the highest priorities for the next day” Source location 2015-0240-Response-by-Brighton-and-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 Integrate the fractured-neck-of-femur service at Princess Royal Hospital to provide continuity and avoid cross-site communication failures.
Verbatim wording from the response “May we start by expressing our sympathy on their sad loss to the family of Mr Geerts. Since he died, considerable changes have been implemented within this Trust specifically relating to the management of patients who have suffered a fractured neck of femur. Instead of routinely operating at the Royal Sussex County Hospital and then transferring the patients to the Princess Royal Hospital for rehabilitation, the whole service is now provided at the Princess Royal Hospital. This provides greater continuity for the patients, and indeed for the staff, and eliminates an opportunity for confusion or breakdown in communication between staff working in different places.” Source location 2015-0240-Response-by-Brighton-and-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 Introduce integrated documentation for all clinical staff treating patients on Twineham ward.
Verbatim wording from the response “b) introduction of integrated documentation for use by all the clinical staff treating each patient on the ward” Source location 2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
Concerns raised 3 Failure to ensure locum staff awareness of analgesia guidance for patients with Chronic Kidney Disease View source Failure to prescribe analgesia in accordance with guidance for patients with Stage 4 Chronic Kidney Disease View source Failure of senior nurses to identify medication anomalies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr. Isaac BAHAR · 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
Mr. Isaac Bahar was admitted to hospital after a fall caused fractured ribs and a traumatic pneumothorax. Despite known stage four chronic kidney disease, he was prescribed and given codeine in contravention of national and local guidance, and later developed opioid toxicity and died. The inquest found the prescribing error was one of the causes of his death; chronic obstructive pulmonary disease was also deemed a contributory factor.
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 ensure locum staff awareness of analgesia guidance for patients with Chronic Kidney Disease
Wider context from the report “Mr. Bahar was admitted to the Royal Sussex County Hospital on 10th November 2014 with pneumothorax due to fractured ribs. He was treated urgently and appropriately until his analgesia.
He was a man with known Stage 4 Chronic Kidney Disease, yet in breach of the hospital’s own policy and in breach of national guidance he was prescribed and given four doses of Codeine over 18 hours. Although this was stopped by the ward Pharmacist as soon as she was able to review his drug chart, Mr. Bahar collapsed with severe opiate/opioid toxicity 30 hours later and died just under three hours after the collapse. The Jury at his Inquest found this error to be one of the causes of his death
The Codeine was directed by a locum surgical consultant and the fatal error was compounded when a locum junior doctor wrote up the Codeine in Mr. Bahar’s drug chart.
Their locum status must be relevant and if the Trust employs locum staff they must satisfy themselves that those staff are aware of such guidance particularly in such a common scenario (elderly patient with Chronic Kidney Disease needing analgesia) .
The Trust is responsible for ensuring their patients are in safe hands. Senior nurses should also be aware of such common pitfalls. They would then be in a position when caring for their patients to pick up anomalies.
This is a serious failing and must be urgently addressed.
” 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 analgesia in accordance with guidance for patients with Stage 4 Chronic Kidney Disease
Wider context from the report “Mr. Bahar was admitted to the Royal Sussex County Hospital on 10th November 2014 with pneumothorax due to fractured ribs. He was treated urgently and appropriately until his analgesia.
He was a man with known Stage 4 Chronic Kidney Disease, yet in breach of the hospital’s own policy and in breach of national guidance he was prescribed and given four doses of Codeine over 18 hours . Although this was stopped by the ward Pharmacist as soon as she was able to review his drug chart, Mr. Bahar collapsed with severe opiate/opioid toxicity 30 hours later and died just under three hours after the collapse. The Jury at his Inquest found this error to be one of the causes of his death
The Codeine was directed by a locum surgical consultant and the fatal error was compounded when a locum junior doctor wrote up the Codeine in Mr. Bahar’s drug chart.
Their locum status must be relevant and if the Trust employs locum staff they must satisfy themselves that those staff are aware of such guidance particularly in such a common scenario (elderly patient with Chronic Kidney Disease needing analgesia).
The Trust is responsible for ensuring their patients are in safe hands. Senior nurses should also be aware of such common pitfalls. They would then be in a position when caring for their patients to pick up anomalies.
This is a serious failing and must be urgently addressed.
” 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 senior nurses to identify medication anomalies
Wider context from the report “Mr. Bahar was admitted to the Royal Sussex County Hospital on 10th November 2014 with pneumothorax due to fractured ribs. He was treated urgently and appropriately until his analgesia.
He was a man with known Stage 4 Chronic Kidney Disease, yet in breach of the hospital’s own policy and in breach of national guidance he was prescribed and given four doses of Codeine over 18 hours. Although this was stopped by the ward Pharmacist as soon as she was able to review his drug chart, Mr. Bahar collapsed with severe opiate/opioid toxicity 30 hours later and died just under three hours after the collapse. The Jury at his Inquest found this error to be one of the causes of his death
The Codeine was directed by a locum surgical consultant and the fatal error was compounded when a locum junior doctor wrote up the Codeine in Mr. Bahar’s drug chart.
Their locum status must be relevant and if the Trust employs locum staff they must satisfy themselves that those staff are aware of such guidance particularly in such a common scenario (elderly patient with Chronic Kidney Disease needing analgesia).
The Trust is responsible for ensuring their patients are in safe hands. Senior nurses should also be aware of such common pitfalls. They would then be in a position when caring for their patients to pick up anomalies.
This is a serious failing and must be urgently addressed.
” 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 Stop making codeine routinely available for prescription by general surgeons.
Verbatim wording from the response “This incident, and the sad death of Mr Bahar, has been discussed in detail with both the general surgeons and the nursing team on Level 9a, as well as with the pharmacy team. As a direct result, the general surgeons decided that codeine should no longer be routinely available for them to prescribe. Discussions are continuing to seek a consensus as to whether the benefits of withdrawing codeine altogether from use within the Trust by other specialists would outweigh the associated disadvantages of such a step.” Source location 2015-0229-Response-by-Brighton-and-Sussex-University-Hospitals-Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue discussions to determine whether withdrawing codeine from Trust-wide use by other specialists would outweigh the disadvantages.
Verbatim wording from the response “This incident, and the sad death of Mr Bahar, has been discussed in detail with both the general surgeons and the nursing team on Level 9a, as well as with the pharmacy team. As a direct result, the general surgeons decided that codeine should no longer be routinely available for them to prescribe. Discussions are continuing to seek a consensus as to whether the benefits of withdrawing codeine altogether from use within the Trust by other specialists would outweigh the associated disadvantages of such a step.” Source location 2015-0229-Response-by-Brighton-and-Sussex-University-Hospitals-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 Discuss the incident and medication-safety concerns with general surgeons, nursing staff and the pharmacy team.
Verbatim wording from the response “This incident, and the sad death of Mr Bahar, has been discussed in detail with both the general surgeons and the nursing team on Level 9a, as well as with the pharmacy team. As a direct result, the general surgeons decided that codeine should no longer be routinely available for them to prescribe. Discussions are continuing to seek a consensus as to whether the benefits of withdrawing codeine altogether from use within the Trust by other specialists would outweigh the associated disadvantages of such a step.” Source location 2015-0229-Response-by-Brighton-and-Sussex-University-Hospitals-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 Nurses administering the prescription were not expected to recognise the renal-impairment risks requiring them to query it.
Verbatim wording from the response “Codeine was also used on the gastroenterology ward where Mr Bahar was a patient to help reduce diarrhoea, a common symptom for gastroenterology patients. The lead pharmacist has confirmed that she would not expect nurses to be aware of the nuances of codeine metabolism in patients with renal impairment, and there was therefore no reason for the nurses administering the prescription to query this prescription before administering it.” Source location 2015-0229-Response-by-Brighton-and-Sussex-University-Hospitals-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 medication error was not caused or contributed to by inadequate knowledge, education, or locum staff selection and induction.
Verbatim wording from the response “The Trust’s lead pharmacist in patient safety carried out a detailed investigation of this matter. She found no evidence that there was a failure in knowledge or education, or any failure in selection or induction of locum staff, which caused or contributed to the medication being prescribed outside the Trust’s recommended analgesia guidance. The British National Formulary (BNF) makes it clear that codeine and other opioid analgesics should be avoided or used with caution at reduced doses in patients with renal impairment.” Source location 2015-0229-Response-by-Brighton-and-Sussex-University-Hospitals-Trust
Open published response
Concerns raised 25 Delays in prescribing food supplements View source Failure to maintain patient warmth View source Failure to provide senior clinical review View source Failure to weigh the patient View source Failure to complete the daily catheter care bundle View source Failure to remove an IV cannula after 72 hours View source Failure to record NEWS scores on drug charts View source Failure to prescribe and administer prescribed Sertraline View source Failure to provide falls-risk wristbands for patients at risk of falling View source Incomplete and ineffective clinical handover View source Failure to escalate NEWS scores to doctors View source Failure to provide required personal and oral care View source Pressure damage to the hips and buttocks View source Failure to record food intake View source Failure to provide specialling when required View source Failure to provide allergy wristbands for patients with known allergies View source Failure to complete the malnutrition assessment tool View source Failure to use the required trolley for patient transfer View source Failure to complete patient care plans View source Failure to complete daily oral assessments View source Failure to record fluid intake and output View source Failure to complete handling assessments View source Incomplete and poor repositioning records View source Failure to record bowel movements View source Failure to provide patient identity wristbands View source See 22 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.
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 prescribing food supplements
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to maintain patient warmth
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to provide senior clinical review
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to weigh the patient
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to complete the daily catheter care bundle
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to remove an IV cannula after 72 hours
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to record NEWS scores on drug charts
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to prescribe and administer prescribed Sertraline
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to provide falls-risk wristbands for patients at risk of falling
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Incomplete and ineffective clinical handover
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to escalate NEWS scores to doctors
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to provide required personal and oral care
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Pressure damage to the hips and buttocks
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to record food intake
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to provide specialling when required
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to provide allergy wristbands for patients with known allergies
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to complete the malnutrition assessment tool
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to use the required trolley for patient transfer
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to complete patient care plans
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to complete daily oral assessments
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to record fluid intake and output
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to complete handling assessments
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Incomplete and poor repositioning records
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to record bowel movements
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit 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 Failure to provide patient identity wristbands
Wider context from the report “(1) Once again my concerns involve the Acute Medical Unit (AMU).
(2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley.
(3) Handover was incomplete and unhelpful.
(4) She arrived unkempt.
(5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care.
(6) She felt cold and said she was cold.
(7) She had been incontinent of faeces and had not been cleaned for some time.
(8) She had no name wrist band.
(9) In spite of known allergies she had no allergy wrist band.
(10) In spite of falling regularly she had no falls risk wrist band.
(11) She still had an IV cannula in place; this should have been removed after 72 hours.
(12) Her daily catheter care bundle had not been completed for 3 days.
(13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th.
(14) Care plans were not completed for 17th, 18th, 19th or 20th.
(15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th.
(16) The handling assessment was not completed for 16th, 18th, 19th or 20th.
(17) No food chart was completed for her entire time in AMU.
(18) She had pressure damage to her hips and bottom.
(19) No daily oral assessment was completed for her entire time on AMU.
(20) She was not weighed.
(21) The malnutrition tool was not completed.
(22) Her bowel movements were not recorded.
(24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart.
PLUS
(25) No personal care over the weekend of 18th and 19th.
(26) No senior review over that weekend.
(27) Not written up for her Sertraline, therefore not given
(28) Not written up for any food supplements until 21st October.
(29) She should have been specialled, but wasn’t.
Once again AMU has been found to be chaotic and not fit for purpose.
” 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 Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-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 Improve information quality and clinical handover when patients transfer from the Acute Medical Unit to specialist wards.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-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 Monitor documentation more closely and provide nurses with real-time feedback.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-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 Assign a critical care outreach nurse to link the Acute Medical Unit with critical care services.
Verbatim wording from the response “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:” Source location 2015-0178-Response-by-Brighton-and-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 Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.
Verbatim wording from the response “Extensive and complex work is also being undertaken to” Source location 2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
21 Apr 2015 Bruce LONGDEN · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 7 Failure to conduct observations and therapeutic engagement in accordance with policy View source Failure of the Mental Health Team to adhere to commonly understood terminology View source Delays in reporting an absconsion to Sussex Police View source Failure to understand terminology used by the mental health liaison team View source Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust View source Failure to follow protocols for transferring Sussex Partnership Trust patients to the acute hospital View source Failure to appreciate the significance of a patient’s mental health condition 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
Bruce LONGDEN · 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
Bruce LONGDEN’s death was investigated by an inquest, but the circumstances of the death are referred to separately in the Record of Inquest. The substantive concerns included failures to follow Sussex Partnership Trust protocols, poor communication between trusts, inadequate understanding of his mental health condition and terminology, and delayed reporting of his absconsion to Sussex Police.
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 conduct observations and therapeutic engagement in accordance with policy
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 the Mental Health Team to adhere to commonly understood terminology
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 reporting an absconsion to Sussex Police
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 understand terminology used by the mental health liaison team
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 follow protocols for transferring Sussex Partnership Trust patients to the acute hospital
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” 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 significance of a patient’s mental health condition
Wider context from the report “(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :-
a) Transfer of Sussex Partnership Trust patients to the acute hospital and
b) Observations and Therapeutic Engagement policy
These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond.
2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
3)Poor communication within Brighton & Sussex University Hospital Trust particularly:
• Failure to appreciate the significance of Mr Bruce Longden’s mental health condition
• Failure to understand the terminology used by the mental health liaison team
• Failure of the Mental Health Team to adhere to commonly understood terminology
• Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost
” Open source report
Concerns raised 15 Failure to provide in-person clinical review of unclear ECGs View source Excessive shifts and inadequate breaks for Clinical Decisions Unit nursing staff View source Failure to complete initial N.E.W.S. scoring View source Failure to complete emergency department nursing documentation and falls assessment View source Excessive shifts and inadequate breaks for A & E staff View source Failure to formulate a detailed and complete senior clinical plan View source Failure of Senior Nurse verification and completion of N.E.W.S. scores View source Lack of protocol and assigned responsibility for admission bloods View source Unavailability of ECG machines in the Clinical Decisions Unit View source Failure to account for junior doctor unfamiliarity during senior review View source Failure to document ECG review, instructions and reviewer identification View source Failure to complete initial A & E assessment documentation View source Failure to complete required transfer documentation and countersignature View source Failure to use a hands-on approach during observations View source Deployment of an inexperienced agency nurse in the Clinical Decisions Unit View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maureen Annette ELLETT · 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 report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.
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 provide in-person clinical review of unclear ECGs
Wider context from the report “(7) If, as in this case, the first ECG is unclear ; rather than simply requesting that it should be repeated, the Doctor who reviews it should take the opportunity to review the patient in person and if it was the Junior Doctor who requested the ECG (as it was in Mrs. Ellett's case) it is considered that it is that Junior Doctor who should have the opportunity of reviewing that ECG, thus giving continuity of care to the patient.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Excessive shifts and inadequate breaks for Clinical Decisions Unit nursing staff
Wider context from the report “(8) The Staff Nurse in the Clinical Decisions Unit on the night of the 16th / 17th June 2014 was an Agency Nurse who had no previous experience ever of working in the Emergency Department or a Clinical Decisions Unit. She was assisted by an experienced Health Care Assistant. However, the Staff Nurse was also working a 12½ hour shift and had had no break until over nine hours into that shift . It is considered that this compromises the care of the patients in the Clinical Decisions 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 complete initial N.E.W.S. scoring
Wider context from the report “(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet.
Acopia was recorded as the main diagnosis.
None of the early A & E paperwork was completed.
The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed .
No Admission bloods were taken and in this respect there is no protocol or guidance concerning:
a) that bloods should be taken when patients are admitted to A & E by Ambulance or
b) who should take these bloods.
” 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 emergency department nursing documentation and falls assessment
Wider context from the report “(4) The second Triage Nurse in A & E did the assessment on Mrs. Ellett at the end of a 12½ hour shift which was due to end at 20:00 hours on the 16th June, 2014. She saw Mrs. Ellett at approximately 19:20 hours and out of the two pages of emergency department Nursing Documentation which require over 80-pieces of information recorded, she recorded merely 12 pieces of information . The Falls Risk Assessment was completely blank and yet Mrs. Ellett was at high risk of falls and should have been provided with a green wrist band to alert all staff to this. It is thought that this shift is too long and at the end of it, staff who have had no proper breaks will be exhausted.
It is considered that all staff should be trained on the importance of completing hospital documentation.
” 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 Excessive shifts and inadequate breaks for A & E staff
Wider context from the report “(4) The second Triage Nurse in A & E did the assessment on Mrs. Ellett at the end of a 12½ hour shift which was due to end at 20:00 hours on the 16th June, 2014. She saw Mrs. Ellett at approximately 19:20 hours and out of the two pages of emergency department Nursing Documentation which require over 80-pieces of information recorded, she recorded merely 12 pieces of information. The Falls Risk Assessment was completely blank and yet Mrs. Ellett was at high risk of falls and should have been provided with a green wrist band to alert all staff to this. It is thought that this shift is too long and at the end of it, staff who have had no proper breaks will be exhausted .
It is considered that all staff should be trained on the importance of completing hospital documentation.
” 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 formulate a detailed and complete senior clinical plan
Wider context from the report “(2) Discussion by the Junior Doctor with the Senior Doctor as to the plan for Mrs. Ellett was brief to the point of transient.
No proper detailed plan was formulated.
Clues to the patient's condition were missed, probably because the discussion was so brief and the paperwork required for transfer to the short-stay ward, also known as the Clinical Decisions Unit, was signed by the A&E Consultant but neither dated nor timed by him.
The plan was incomplete and the counter-signatory of the Senior Nurse with date and time was completely missing. Therefore the transfer should not have taken 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Senior Nurse verification and completion of N.E.W.S. scores
Wider context from the report “(10) The Hospital's own Observation Policy states that if N.E.W.S observations are taken by a Health Care Assistant they should be checked within 30 minutes by the Senior Nurse (in this case the Agency Staff Nurse) who should complete the N.E.W.S scores . This did not happen in Mrs. Ellett's case and thus another opportunity to spend some time with her and review her in person was lost.
” 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 protocol and assigned responsibility for admission bloods
Wider context from the report “(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet.
Acopia was recorded as the main diagnosis.
None of the early A & E paperwork was completed.
The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed.
No Admission bloods were taken and in this respect there is no protocol or guidance concerning :
a) that bloods should be taken when patients are admitted to A & E by Ambulance or
b) who should take these bloods .
” 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 ECG machines in the Clinical Decisions Unit
Wider context from the report “(5) There are no ECG machines in the Clinical Decisions Unit ; either they should be provided or staff on the Clinical Decisions Unit should not be expected to perform ECG's there.
” 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 account for junior doctor unfamiliarity during senior review
Wider context from the report “(3) No notice appears to have been taken that the junior Doctor, discussing with the Senior was an Agency Doctor who had only worked in this busy department on two previous shifts in the last three weeks. Her last experience in an Emergency Department had been eleven months earlier when she did her rotation training. It is suggested that if the Junior Doctor is not a regular member of staff this should be noted when the Senior Review takes place to ensure that no mistakes, due to inexperience or lack of knowledge of the Hospital's own systems is impinging on the Junior Doctors work.
” 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 document ECG review, instructions and reviewer identification
Wider context from the report “(6) When the ECG is shown to one of the Doctors there should be a proper documented note of the identity of the Doctor, the time and date when he or she reviews the ECG , the Doctor's instructions on what should happen next with a time period within which this is to occur and this note should be signed and timed by the Doctor who should also print his or her name .
” 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 initial A & E assessment documentation
Wider context from the report “(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet .
Acopia was recorded as the main diagnosis.
None of the early A & E paperwork was completed .
The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed.
No Admission bloods were taken and in this respect there is no protocol or guidance concerning:
a) that bloods should be taken when patients are admitted to A & E by Ambulance or
b) who should take these bloods.
” 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 required transfer documentation and countersignature
Wider context from the report “(2) Discussion by the Junior Doctor with the Senior Doctor as to the plan for Mrs. Ellett was brief to the point of transient.
No proper detailed plan was formulated.
Clues to the patient's condition were missed, probably because the discussion was so brief and the paperwork required for transfer to the short-stay ward, also known as the Clinical Decisions Unit, was signed by the A&E Consultant but neither dated nor timed by him .
The plan was incomplete and the counter-signatory of the Senior Nurse with date and time was completely missing . Therefore the transfer should not have taken 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 Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a hands-on approach during observations
Wider context from the report “(9) The Hospital's own Protocol on Observations commends the hands-on approach to the patient which was not the approach used with Mrs. Ellett .
” 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 Deployment of an inexperienced agency nurse in the Clinical Decisions Unit
Wider context from the report “(8) The Staff Nurse in the Clinical Decisions Unit on the night of the 16th / 17th June 2014 was an Agency Nurse who had no previous experience ever of working in the Emergency Department or a Clinical Decisions Unit. She was assisted by an experienced Health Care Assistant. However, the Staff Nurse was also working a 12½ hour shift and had had no break until over nine hours into that shift. It is considered that this compromises the care of the patients in the Clinical Decisions Unit.
” 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 Remind consultants and shift leaders to require a detailed management plan and shift-leader confirmation before transferring patients.
Verbatim wording from the response “2. We believe the A&E consultant’s failure to date and time his signature on the transfer documentation, while not best practice, is not relevant to the clinical care of Mrs Ellett. However, we agree that she should not have been transferred until an appropriately detailed plan for her management had been agreed and summarized in a series of bullet points in the documentation, and the clinical shift leader had confirmed his agreement by signing the proforma. All the consultants and the relevant shift leaders have been reminded of the importance of this aspect of their duties.” Source location 2014-0473-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 Introduce an Emergency Department ECG stamp for documenting, signing and dating ECG interpretations and associated management plans.
Verbatim wording from the response “6. A stamp has been devised for use in the Emergency Department on ECG print outs so that doctors can document, sign and date on their interpretation of the ECG and any associated plan for the patient’s management.” Source location 2014-0473-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 Provide further documentation training through departmental nurse induction and nurse development training days.
Verbatim wording from the response “4. We have established that the triage nurse to whom you refer handed over to her colleague starting the next shift that there were several outstanding assessments to be completed and documented for Mrs Ellett. We deeply regret that this next member of staff, who had newly come on duty, did not complete these tasks as he should have done. We have not been able to take this up with him in the light of your comments as he had already left the Trust before Mrs Ellett’s inquest took place. Arrangements have been made for further training on documentation to be included in both the departmental nurse induction programme and also in the nurse development training days held in the department.” Source location 2014-0473-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 Amend the doctors’ induction programme to emphasize doctors’ responsibility for ensuring appropriate blood tests are taken and ordered.
Verbatim wording from the response “We do not believe it is appropriate for any decision about whether or not blood is to be taken to be based on the mode of transport by which they arrive (ambulance, own transport etc). We agree that Mrs Ellett’s blood should have been taken for testing, and confirm that while blood may be taken by medical or nursing staff, it is the responsibility of the doctor to ensure that appropriate blood tests have been taken and appropriate blood tests ordered. The doctors’ induction programme has” Source location 2014-0473-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 Continue educating staff to avoid inappropriate terminology describing patients’ condition on Emergency Department arrival.
Verbatim wording from the response “1. We agree that there were shortcomings in the record keeping when Mrs Ellett first arrived in the Emergency Dept. Since then, several changes have been made. Agreement has been reached with the South East Coast Ambulance NHS foundation Trust (SECAMB) that they will start calculating National Early Warning Scores (NEWS) and the triage nurse will note this when the patient arrives. We agree that the phrase is inappropriate and misleading, and should not be used to describe the condition of a patient on arrival to the Emergency department. We are continuing to educate staff about avoiding this term, while recognizing that it may be used by other people outside this Trust.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind senior clinicians to exercise extreme caution when reviewing patients assessed by unfamiliar or locum junior staff without personally seeing them.
Verbatim wording from the response “3. We agree that it is particularly important for senior staff to be vigilant when working with less experienced agency junior staff. All the Emergency Department consultants and other senior doctors in the department have been asked, in the light of these events, to reflect upon their current approach, practice and vigilance. These clinicians have been strongly reminded that extreme caution should be taken if a patient is not being seen in person by them, after assessment by any locum staff who are not familiar with the department or any locum not previously known to the senior clinician.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct regular audits to ensure Short Stay Ward and Clinical Decisions Unit proformas are used correctly.
Verbatim wording from the response “The nursing and medical staff in the Emergency Department, as well as the locum staff involved in the care of Mrs Ellett, and we ourselves have taken very seriously all the issues you have raised, and changes have been made to improve different aspects of the quality of care. As an over-arching step, individual named emergency consultants have recently been given responsibility for each of the Short Stay Ward and Clinical Decisions Unit, in order to provide visible senior medical leadership in each area and to seek ways of improving the quality of care. This will include regular audit to ensure proformas are being used correctly.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The nurse’s interactions with the patient were considered sufficient to provide opportunities for hands-on assessment.
Verbatim wording from the response “9. We agree that a hands on approach to patients is important, and believe that the experienced nurse caring for her did interact with Mrs Ellett on several occasions, for example when helping her to reposition to make sure that she was comfortable, and when helping her to have a drink. This provided her with opportunities to take into account what the policy you refer to describes as the “look, listen and feel” of Mrs Ellett. These interactions did not initially give her cause for concern, and she described a sudden change in Mrs Ellett’s condition later in the night.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Blood-testing decisions should not be based on the patient’s mode of transport.
Verbatim wording from the response “We do not believe it is appropriate for any decision about whether or not blood is to be taken to be based on the mode of transport by which they arrive (ambulance, own transport etc). We agree that Mrs Ellett’s blood should have been taken for testing, and confirm that while blood may be taken by medical or nursing staff, it is the responsibility of the doctor to ensure that appropriate blood tests have been taken and appropriate blood tests ordered. The doctors’ induction programme has” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The consultant’s undated signature on transfer documentation was not relevant to the patient’s clinical care.
Verbatim wording from the response “2. We believe the A&E consultant’s failure to date and time his signature on the transfer documentation, while not best practice, is not relevant to the clinical care of Mrs Ellett. However, we agree that she should not have been transferred until an appropriately detailed plan for her management had been agreed and summarized in a series of bullet points in the documentation, and the clinical shift leader had confirmed his agreement by signing the proforma. All the consultants and the relevant shift leaders have been reminded of the importance of this aspect of their duties.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The failure to countersign the initial observations was considered a documentation oversight without adverse effect on clinical assessment.
Verbatim wording from the response “10. The observations policy requires trained staff to review and countersign the findings, if taking the observations has been delegated to a health care assistant, however experienced that health care assistant may be. The agency staff nurse gave evidence to you that she had reviewed the first set of observations taken on the CDU and satisfied herself that the NEWS score was zero. What she failed to do, and acknowledged she should have done, was to countersign to indicate that she had carried out this check. We do not believe this documentation oversight at 21.55 had any adverse effect on Mrs Ellett’s clinical assessment, but we appreciate - as does the agency nurse herself - that detailed documentation of this kind is nevertheless important.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Although an earlier break would have been preferable, the delayed break was not considered to have compromised patient care.
Verbatim wording from the response “On reflection, we agree that it would have been preferable for her to have been encouraged more strongly to take an earlier break, even though we have no reason to think that the clinical care of any patient was compromised by her commitment to continuing their care without taking a formal break for several hours.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It was not considered clinically necessary or safest for every repeat ECG to receive an in-person review by the same doctor.
Verbatim wording from the response “7. While we do not accept that it is necessarily clinically appropriate for every patient to be reviewed in person by a doctor if a decision is taken that a further ECG should be taken after an interval, we do agree that continuity of care is desirable (see 4, above). However, we are not convinced that it is always safest to insist that a particular doctor reviews a second ECG, especially in a busy Emergency Department. This reflects both the risks inherent in interrupting a doctor who may be in the middle of some other complex patient assessment, and also the recognized advantage of using fresh eyes to assess a new heart trace.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Shared ECG access between the Clinical Decisions Unit and Short Stay Ward was considered sufficient, so a dedicated female-ward ECG was unnecessary.
Verbatim wording from the response “Unit (CDU) and the neighbouring Short Stay Ward (SSW) - effectively the small adjacent male and female ward areas within the Emergency Department for patients who are asked to stay in the department for a longer period. We believe this provides sufficient access for ECGs to be requested and performed safely in both areas, and that it is not necessary to have a dedicated ECG solely for the 7 female patients in the SSW.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The failure to complete outstanding assessments did not arise from staff working long shifts, whose benefits were considered to counterbalance associated risks.
Verbatim wording from the response “We do not believe the failure to complete and document these outstanding assessments arose from the length of shifts being worked by the staff. While we acknowledge that there are recognized risks associated with staff working these long shifts, the Trust’s Chief Nurse agrees with the national view that these risks are counter-balanced by the benefits associated with such shifts. In particular, the continuity of care for individual patients is preferred by most patients and many staff. Such continuity makes it easier to detect what may be subtle changes in a patient’s condition, as the same clinical member of staff has direct contact with the patient over a longer period. We are also aware that it is at handovers between staff that there is a particular risk of miscommunication, and by reducing the numbers of handovers in a 24 hour period, there is a reduction in this risk.” Source location 2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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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