Concerns raised 4 Failure to order microbiology tests promptly when antibiotics have no immediate effect View source Failure of policies, systems and electronic records to proactively drive infection testing and follow-up View source Failure of clinicians to actively consider and follow infection review guidance View source Lack of systemic checks and failsafes for infection testing, treatment and review View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Mary (also known as Moira) Forlin · 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 Mary Forlin was admitted to hospital after a fall at home with a long lie and was suffering from respiratory failure, likely driven by an infection of unknown source. She later collapsed and died from multiorgan failure arising from the infection and respiratory failure. The principal concerns were that clinicians did not actively follow guidance to review antibiotic treatment, microbiological testing was not undertaken early, and policies, systems and electronic records did not provide proactive checks or alerts to support infection testing, treatment and review when treatment was ineffective.
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 order microbiology tests promptly when antibiotics have no immediate effect
Wider context from the report “Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect ; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered.
Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests, including whether and when results have been obtained, or whether further specialist tests should then be required, enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell.
Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working.
” Open source report × Source evidence
How this 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 policies, systems and electronic records to proactively drive infection testing and follow-up
Wider context from the report “Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered.
Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests , including whether and when results have been obtained, or whether further specialist tests should then be required , enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell.
Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working.
” Open source report × Source evidence
How this 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 clinicians to actively consider and follow infection review guidance
Wider context from the report “Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance , despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced . Nor were microbiology tests ordered early on when antibiotics had had no immediate effect; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered.
Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests, including whether and when results have been obtained, or whether further specialist tests should then be required, enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell.
Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working.
” Open source report × Source evidence
How this 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 systemic checks and failsafes for infection testing, treatment and review
Wider context from the report “Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered.
Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests, including whether and when results have been obtained, or whether further specialist tests should then be required, enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell.
Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working .
” 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 Maintain microbiology systems for identifying deteriorating infection cases, escalating significant results, reviewing patients and coordinating specialist investigation and treatment advice.
Verbatim wording from the response “Systems in place within the Microbiology Department to identify patients with infection, critically ill with infection, those at risk of or already deteriorating, ones with significant positive cultures, those that need changes to treatment or initiation and those that need discussion with regards to investigations or further microbiological samples:” Source location Response from University Hospitals Sussex NHS Foundation 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 implement clinical decision support within phase three of the electronic patient record implementation.
Verbatim wording from the response “Delivering the greatest benefits with clinical decision support (CDS) requires mature data, careful design and collaboration between digital teams and clinicians. Clinical decision support is included in phase 3 of our EPR implementation.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
Concerns raised 1 Failure to provide a designated clinical area for emergency department patients when capacity is reached View source
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. 11
Action
Explore working with NEWTON to decompress the Emergency Department, strengthen Same Day Emergency Care, and improve flow for patients without a criteria to reside.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2026. View source
Action
Strengthen direct-to-specialty pathways and expand acceptance criteria for patients accepted directly by hospital specialties.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2026. View source
Action
Operate and regularly review the Hospital Alternative Oversight Programme and its admission-avoidance, flow, discharge, virtual-care, frailty, therapy, and urgent-care initiatives.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Implement local corridor-care safety measures, including digital observations and prescribing, intentional rounding, corridor standards, high-risk reviews, and dedicated monitoring space.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2026. View source
Action
Collaborate with the local Mental Health Trust to secure timely mental health admission or avoid Emergency Department attendance.
Stated in progressThe respondent said that this action was in progress when they made their response on 17 July 2026. View source
Action
Use ambulatory Emergency Department space effectively to maximise clinical capacity and reduce overcrowding.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Operate a 24/7 medical Same Day Emergency Care unit to stream suitable patients away from the Emergency Department.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Operate the Medicine Division’s Continuous Flow Model to move patients earlier from the Acute Floor and reduce Emergency Department admission waits.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Direct inter-hospital referrals to inpatient beds rather than routing them through the Emergency Department.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Complete phase one of the Acute Floor Reconfiguration programme, including opening the new Acute Medical Unit and 24/7 Medical Same Day Emergency Care unit.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source
Action
Run Emergency Physician In Charge and corridor huddles continuously to review corridor patients, identify pathways, and escalate risks.
Stated completedThe respondent said that this action was complete when they made their response on 17 July 2026. View source See 8 more actions
×
AI-generated summary
David John Smart · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David John Smart developed a life-threatening rectal bleed after a polypectomy and required surgery after conservative management continued to be unsuccessful. He died from known complications of Andexanet Alfa, used to reverse Rivaroxaban so that surgery could be performed. The inquest raised concerns about patients being cared for in corridors when the Emergency Department reached capacity, including the continued use of corridors despite actions intended to improve patient flow.
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 a designated clinical area for emergency department patients when capacity is reached
Wider context from the report “During the inquest I heard evidence that at the of Mr Smart's attendance to the Emergency Department of the Royal Sussex County Hospital, Brighton that there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so . I understand from previous inquests that the area is not designated as a clinical area .
I have heard in other inquests relating to deaths prior to June 2025 that is being taken by University Hospitals Sussex NHS Foundation Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital.
The evidence in this inquest was that, despite these actions, the corridor continues to be used when the Emergency Department reaches capacity .
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country .
Prevention of Future Death reports in relation to the use of the corridor for patient care was made during investigations into deaths which occurred in December 2022 and February 2025 and the use of the corridor remains ongoing .
” 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 Explore working with NEWTON to decompress the Emergency Department, strengthen Same Day Emergency Care, and improve flow for patients without a criteria to reside.
Verbatim wording from the response “The Trust is currently exploring working with a company (NEWTON) to increase the opportunity for decompressing the EDs, further strengthening the SDECs across the Trust, and improving flow once patients do not have a criteria to reside.” Source location Response from University Hospitals Sussex NHS Foundation 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 direct-to-specialty pathways and expand acceptance criteria for patients accepted directly by hospital specialties.
Verbatim wording from the response “The key workstreams include strengthening the ‘Direct to Specialty Pathways between the Emergency Department and the Trust’s specialties for patients who are accepted for care directly by the relevant specialty on presentation to the ED. We are continually looking to expand the acceptance criteria to ensure that we are maximising this process. Additionally, we are directing inter-hospital referrals away from the ED and transferring patients directly to the in-patient bed base. We have strengthened our Same Day Emergency Care (SDEC) medical model from a 7 day a week service to a 24/7 unit where patients can be streamed away from the ED and seen and treated on the Acute Medical Unit (AMU). These workstreams have all been overseen through the ED Quality Oversight Group.” Source location Response from University Hospitals Sussex NHS Foundation 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 Operate and regularly review the Hospital Alternative Oversight Programme and its admission-avoidance, flow, discharge, virtual-care, frailty, therapy, and urgent-care initiatives.
Verbatim wording from the response “The Hospital Alternative Oversight Programme (HALO) is embedded in daily practice and continues to be reviewed regularly to ensure all opportunities are maximised. This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:” Source location Response from University Hospitals Sussex NHS Foundation 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 local corridor-care safety measures, including digital observations and prescribing, intentional rounding, corridor standards, high-risk reviews, and dedicated monitoring space.
Verbatim wording from the response “We recognise that the contributory factors leading to corridor care are multi-faceted and complex. As these issues involve a multi-agency approach, working alongside our system partners, we acknowledge that eradicating care in non-clinical environments will take considerable time. Therefore, alongside these actions, the ED team is continuing to implement local measures to improve the quality and safety for patients receiving care in these areas. Examples of these are:” Source location Response from University Hospitals Sussex NHS Foundation 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 Collaborate with the local Mental Health Trust to secure timely mental health admission or avoid Emergency Department attendance.
Verbatim wording from the response “There continues to be ongoing collaborative work with the local Mental Health Trust, SPFT to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible or avoid ED attendance in the first place.” Source location Response from University Hospitals Sussex NHS Foundation 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 ambulatory Emergency Department space effectively to maximise clinical capacity and reduce overcrowding.
Verbatim wording from the response “We continue to use ambulatory space as effectively as possible across the ED to maximise clinical space and reduce overcrowding.” Source location Response from University Hospitals Sussex NHS Foundation 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 Operate a 24/7 medical Same Day Emergency Care unit to stream suitable patients away from the Emergency Department.
Verbatim wording from the response “The key workstreams include strengthening the ‘Direct to Specialty Pathways between the Emergency Department and the Trust’s specialties for patients who are accepted for care directly by the relevant specialty on presentation to the ED. We are continually looking to expand the acceptance criteria to ensure that we are maximising this process. Additionally, we are directing inter-hospital referrals away from the ED and transferring patients directly to the in-patient bed base. We have strengthened our Same Day Emergency Care (SDEC) medical model from a 7 day a week service to a 24/7 unit where patients can be streamed away from the ED and seen and treated on the Acute Medical Unit (AMU). These workstreams have all been overseen through the ED Quality Oversight Group.” Source location Response from University Hospitals Sussex NHS Foundation 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 Operate the Medicine Division’s Continuous Flow Model to move patients earlier from the Acute Floor and reduce Emergency Department admission waits.
Verbatim wording from the response “The Continuous Flow Model is embedded within the Medicine Division and continues to ensure earlier movement of patients from the Acute Floor and reducing the time patients are waiting in the ED for admission to a ward. There are ongoing discussions with clinical Divisions outside the Medicine Division to implement a similar model.” Source location Response from University Hospitals Sussex NHS Foundation 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 Direct inter-hospital referrals to inpatient beds rather than routing them through the Emergency Department.
Verbatim wording from the response “The key workstreams include strengthening the ‘Direct to Specialty Pathways between the Emergency Department and the Trust’s specialties for patients who are accepted for care directly by the relevant specialty on presentation to the ED. We are continually looking to expand the acceptance criteria to ensure that we are maximising this process. Additionally, we are directing inter-hospital referrals away from the ED and transferring patients directly to the in-patient bed base. We have strengthened our Same Day Emergency Care (SDEC) medical model from a 7 day a week service to a 24/7 unit where patients can be streamed away from the ED and seen and treated on the Acute Medical Unit (AMU). These workstreams have all been overseen through the ED Quality Oversight Group.” Source location Response from University Hospitals Sussex NHS Foundation 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 Complete phase one of the Acute Floor Reconfiguration programme, including opening the new Acute Medical Unit and 24/7 Medical Same Day Emergency Care unit.
Verbatim wording from the response “Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County” Source location Response from University Hospitals Sussex NHS Foundation 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 Emergency Physician In Charge and corridor huddles continuously to review corridor patients, identify pathways, and escalate risks.
Verbatim wording from the response “All specialties in-reach to the ED and we operate a 3/2/1 bleep system to ensure this is fast and effective. We continue to run ‘Emergency Physician In Charge’ (EPIC) huddles and Corridor huddles multiple times a day 24/7 days a week. These allow line-by-line reviews of every patient in the corridor to ensure all appropriate pathways are considered; this is known as check and challenge and provides live escalation.” Source location Response from University Hospitals Sussex NHS Foundation 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 Trust cannot eradicate corridor care without all partner organisations working together to address the wider system problem.
Verbatim wording from the response “The use of Emergency Department (ED) corridors to care for patients is a significant national problem. The Executive team is working closely with very senior members of the local ICB (Integrated Care Board), CQC (Care Quality Commission), local mental health Trust, and social care providers to tackle the problem. As a Trust we cannot solve the problem without all partner organisations working together. I am so sorry you have had the need to write to us again with your concerns and I too share these concerns.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
Concerns raised 4 Failure to translate GP-expressed urgency into accurate urgent booking codes View source Failure to report or urgently highlight clinically significant incidental ED findings to the GP View source Incomplete integration of referral IT systems View source Failure to provide or report the reason for the proposed referral urgency to the GP View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul Guy Robert Harries · 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 Guy Robert Harries was diagnosed with an abdominal aortic aneurysm and was subsequently lost to follow-up after missing a surveillance scan. He later died at home in Brighton on 9 October 2024 from a ruptured AAA while awaiting an outpatient appointment. Concerns included the handling of missed appointments, the downgrading and delayed booking of an urgent referral, reliance on separate referral systems, and failure to consistently report significant incidental emergency-department findings to the GP.
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 translate GP-expressed urgency into accurate urgent booking codes
Wider context from the report “Although I accept that a system of audits is now under way, these are evidently retrospective and the changes made do not appear to fully resolve the observed weaknesses and risk of differences apparent in the inquest within the GP-Consultant surgeon-Careflow booking chain whereby the urgency expressed by the GP does not successfully translate into an urgent booking , because there remains the risk of manual coding error and/or that there is no express reason given or reported back to the GP as to why their patient is or will be afforded the proposed 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 report or urgently highlight clinically significant incidental ED findings to the GP
Wider context from the report “Incidental findings from tests conducted in the ED are not always reported to the GP where these may not relate to the presenting complaint. ED policy appears to remain inconsistent. This is especially important as it means a Patient with a significant condition, for which they are under their GP, may have a change in that condition identified at the ED which is not then always reported back or highlighted urgently to the GP .
” Open source report × Source evidence
How this 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 integration of referral IT systems
Wider context from the report “Again, although there is current and considerable planned progress on integration of IT systems, this work is not yet complete and referrals remain reliant on 3 separate systems which are not yet fully joined 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 to provide or report the reason for the proposed referral urgency to the GP
Wider context from the report “Although I accept that a system of audits is now under way, these are evidently retrospective and the changes made do not appear to fully resolve the observed weaknesses and risk of differences apparent in the inquest within the GP-Consultant surgeon-Careflow booking chain whereby the urgency expressed by the GP does not successfully translate into an urgent booking, because there remains the risk of manual coding error and/or that there is no express reason given or reported back to the GP as to why their patient is or will be afforded the proposed urgency .
” 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 referral categorisation against triaging Consultants’ clinical narratives.
Verbatim wording from the response “The function of e-RS allows for identification of urgent or routine patients providing referring GPs and triaging Consultants use this function accurately and convert referrals from one category to another when clinically appropriate. Internally, this has resulted in education for the triaging Consultants to ensure that they are aware of the functions of e-RS and are able to use it accurately. It has also resulted in regular audits to check the categorisation of referrals against the narrative provided by the triaging Consultants.” Source location Response from University Hospitals Sussex NHS Foundation 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 all Emergency Department imaging reports, follow up incidental or relevant findings, and inform GPs where appropriate.
Verbatim wording from the response “The Lead Consultant for the Emergency Department (ED) at the Royal Sussex County Hospital has confirmed that there is now a system in place, introduced in 2026, to review all imaging reports obtained in the ED. The ED team check on incidental or relevant unrelated findings and ensure that follow-up arrangements are in place and/or the patient’s GP is informed. In addition, our hospital imaging reports are also available on the electronic system which the GPs access and review.” Source location Response from University Hospitals Sussex NHS Foundation 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 Educate triaging Consultants to use e-RS accurately for referral categorisation.
Verbatim wording from the response “The function of e-RS allows for identification of urgent or routine patients providing referring GPs and triaging Consultants use this function accurately and convert referrals from one category to another when clinically appropriate. Internally, this has resulted in education for the triaging Consultants to ensure that they are aware of the functions of e-RS and are able to use it accurately. It has also resulted in regular audits to check the categorisation of referrals against the narrative provided by the triaging Consultants.” Source location Response from University Hospitals Sussex NHS Foundation 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 Fully implement the Trust-wide electronic patient record system with Chief Information Officer support.
Verbatim wording from the response “Our Chief Information Officer is supporting this work while the Trust fully implements the Trust wide EPR (electronic patient record) system.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
Concerns raised 1 Failure to provide sufficient designated clinical space for Emergency Department patients View source
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. 19
Action
Operate the Direct to Specialty Pathway Agreement with specialty acceptance, rapid in-reach, escalation via the bleep system, daily referral monitoring, and cross-specialty flow meetings.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source
Action
Realign bed spaces and workforce through capacity-and-demand modelling to match service demand.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Implement a hospital-wide no-corridor culture through nominated leaders, staff empowerment, rapid response, feedback, learning, recognition, and scenario-based training.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Educate high-presenting nursing homes about avoiding unnecessary emergency-department attendances and navigating alternative care.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Provide consultant advice to ambulance services at the point of contact to support appropriate emergency-department referrals and avoid unnecessary attendances.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce emergency-department waits for ward admission.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source
Action
Progress the Acute Floor Reconfiguration capital programme to improve patient flow, capacity, and the clinical environment.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Coordinate with the local mental health trust to support rapid admission of patients requiring mental health care to appropriate units.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Lead the Hospital Alternative Oversight Programme to reduce inappropriate admissions and improve hospital flow and discharge through alternative-care, urgent-treatment, same-day, virtual, frailty, therapy, planning, and acuity initiatives.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Convert a trolley cubicle into a reclining-chair area in the emergency department to increase clinical space.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source
Action
Convert a trolley cubicle into a reclining-chair area in ED Majors to increase clinical space.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source
Action
Operate the Direct to Specialty Pathway Agreement, supported by specialty in-reach, rapid bleep escalation, daily referral monitoring and cross-specialty flow meetings.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source
Action
Educate teams at ten local nursing homes about avoidable ED attendances and alternatives to ED care.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Lead a hospital-wide no-corridor culture programme using nominated leaders, staff empowerment, response targets, feedback, recognition and scenario-based training.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Realign bed spaces and matching workforce through capacity-and-demand modelling.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Deliver the Acute Floor Reconfiguration capital programme to improve capacity, patient flow and the clinical environment.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Lead the Hospital Alternative Oversight Programme to avoid inappropriate admissions, improve hospital flow and smooth discharge through alternative-care and same-day emergency initiatives.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce ED waits for ward admission.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source
Action
Provide Trust consultant advice at ambulance point of contact with SECAmb to direct only patients requiring emergency care to the ED.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source See 16 more actions
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AI-generated summary
Maureen Brenda Batchelor · 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
Maureen Brenda Batchelor was admitted to hospital with diarrhoea and vomiting, was diagnosed with gastroenteritis and aspiration pneumonia, and died on 26 February 2025 from septicaemia caused by aspiration pneumonia. The report raised concerns that patients were being treated in the Emergency Department corridor, a non-clinical area, because of insufficient capacity, with this practice continuing and no evidence as to when it would end.
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 sufficient designated clinical space for Emergency Department patients
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area.
I understand that at the time of Mrs Batchelor's attendance on 25 February there were 25 patients in the Emergency Department corridor, and this increased to 32 patients.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. When asked there was no evidence as to when this practice would no longer be necessary.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to treat patients and the only other alternative would be to hold patients in ambulances outside of the hospital.
A Prevention of Future Deaths report in relation to the use of the corridor for patient care was made during an investigation into a death which occurred in December 2022 and the use of the corridor remains ongoing.
” 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 Operate the Direct to Specialty Pathway Agreement with specialty acceptance, rapid in-reach, escalation via the bleep system, daily referral monitoring, and cross-specialty flow meetings.
Verbatim wording from the response “We now have a Direct to Specialty Pathway Agreement between ED and the Trust’s specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Realign bed spaces and workforce through capacity-and-demand modelling to match service demand.
Verbatim wording from the response “There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand.” Source location 2025-0406 - Response from Hospital 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 hospital-wide no-corridor culture through nominated leaders, staff empowerment, rapid response, feedback, learning, recognition, and scenario-based training.
Verbatim wording from the response “Our Interim Assistant Director for Leadership and Management is leading on a cultural mindset change throughout the hospital, so we have a ‘no corridor culture’. This includes nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change.” Source location 2025-0406 - Response from Hospital 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 Educate high-presenting nursing homes about avoiding unnecessary emergency-department attendances and navigating alternative care.
Verbatim wording from the response “One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.” Source location 2025-0406 - Response from Hospital 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 consultant advice to ambulance services at the point of contact to support appropriate emergency-department referrals and avoid unnecessary attendances.
Verbatim wording from the response “I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8 -10 ambulance attendances are avoided each day.” Source location 2025-0406 - Response from Hospital 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 Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce emergency-department waits for ward admission.
Verbatim wording from the response “The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward.” Source location 2025-0406 - Response from Hospital 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 Progress the Acute Floor Reconfiguration capital programme to improve patient flow, capacity, and the clinical environment.
Verbatim wording from the response “As you know from the evidence heard at the inquest, the Medicine Divisional Leadership team, the Hospital Directors, and Executive team are continuously working on several separate but linked workstreams, which were previously in their infancy, to eradicate the use of the ED corridor for patient care and ensure they are treated in the most appropriate clinical environment with dignity and without delays.” Source location 2025-0406 - Response from Hospital 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 Coordinate with the local mental health trust to support rapid admission of patients requiring mental health care to appropriate units.
Verbatim wording from the response “Furthermore, we work closely with the local Mental Health Trust, SPFT, as part of HALO to try to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible.” Source location 2025-0406 - Response from Hospital 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 Lead the Hospital Alternative Oversight Programme to reduce inappropriate admissions and improve hospital flow and discharge through alternative-care, urgent-treatment, same-day, virtual, frailty, therapy, planning, and acuity initiatives.
Verbatim wording from the response “We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:” Source location 2025-0406 - Response from Hospital 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 Convert a trolley cubicle into a reclining-chair area in the emergency department to increase clinical space.
Verbatim wording from the response “We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space.” Source location 2025-0406 - Response from Hospital 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 Convert a trolley cubicle into a reclining-chair area in ED Majors to increase clinical space.
Verbatim wording from the response “We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space.” Source location Response from Hospital 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 Operate the Direct to Specialty Pathway Agreement, supported by specialty in-reach, rapid bleep escalation, daily referral monitoring and cross-specialty flow meetings.
Verbatim wording from the response “We now have a Direct to Specialty Pathway Agreement between ED and the Trust’s specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day.” Source location Response from Hospital 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 Educate teams at ten local nursing homes about avoidable ED attendances and alternatives to ED care.
Verbatim wording from the response “One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.” Source location Response from Hospital 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 Lead a hospital-wide no-corridor culture programme using nominated leaders, staff empowerment, response targets, feedback, recognition and scenario-based training.
Verbatim wording from the response “Our Interim Assistant Director for Leadership and Management is leading on a cultural mindset change throughout the hospital, so we have a ‘no corridor culture’. This includes nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Realign bed spaces and matching workforce through capacity-and-demand modelling.
Verbatim wording from the response “There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Acute Floor Reconfiguration capital programme to improve capacity, patient flow and the clinical environment.
Verbatim wording from the response “Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County Hospital, is well underway.” Source location Response from Hospital 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 Lead the Hospital Alternative Oversight Programme to avoid inappropriate admissions, improve hospital flow and smooth discharge through alternative-care and same-day emergency initiatives.
Verbatim wording from the response “We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:” Source location Response from Hospital 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 Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce ED waits for ward admission.
Verbatim wording from the response “The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward.” Source location Response from Hospital 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 Trust consultant advice at ambulance point of contact with SECAmb to direct only patients requiring emergency care to the ED.
Verbatim wording from the response “I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8-10 ambulance attendances are avoided each day.” Source location Response from Hospital Trust
Open published response
Concerns raised 1 Insufficient funding for urgent mechanical thrombectomy provision outside daytime hours View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barry Myers · 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
Barry Myers died at Royal Sussex County Hospital on 28 January 2024 after suffering an ischaemic cerebral artery stroke. The report describes that a mechanical thrombectomy was not available outside departmental operational hours, and notes insufficient funding for urgent thrombectomy provision between 4 pm and 8 am, as well as missed opportunities for transfer to another centre.
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 funding for urgent mechanical thrombectomy provision outside daytime hours
Wider context from the report “The court heard there is insufficient funding in place for patients to be provided with an urgent mechanical thrombectomy between the hours of 4 pm and 8 am at University Hospitals Sussex NHS Foundation 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 Establish 24/7 mutual-aid pathways to UCL and UHS for clinically indicated mechanical thrombectomy.
Verbatim wording from the response “The local service at the Royal Sussex County Hospital remains in place 08:00-16:00 hours Monday to Friday. Outside of these hours, we now have mutual aid pathways 24/7 for all of these sites to University College London Hospital (UCL) or University Hospital Southampton NHS Foundation Trust (UHS), to ensure patients have access to mechanical thrombectomy when clinically indicated.” Source location Response from University Hospitals Sussex NHS Foundation 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 local thrombectomy service to 24/7 following implementation of the expanded service.
Verbatim wording from the response “As you know from the evidence heard at the inquest, there was a Business Case in development to extend the hours of the local service. I am delighted to confirm the Business Case has now been approved to extend the local service to 7 days a week, 12 hours a day, at the Royal Sussex County Hospital. We are actively recruiting to all staff groups required to provide this specialised service. We intend to extend the service to 24/7 following this. This work is being monitored at our monthly Thrombectomy Delivery Group meetings.” Source location Response from University Hospitals Sussex NHS Foundation 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 required staff and extend the Royal Sussex County Hospital thrombectomy service to seven days a week, 12 hours a day.
Verbatim wording from the response “As you know from the evidence heard at the inquest, there was a Business Case in development to extend the hours of the local service. I am delighted to confirm the Business Case has now been approved to extend the local service to 7 days a week, 12 hours a day, at the Royal Sussex County Hospital. We are actively recruiting to all staff groups required to provide this specialised service. We intend to extend the service to 24/7 following this. This work is being monitored at our monthly Thrombectomy Delivery Group meetings.” Source location Response from University Hospitals Sussex NHS Foundation 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 Approve the business case to extend the Royal Sussex County Hospital thrombectomy service to seven days a week, 12 hours a day.
Verbatim wording from the response “As you know from the evidence heard at the inquest, there was a Business Case in development to extend the hours of the local service. I am delighted to confirm the Business Case has now been approved to extend the local service to 7 days a week, 12 hours a day, at the Royal Sussex County Hospital. We are actively recruiting to all staff groups required to provide this specialised service. We intend to extend the service to 24/7 following this. This work is being monitored at our monthly Thrombectomy Delivery Group meetings.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
Concerns raised 3 Lack of sufficient recording, flow and sharing of information across agencies and teams View source Failure to notify Police when a patient is missing or leaves the emergency department View source Delays in emergency department triage 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
Mark-Anthony SUMMERSETT · 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
Mark-Anthony Summerset attended Worthing Hospital Emergency Department on 5 February 2024 after expressing suicidal thoughts, but left before triage or assessment and was found deceased in his car in Arundel on 7 February 2024. The principal concern was insufficient recording, information flow and information sharing between the agencies involved, including failures to notify Police that he had left the Emergency Department, which may have limited efforts to locate, contact and urgently treat 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 Lack of sufficient recording, flow and sharing of information across agencies and teams
Wider context from the report “Whilst I heard evidence that the UHS Foundation Trust has a Missing Person policy – Walkouts/absconding patients (approved 23 May 2024), in Mr Summerset’s case there was a lack of recorded and/or shared information across all the agencies and teams with whom he had contact, or to whom he was known , such that an accurate and fully reflective risk assessment was not achieved , exacerbated by delays in the triage process in the ED.
Mr Summerset was not notified to Police as a missing person and nor were Police informed he had left the ED, despite them simultaneously raising a safeguarding risk via a Vulnerable Adult Single Combined Assessment of Risk Form.
In sum, there was therefore a lack of information sufficiency, flow and sharing across the agencies whilst he was present in, and at and after the point he left, the ED, which might have enabled greater efforts to locate, contact and more urgently treat him.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify Police when a patient is missing or leaves the emergency department
Wider context from the report “Whilst I heard evidence that the UHS Foundation Trust has a Missing Person policy – Walkouts/absconding patients (approved 23 May 2024), in Mr Summerset’s case there was a lack of recorded and/or shared information across all the agencies and teams with whom he had contact, or to whom he was known, such that an accurate and fully reflective risk assessment was not achieved, exacerbated by delays in the triage process in the ED.
Mr Summerset was not notified to Police as a missing person and nor were Police informed he had left the ED , despite them simultaneously raising a safeguarding risk via a Vulnerable Adult Single Combined Assessment of Risk Form.
In sum, there was therefore a lack of information sufficiency, flow and sharing across the agencies whilst he was present in, and at and after the point he left, the ED, which might have enabled greater efforts to locate, contact and more urgently treat him.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in emergency department triage
Wider context from the report “Whilst I heard evidence that the UHS Foundation Trust has a Missing Person policy – Walkouts/absconding patients (approved 23 May 2024), in Mr Summerset’s case there was a lack of recorded and/or shared information across all the agencies and teams with whom he had contact, or to whom he was known, such that an accurate and fully reflective risk assessment was not achieved, exacerbated by delays in the triage process in the ED .
Mr Summerset was not notified to Police as a missing person and nor were Police informed he had left the ED, despite them simultaneously raising a safeguarding risk via a Vulnerable Adult Single Combined Assessment of Risk Form.
In sum, there was therefore a lack of information sufficiency, flow and sharing across the agencies whilst he was present in, and at and after the point he left, the ED, which might have enabled greater efforts to locate, contact and more urgently treat him.
” Open source report
Concerns raised 2 Failure to include corridor patient care areas in the Emergency Department nursing staffing template View source Failure to provide sufficient designated clinical space for Emergency Department patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Tamara DAVIS · 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
Tamara Davis attended hospital after being unwell for five days and was treated for suspected chest infection before deteriorating and dying on 13 December 2022 from multi-organ failure associated with bronchopneumonia caused by Influenza A infection. A substantive concern was the use of an overcrowded Emergency Department corridor for patient care, where patients lacked privacy, toilet facilities and confidentiality, and where the area was not designated as a clinical area or included in the nursing staffing template.
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 include corridor patient care areas in the Emergency Department nursing staffing template
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED . When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who are sent to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. There was no evidence as to when, and if, this practice would no longer be necessary.
I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.
” Open source report × Source evidence
How this 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 sufficient designated clinical space for Emergency Department patients
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved and treated in the corridor as there was no clinical area available to do so . The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED. When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who are sent to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients . There was no evidence as to when, and if, this practice would no longer be necessary.
I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality . I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to.
” 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 Advance the Unscheduled Care Navigation Hub to reduce avoidable emergency-department attendance and support alternative admission pathways.
Verbatim wording from the response “The Medicine Division have employed an Operational Flow Improvement Manager who is leading the Hospital Alternative Oversight Programme. The aim of this work is to reduce admissions, optimise flow through the hospital, and smooth discharge pathways and processes. A number of the initiatives already in progress are as follows:” Source location Response from University Hospitals Sussex
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 the Surgical Assessment Unit by adding trolley beds and patient chairs as nursing recruitment allows.
Verbatim wording from the response “The SAU opened in October 2024 and is being expanded in line with nursing recruitment. This will increase the hospital’s bed stock by 12 patient trolley beds and 12 patient chairs. It is expected to manage most surgical patient presentations to the ED and receive ambulances directly.” Source location Response from University Hospitals Sussex
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 continuous flow with scheduled transfers from the Acute Assessment Unit to specialty medicine and frailty wards.
Verbatim wording from the response “Continuous Flow Model - Reducing overcrowding in the Emergency Department” Source location Response from University Hospitals Sussex
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 Open the Surgical Assessment Unit to receive surgical presentations and ambulances.
Verbatim wording from the response “Surgical Assessment Unit (SAU)” Source location Response from University Hospitals Sussex
Open published response
Concerns raised 1 Variability in on-call Neonatology Consultant attendance times View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Felix Burton HARTLEY · 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
Felix Burton Hartley was born without a heartbeat on 19 February 2023, was resuscitated after around 20 minutes without a heartbeat, and later could not recover from hypoxia and chorioamnionitis. The concern was that variable attendance times for the on-call Neonatology Consultant, covering two geographically separated hospitals, could create a risk of future deaths, although the report did not find the consultant’s attendance time causative or contributory to Felix’s 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 Variability in on-call Neonatology Consultant attendance times
Wider context from the report “In this case, I heard that over the weekend and overnight Neonatology Consultants are not available immediately on site at either the Princess Royal Hospital, Haywards Heath or the Royal Sussex County Hospital in Brighton . I heard that on-call Consultants over the weekend are on site at Brighton for some of the period but for the majority they are contactable by telephone in the first instance only . I heard that the Trust position is that this is not unusual in many settings as Consultants are not intended to be the first responders to emergency calls.
At University Hospitals Sussex NHS Foundation Trust (“the Trust”), the on-call Consultant covers both the Princess Royal Hospital and the Royal Sussex County Hospital . These two sites are not close in proximity, and I heard that the traffic impacts on the time it would take for a Consultant to attend . The on-call Consultant does not always have access to an emergency vehicle and if called to attend either site would use their own vehicle and be subject to the usual road traffic laws . I heard that the Trust practice, as opposed to Policy, is that the on-call Consultant cannot be more than 30 minutes from either Brighton or Haywards Heath. The Trust facilitates accommodation at Brighton for the on-call Consultant so that they are within 30 minutes of Brighton if required.
I was told that the arrangements for Neonatal care at the Princess Royal are in accordance with the British Association of Perinatal Medicine guidelines and that there is no national guidance as to the time that an on-call Neonatology Consultant should be expected to attend a hospital in the event of an emergency or as to whether multiple sites can be covered by one on-call Consultant. Whilst I did not find the timing of the attendance of the on-call Consultant causative or contributory in relation to Felix’s death, I am concerned that the time period in which attendance is made may vary and create a risk of future deaths .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore options for establishing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit.
Verbatim wording from the response “The Trust is aware that the current Neonatal Consultant on-call arrangements for the Trevor Mann Baby Unit and the Princess Royal Hospital Special Care Baby Unit do not meet the current British Association of Perinatal Medicine standards, but our review of outcomes did not find evidence that the current arrangements we have in place are unsafe. However, it is acknowledged that it is right to review these arrangements. We are exploring the options for providing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit, but we do not have existing Consultant resources to meet this need.” Source location Response from University Hospitals Sussex
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 Approach the Integrated Care Board about externally reviewing current arrangements and options to strengthen Neonatal Consultant on-call provision for the Princess Royal Hospital service.
Verbatim wording from the response “The Trevor Mann Baby Unit Consultants are already fully committed clinically, and the workforce and financial resources are not currently available to fund the large Consultant expansion that would be needed to provide a freestanding Princess Royal Hospital Special Care Baby Unit rota. Therefore, in view of the complexity and interdependency of the provision of maternity services, the Trust is approaching the Integrated Care Board (ICB) to consider externally reviewing the current arrangements and the options for strengthening our Neonatal Consultant on-call arrangements for the Princess Royal Hospital Neonatal service.” Source location Response from University Hospitals Sussex
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 Trust is asking the Integrated Care Board to externally review current arrangements and options for strengthening Neonatal Consultant on-call provision.
Verbatim wording from the response “The Trevor Mann Baby Unit Consultants are already fully committed clinically, and the workforce and financial resources are not currently available to fund the large Consultant expansion that would be needed to provide a freestanding Princess Royal Hospital Special Care Baby Unit rota. Therefore, in view of the complexity and interdependency of the provision of maternity services, the Trust is approaching the Integrated Care Board (ICB) to consider externally reviewing the current arrangements and the options for strengthening our Neonatal Consultant on-call arrangements for the Princess Royal Hospital Neonatal service.” Source location Response from University Hospitals Sussex
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 Outcome reviews found no evidence that the current Neonatal Consultant on-call arrangements at Princess Royal Hospital are unsafe or contribute to neonatal deaths.
Verbatim wording from the response “Neonatal deaths are reviewed at a regional level and local data is benchmarked by MBRRACE. These reviews of neonatal deaths have not highlighted the availability of the Neonatal Consultant at the Princess Royal Hospital as a contributory factor to neonatal deaths.” Source location Response from University Hospitals Sussex
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 Trust cannot currently provide a separate Princess Royal Hospital rota because Consultant, workforce and financial resources are unavailable.
Verbatim wording from the response “The Trust is aware that the current Neonatal Consultant on-call arrangements for the Trevor Mann Baby Unit and the Princess Royal Hospital Special Care Baby Unit do not meet the current British Association of Perinatal Medicine standards, but our review of outcomes did not find evidence that the current arrangements we have in place are unsafe. However, it is acknowledged that it is right to review these arrangements. We are exploring the options for providing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit, but we do not have existing Consultant resources to meet this need.” Source location Response from University Hospitals Sussex
Open published response
Concerns raised 2 Failure to maintain timely and sufficient clinical notes of events and treatment View source Failure to identify when clinical notes are based on assumption rather than first-hand knowledge View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Alissa Claire NORTON · 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
Alissa Claire Norton died on 22 April 2022 at Royal Sussex County Hospital from hypoxic ischaemic encephalopathy caused by chorioamnionitis to which she was exposed before birth. The report raises concerns that most notes about her events and treatment were completed retrospectively, with limited contemporaneous documentation and some entries based on assumption rather than first-hand knowledge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain timely and sufficient clinical notes of events and treatment
Wider context from the report “2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter .
3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her .
4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge. This was not clear in the 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 Failure to identify when clinical notes are based on assumption rather than first-hand knowledge
Wider context from the report “2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter.
3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her.
4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge . This was not clear in the notes .
” 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 Disseminate accurate, contemporaneous record-keeping requirements through maternity, Trust-wide, professional, governance and board communications.
Verbatim wording from the response “1. Sharing of a ‘message of the week’ within maternity on 4th March 2024 and a global message to all Trust staff on 5th April 2024 regarding the importance of accurate and contemporaneous record keeping, adhering to the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) codes of conduct.” Source location Response from University Hospitals Sussex
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 Complete an audit assessing retrospective entries and maternity record-keeping quality and prevalence.
Verbatim wording from the response “5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.” Source location Response from University Hospitals Sussex
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 Continue retrospective-entry and maternity-record audits through the service annual audit plan.
Verbatim wording from the response “5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.” Source location Response from University Hospitals Sussex
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require the labour ward coordinator to check staff documentation completion during shift checkout.
Verbatim wording from the response “4. Action as part of the shift ‘check out’ that the labour ward coordinator checks that all staff have completed their documentation before leaving the shift.” Source location Response from University Hospitals Sussex
Open published response
Concerns raised 1 Lack of venous thromboembolism risk assessment for hospital patients who are not admitted View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ann Dorothy PEARCE · 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
Ann Dorothy Pearce was discharged from hospital on 28 March 2022 after treatment for a tibial spine fracture, having been immobilised in a brace and only partially weight bearing. No venous thromboembolism assessment was undertaken during her admission or on discharge, and she died from a massive pulmonary embolism on 1 April 2022; the inquest also identified that the relevant policy did not cover patients attending hospital without being admitted.
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 venous thromboembolism risk assessment for hospital patients who are not admitted
Wider context from the report “Evidence at the inquest revealed that the Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 did not make provision for assessment of risk to patients who attended hospital but were not admitted . There was no evidence of any other policy or procedure which did so .
” 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 Develop a Trust thromboprophylaxis policy for ambulatory trauma patients discharged from the Emergency Department.
Verbatim wording from the response “We have developed a Trust policy for Thromboprophylaxis in Ambulatory Trauma Patients discharged from the Emergency Department.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
Concerns raised 1 Lack of guidance for monitoring self-administered medications not taken at dispensing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alison Mary ROSS · 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
Alison Mary Ross died on 11 November 2022 from an intraabdominal haemorrhage following an ascitic drain procedure performed on 10 November 2022. The report raises concern that there was no guidance for monitoring medicines self-administered by patients who did not take them when dispensed, relevant to the administration of apixaban before the procedure.
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 guidance for monitoring self-administered medications not taken at dispensing
Wider context from the report “It was brought to my attention that the competencies for those involved in medicine administration stated that medications should not be left at the bedside, but no guidance for the monitoring of medication for those patients who self administer prescriptions dispensed to them who do not take their medication at the time of dispensing it .
” 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 The Trust considers there is no ongoing patient-safety risk concerning medication administration.
Verbatim wording from the response “Our new Divisional Director of Nursing for the Medicine Division has reviewed your concerns in relation to medication administration in conjunction with the safety, quality and governance team in her Division, and is confident that there is not an ongoing risk to patient safety in this respect. We have made significant improvements to the systems and processes in place following Mrs Ross’ sad death, and I will summarise these below.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
17 Jan 2023 Teegan Marie Barnard · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 9 Failure to undertake anaesthetic morbidity and mortality reviews and share learning View source Failure to disseminate institutional learning from unexpected deaths View source Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event View source Failure to investigate potential anaesthetic-related causes of unexpected deaths View source Failure to remove and assess anaesthetic equipment for faults after a suspected equipment-related event View source Lack of a robust system to trigger investigations into unexpected deaths View source Delays in recognition of surgical emphysema during cardiac arrest View source Failure to comply with the Statutory Duty of Candour by sharing investigation findings and prevention steps View source Failure to consider and exclude tension pneumothorax during PEA cardiac arrest View source See 6 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
Teegan Marie Barnard · 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
Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her 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 undertake anaesthetic morbidity and mortality reviews and share learning
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths , and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this 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 institutional learning from unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths .
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to download and interrogate anaesthetic machine data after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated , which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this 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 investigate potential anaesthetic-related causes of unexpected deaths
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure ) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault. Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this 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 and assess anaesthetic equipment for faults after a suspected equipment-related event
Wider context from the report “3. Investigation after Teegan’s death
Following this incident, and despite Teegan being intubated and ventilated at the time, with a real possibility of this being an anaesthetic related event, no steps were taken by the anaesthetic department at St Richard’s Hospital, Chichester, either before or after the publication of the HSIB report, to explore potential iatrogenic or other anaesthetic related causes (such as exposure of Teegan’s lungs to excessive volume or pressure) as a possible or probable cause of Teegan’s death.
Furthermore, the anaesthetic machine/ventilator was not taken out of service and assessed to see if there was a fault . Neither was the data from the anaesthetic machine downloaded and interrogated, which may have assisted in establishing how Teegan came to develop bilateral tension pneumothoraces during her emergence from general anaesthesia.
The failure of the anaesthetic department to undertake any morbidity or mortality review/meeting following Teegan’s death led to a lost opportunity to share any possible learning opportunities both within and outside their department to prevent future deaths, and as a corollary to have been in a position to fully assist both the investigation by the HSIB and the inquest hearing.
” Open source report × Source evidence
How this 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 robust system to trigger investigations into unexpected deaths
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in recognition of surgical emphysema during cardiac arrest
Wider context from the report “2. Surgical emphysema
There was a delay in the recognition of surgical emphysema by clinical attendees at the cardiac arrest (medical specialist registrar, consultant obstetricians, anaesthetic core trainee, anaesthetic specialist registrar and the on call consultant anaesthetist) despite indicative clinical signs of deep cyanosis, gross whole body swelling with the need to remove the increasingly constrictive hospital wrist band and endotracheal tube tie, alongside sub-cutaneous crepitus and an abdominal drainage bag noted to be tense with air .
” Open source report × Source evidence
How this 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 the Statutory Duty of Candour by sharing investigation findings and prevention steps
Wider context from the report “4. Trust Clinical Governance procedures
The senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation into all the circumstances of the death of a 17-year-old patient, with no steps taken by them to do so either before or after the publication of the HSIB report or at any time prior to the Inquest hearing.
This gives rise to a concern of a lack of insight within the senior management team of the importance of undertaking a comprehensive investigation into unexpected deaths within their organisation and for there to be wider dissemination of any institutional learning with the aim of preventing future deaths.
The failure of the Trust to fully investigate how Teegan came by her death also gives rise to a concern regarding the Trust’s obligation to comply with the Statutory Duty of Candour and their requirement to share their findings with both the regulators and Teegan’s family as well as to indicate the steps, if any, they have taken to prevent future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
Wider context from the report “1. Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest
I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation . Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces . Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest.
” 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 Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
Verbatim wording from the response “c. The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on the management of increased airway pressure for the ventilated patient which forms part of their Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or tension pneumothorax in the management of increased airway pressures, we also note that, in their response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery-through the SALG’s Patient Safety Update.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
Verbatim wording from the response “However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the training program since the beginning of the year and includes reference to the 4H’s and 4T’s.” Source location Response from St Richards Hospital
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 Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.
Verbatim wording from the response “The anaesthetic team cooperated fully with the HSIB investigation and responded comprehensively to the draft report. The outputs were discussed at length within the Trust in a number of forums and continues to be, including at the Intensive Care and Maternity Mortality and Morbidity meetings. This feedback was not fully reflected in the final report.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
Verbatim wording from the response “b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.” Source location Response from St Richards Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and ratify a standard operating procedure defining actions for HSIB investigations and considering parallel local investigation.
Verbatim wording from the response “Although the Trust followed existing national guidance, additional safeguards have been put in place to ensure our processes for investigating maternal deaths are robust. In the Regulation 28 notice, the Trust’s decision not to undertake a local investigation alongside the one initiated by HSIB is highlighted. At the inquest the Trust presented evidence demonstrating the very clear national guidance indicating that the HSIB investigation should replace the need for local scrutiny as described above. However, in response to the coroner’s concerns, the Trust has developed a draft SOP that defines the actions required when an HSIB investigation takes place” Source location Response from St Richards Hospital
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 Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
Verbatim wording from the response “b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.” Source location Response from St Richards Hospital
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 Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.
Verbatim wording from the response “You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical emphysema despite the presence of indicative signs.” Source location Response from St Richards Hospital
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 HSIB investigation replaced the need for a parallel local investigation under national guidance, so no concurrent local investigation was required.
Verbatim wording from the response “The coroner raises the concern that there was no local investigation by the anaesthetic team before or after the HSIB report. However, initiating a local investigation in parallel to the HSIB investigation would have been contrary to national guidance.” Source location Response from St Richards Hospital
Open published response
Concerns raised 14 Lack of a written procedure for making a 999 emergency call View source Lack of a national system for managing and sharing Health and Safety information across company sites View source Lack of guidance for urgent referral of children to hospital or tertiary care View source Lack of a written procedure for obtaining first aid help quickly View source Failure to provide adequately for visitors' first aid needs across sites View source Insufficient availability of AEDs in key site areas View source Lack of national guidance for consistent referral of children for tonsillectomy and similar treatment View source Failure to provide direct ENT referral or follow-up assessment after a child chokes View source Insufficiently robust incident investigation and reporting system View source Delays in reassessment and referral of urgent cases due to inadequate cover View source Inadequate systems for reviewing local information sharing View source Unavailability of an external phone line for emergencies View source Failure to communicate specialist referral priorities to local hospitals View source Absence of choking-related red flags in tonsillectomy guidance View source See 11 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
James Joseph MANNING · 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
James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.
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 written procedure for making a 999 emergency call
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a national system for managing and sharing Health and Safety information across company sites
Wider context from the report “a) From speaking to a number of witnesses in this case, I was deeply concerned that there was no national system for managing Health & Safety issues across company sites . Staff agreed it would help to share information and learning on a reciprocal basis across all sites .
” Open source report × Source evidence
How this 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 guidance for urgent referral of children to hospital or tertiary care
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care ; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” Open source report × Source evidence
How this 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 written procedure for obtaining first aid help quickly
Wider context from the report “e) Witnesses confirmed that there was no written standard operating procedure setting out how staff can get first aid help quickly as well as when and how to make a 999-emergency call especially if a trained first aider is not immediately available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequately for visitors' first aid needs across sites
Wider context from the report “c) I am concerned that the Health & Safety Executive’s strong recommendation in the First Aid Regulations to consider the first aid of visitors and what will be offered in terms of provision across each site was not sufficiently reflected in company practices .
” Open source report × Source evidence
How this 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 availability of AEDs in key site areas
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance for consistent referral of children for tonsillectomy and similar treatment
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment . In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide.
” Open source report × Source evidence
How this 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 direct ENT referral or follow-up assessment after a child chokes
Wider context from the report “b) I also heard evidence from experts that when a child chokes as James did in May 2017, the risk of a life-threatening event is high. I was concerned to hear that A&E paediatricians could either refer directly to ENT specialists or arrange a follow-up visit to assess the likelihood of a repeat choking episode but in this case the child’s mother was referred back to the GP .
” Open source report × Source evidence
How this 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 Insufficiently robust incident investigation and reporting system
Wider context from the report “b) After hearing extensive evidence, I was deeply concerned about whether there was a sufficiently robust incident investigation and reporting system in place so that lessons could be learned then shared with staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in reassessment and referral of urgent cases due to inadequate cover
Wider context from the report “c) I heard evidence that at some points in James’s medical care there were delays in being reassessed especially following the sleep study . The delay in being reassessed and referred to tertiary care was contributed to by medical staff being off leave. Doctors will inevitably have leave yet I am still concerned that systems in place at that time were not sufficiently robust to ensure suitable cover was in place to progress urgent cases .
” Open source report × Source evidence
How this 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 systems for reviewing local information sharing
Wider context from the report “f) At several points during the inquest, questions were asked of medical witnesses about how best practice is shared between local NHS Trusts and GP surgeries. I am concerned that systems to review how information is shared locally may need to be reconsidered .
” Open source report × Source evidence
How this 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 an external phone line for emergencies
Wider context from the report “d) I was concerned to hear evidence that many months after this tragic incident during Tots Week, installation of an external phone line and sufficient AEDs in key areas such as restaurants and swimming pool areas had not been completed .
” Open source report × Source evidence
How this 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 specialist referral priorities to local hospitals
Wider context from the report “d) I also heard evidence to suggest that locally devised priorities agreed in specialist or tertiary centres (in this case the Royal Sussex County Hospital, Brighton) had not been communicated to local hospitals and shared so that doctors making a referral can consider the best place to refer a case taking into consideration relative waiting times .
” Open source report × Source evidence
How this 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 Absence of choking-related red flags in tonsillectomy guidance
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide .
” Open source report
5 Jan 2022 Richard Paul Victor Sanders · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3 Lack of awareness of immersion pulmonary oedema risks among people participating in diving View source Inefficient diver removal methods and techniques at the diving centre View source Failure to give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation 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
Richard Paul Victor Sanders · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Sanders, an experienced diver aged 52, became unresponsive during a dive to 45 metres on 11 April 2019 and was pronounced deceased at the scene. The concerns included awareness of immersion pulmonary oedema risks, the need for fitness-to-dive medical certification, and methods for removing divers from the water.
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 awareness of immersion pulmonary oedema risks among people participating in diving
Wider context from the report “1. Whether there is sufficient awareness of the risks & affects of immersion pulmonary oedema by those engaged &/ or participating in the activity of diving.
” Open source report × Source evidence
How this 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 Inefficient diver removal methods and techniques at the diving centre
Wider context from the report “3. Whether more efficient methods and/ techniques of diver removal from the water could be employed at the diving centre .
” Open source report × Source evidence
How this 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 give sufficient consideration to a fitness-to-dive medical certificate as a prerequisite for diving participation
Wider context from the report “2. Whether sufficient consideration has been given to the requirement for a “fitness to dive” medical certificate as a prerequisite to participation in diving activities .
” Open source report
20 Jun 2021 Anne BRADLEY · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 2 Lack of a formal system for surgeons to provide endoscopists with information about tumour localisation errors and tattooing problems View source Failure to require or recommend equipment that increases tumour localisation accuracy in routine colonoscopies View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anne BRADLEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anne Bradley underwent a colonoscopy that identified and tattooed a tumour, but the tumour was not located where expected during colectomy, requiring removal of a further section of colon. Post-operative complications led to bowel ischaemia and her death. Concerns included the lack of routine use of equipment that could improve tumour localisation and the absence of a formal system for sharing information about incorrect localisation or tattooing problems with endoscopists.
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 formal system for surgeons to provide endoscopists with information about tumour localisation errors and tattooing problems
Wider context from the report “(2) Feedback to endoscopists at St Richards Hospital
I heard evidence that at St Richards Hospital surgeons do not necessarily feedback information regarding tattooing problems or incorrect localisation of tumours to endoscopists .
The concern that I therefore have is that there is no formal system at St Richards Hospital which requires surgeons to provide information about the incorrect localisation of tumours or tattooing problems which is then shared with endoscopists .
” Open source report × Source evidence
How this 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 require or recommend equipment that increases tumour localisation accuracy in routine colonoscopies
Wider context from the report “(1) Use of scope guides/scope pilots
The colonoscopy was carried out without the use of a scope guide or scope pilot as none were available in the room used for Anne Bradley’s procedure. A scope guide or scope pilot is an additional piece of equipment which assists the endoscopist in carrying out a colonoscopy. I heard evidence from the endoscopist and 3 consultant colorectal surgeons who all agreed that the use of scope guides or scope pilots assist in accurately recording the location of a tumour.
The accuracy of this information is important in assisting the surgeons to locate the tumour especially during laparoscopic (keyhole) surgery with early stage tumours. I heard evidence that there are limited markers within the colon to assist the endoscopist to know the location and that tattoos used to mark the location of a tumour can, and in this case did, pierce through the colon and mark multiple areas.
Whilst St Richards Hospital explained that they have now equipped all rooms with scope guides or scope pilots I heard that use of such equipment is not required by quality assurance organisations.
The concern I have is that equipment which increases the accuracy of the localisation of a tumour is not required or recommended for use in routine colonoscopies.
” 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 Put a Local Safety Standard for Invasive Procedures document in place to support the standardised tattooing process.
Verbatim wording from the response “We are pleased to confirm that the Trust has instigated a robust system to ensure information in relation to tattooing is documented, monitored and, where appropriate, fed back to endoscopists. The system involves the introduction of a dedicated sticker into the colorectal theatre care plan for the operating surgeon to confirm the tumour was correctly identified by the tattoo. A negative answer will trigger completion of a Ditex incident report. A Local Safety Standard for Invasive Procedures (LocSSIP) document will be put in place which supports and describes the standardised process. All incident reports will continue to be subject to regular monitoring by the Surgical and Medical Divisional governance processes.” Source location 2021-0214-Response-from-St-Richards-Hospital_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend use of scope guides across all Trust sites.
Verbatim wording from the response “Scope guides are already in place on the St Richard’s site with a move to using scope guides across all sites. We are pleased to note that the Regulation 28 report was also addressed to four national bodies who will be best placed to consider your concerns and to implement guidance and recommendations at a national level as currently scope guides are only available from certain manufacturers.” Source location 2021-0214-Response-from-St-Richards-Hospital_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a system documenting, monitoring and feeding back tattooing information, using a dedicated theatre-care-plan sticker and incident-report escalation.
Verbatim wording from the response “We are pleased to confirm that the Trust has instigated a robust system to ensure information in relation to tattooing is documented, monitored and, where appropriate, fed back to endoscopists. The system involves the introduction of a dedicated sticker into the colorectal theatre care plan for the operating surgeon to confirm the tumour was correctly identified by the tattoo. A negative answer will trigger completion of a Ditex incident report. A Local Safety Standard for Invasive Procedures (LocSSIP) document will be put in place which supports and describes the standardised process. All incident reports will continue to be subject to regular monitoring by the Surgical and Medical Divisional governance processes.” Source location 2021-0214-Response-from-St-Richards-Hospital_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National bodies are best placed to consider concerns and implement guidance on scope guides, which are available only from certain manufacturers.
Verbatim wording from the response “Scope guides are already in place on the St Richard’s site with a move to using scope guides across all sites. We are pleased to note that the Regulation 28 report was also addressed to four national bodies who will be best placed to consider your concerns and to implement guidance and recommendations at a national level as currently scope guides are only available from certain manufacturers.” Source location 2021-0214-Response-from-St-Richards-Hospital_Published
Open published response
9 Apr 2021 Janet WILLCOCK · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Failure to auscultate the chest during clinical assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janet WILLCOCK · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janet Willcock, aged 61, was diagnosed with critical aortic stenosis and underwent surgery on 17 November 2020. She suffered a major stroke on 19 November and died on 21 November 2020; a principal concern was that her chest was not auscultated during two earlier hospital attendances, representing a missed opportunity to diagnose and treat the aortic stenosis earlier.
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 auscultate the chest during clinical assessment
Wider context from the report “On 12th August 20 Mrs Willcock presented at A&E, Princess Royal Hospital having fainted and fallen.
(1) She had a head injury and a fractured wrist. There is no evidence that her chest was auscultated.
(2) On the 28th August 2020 Mrs Willcock attended for day surgery (fixation of her wrist fracture). Again, there is no evidence that her chest was auscultated.
(3) The evidence I heard informed me that if it had been a new heart murmur it would have been heard which, taken with the syncope, should have resulted in an immediate referral to Cardiology.
” 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 Document the rationale when clinicians decide not to auscultate a patient presenting with unexplained syncope.
Verbatim wording from the response “case is presented at the next Governance Meeting, to ensure learning and to highlight the importance of auscultation in all patients presenting, like Mrs Willcock with unexplained syncope. Furthermore, if a clinical decision is taken not to auscultate, the rationale should be documented in the records.” Source location 2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Earlier intervention could not have influenced the outcome because death resulted from a documented complication of necessary surgery.
Verbatim wording from the response “We acknowledge that there is no evidence in Mrs Willcock's clinical records of her heart being auscultated when she attended the hospital during August 2020. However, we agree with you that this did not change the outcome for Mrs Willcock, who died of a documented complication that could not have been influenced by any earlier intervention.” Source location 2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing clinical training, experience and real-time individual judgement are considered sufficient to determine examinations and investigations, including cardiac auscultation.
Verbatim wording from the response “We do not believe that there are issues with the Trust’s systems or processes in relation to cardiac examination – and specifically auscultation. Clinical training and experience determine the examinations and investigations that are undertaken in all our patients; whether or not the heart is examined in a particular patient is always an individual clinical judgement, determined in real time by the specific clinical presentation.” Source location 2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Open published response
Concerns raised 1 Failure to regularly update and review A&E paper notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Steven Charles Costello · 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
Steven Charles Costello attended the Princess Royal Hospital on 3 October 2019 after disclosing suicidal thoughts and having a rope at home. He remained in A&E overnight because no hospital bed was available, and was found hanging at home on 4 October after leaving the department. The substantive concerns included inadequate documentation and review of his care and condition in A&E, including the failure to update his paper notes at the required intervals.
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 regularly update and review A&E paper notes
Wider context from the report “(1) Patient notes in the Accident and Emergency Department at the Princess Royal
In circumstances where a patient attends A & E at the PRH with a mental health concern they can be seen by a Senior Nurse Practitioner or a Doctor working for SPFT who assesses them; however patient care remains the responsibility of PRH. SPFT have reviewed their practice so that a contemporaneous note of their consultation is copied from Carenotes and placed in the A & E paper notes. Evidence from a PRH witness at the Inquest confirmed that Mr Costello’s paper notes should have been updated every 2-3 hours to provide an accurate account of how he was progressing. The witness indicated that the notes themselves which PRH staff (paper notes) needed updating and reviewing. This had been done previously for the PRH but then discarded following review by a Senior Nurse at the A & E department at Royal Sussex County Hospital which is also run by the same Trust.
It is requested that the Trust consider updating the A and E notes on both sites at the very earliest opportunity and to include note of the need to regularly update them in line with policies and that all staff in A & E receive training on the need to complete those notes regularly with emphasis on the importance of recognising the notes as a vital tool in recording and evaluating a patient’s condition.
” 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 Update Emergency Department mental-health triage documentation and adopt the revised version across all Emergency Departments in the merged Trust.
Verbatim wording from the response “• Work is underway to update our Emergency Department template documentation and the revised documentation will be adopted by all of our Emergency Departments in our newly merged Trust. The new documentation is called Emergency Department Adult Mental Health Triage. It includes good clear guidelines that have been designed to help our Emergency Department staff to assess the risk of self harm, suicide, and the risk of harm to others when a patient is admitted to an Acute Hospital Emergency Department and is suffering from a mental health illness.” Source location 2021-0095-Response-from-Royal-Sussex-County-Hospital-Redacted
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 use of the new Emergency Department documentation to ensure sustained improvement.
Verbatim wording from the response “• We will audit the use of the new documentation to ensure there is a sustained improvement. We also intend to introduce this system of assessment and documentation to our Children’s Emergency Department.” Source location 2021-0095-Response-from-Royal-Sussex-County-Hospital-Redacted
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 Emphasise in staff training the need for high-quality, regularly updated records for patients with mental-health illnesses awaiting beds.
Verbatim wording from the response “The importance of good quality documentation, with regular updates in the records of patients suffering with mental health illnesses, while in our hospitals waiting for a mental health bed, has been emphasised in training to the teams.” Source location 2021-0095-Response-from-Royal-Sussex-County-Hospital-Redacted
Open published response
19 Feb 2021 Mr. Brian David BUTTON · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1 Failure to maintain socially distanced bed spacing View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr. Brian David BUTTON · 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. Brian David BUTTON contracted COVID-19 pneumonia while a patient on Catharine James Ward at The Royal Sussex County Hospital in Brighton. The report raised concern that the ward’s 13 beds were not socially distanced; the inquest concluded with a finding of medical misadventure.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain socially distanced bed spacing
Wider context from the report “(1) That on 29th October 2020 Catharine James Ward at The Royal Sussex county Hospital in Brighton contained 13 beds. These beds are not socially distanced. A patient safety review confirms this. Mr. Button contracted COVID-19 pneumonia on Catharine James Ward. Whilst patients on the ward now have to wear masks (on a respiratory ward!) and there is much more regular and faster testing the beds are still not socially distanced. In October there were 13 beds in the ward. As at today’s date (12th February 2021 there are still 13 beds in the ward.
” 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 Removing beds to increase spacing would create greater patient and staff risks through reduced capacity, emergency-department crowding and delayed admission.
Verbatim wording from the response “We have very carefully considered and discussed widely, the risks associated with hospital bed removal and taken the view that this would create an even greater risk to patients and staff. This is because insufficient in-patient bed capacity inevitably increases the numbers and duration of patients waiting for admission in ED, exposing both patients and staff to conditions of crowding, with the associated and significantly increased risk of CoVid transmission. Prolonged waits in ED are also known to increase the risk of in-hospital mortality.” Source location 2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
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 Two-metre bed spacing is one recommended infection-control measure, not a mandated requirement, and cannot always be achieved in acute care.
Verbatim wording from the response “Two metre distancing between hospital beds is one just one of a broad range of Public Health England (PHE) Infection Prevention and Control (IPC) recommended measures; it is not however a mandated requirement.” Source location 2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A broad, continuously reviewed package of infection-control measures is considered sufficient instead of implementing bed spacing in isolation.
Verbatim wording from the response “The global CoVid pandemic is devastating and our staff have worked extremely hard throughout to maintain services, mitigate risks, and care for our patients. NHS Trusts have to make very difficult decisions on a daily basis and it is entirely appropriate to take a balanced approach to the risks by incorporating all of the available guidance and recommendations available nationally and internationally, instead of implementing one recommendation such as bed spacing in isolation. Throughout the pandemic, we have responded with a range of carefully considered safety measures; we will continue to do so in the interests of patient and staff safety.” Source location 2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Open published response
Concerns raised 2 Failure to mobilize the patient View source Delay in applying the external fixator View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Linda Ann PHILLIPSON · 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
Linda Ann PHILLIPSON died from a major pulmonary embolism during surgery for a complicated tibial fracture. The substantive concerns were delay in applying the external fixator and the apparent failure to mobilize her; the inquest conclusion also referred to unnecessary delay and suboptimal care leading to increased immobility before transfer.
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 mobilize the patient
Wider context from the report “(1) The delay in applying the external fixator
(2) The apparent failure to mobilize 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 Delay in applying the external fixator
Wider context from the report “(1) The delay in applying the external fixator
(2) The apparent failure to mobilize the patient
” 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 Include spanning external fixation, elevation and early physiotherapist-led mobilisation for peri-articular complex fractures in the transfer protocol.
Verbatim wording from the response “We can confirm that a Trust Surgical Board ratified Transfer Policy has been put in place between Brighton & Sussex University Hospitals and Western Sussex Hospitals NHS Foundation Trust hospitals for the management of complex trauma patients who need specialist surgery at the Major Trauma Centre. The immediate management of major trauma in Western Sussex Hospitals whilst awaiting transfer is included within the transfer protocol. The application of spanning external fixator for all Peri-articular complex fractures, elevation and early mobilisation with physiotherapists has been also included within the protocol to prevent any further similar occurrence.” Source location 2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a ratified inter-hospital transfer policy and protocol for complex trauma patients requiring specialist surgery, including interim management while awaiting transfer.
Verbatim wording from the response “We can confirm that a Trust Surgical Board ratified Transfer Policy has been put in place between Brighton & Sussex University Hospitals and Western Sussex Hospitals NHS Foundation Trust hospitals for the management of complex trauma patients who need specialist surgery at the Major Trauma Centre. The immediate management of major trauma in Western Sussex Hospitals whilst awaiting transfer is included within the transfer protocol. The application of spanning external fixator for all Peri-articular complex fractures, elevation and early mobilisation with physiotherapists has been also included within the protocol to prevent any further similar occurrence.” Source location 2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Open published response
Concerns raised 2 Failure to identify mesenteric thrombi in overnight radiology practice View source Failure to use NEWS appropriately View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mrs Frances Jean Gibb · 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 Frances Jean Gibb died in circumstances considered at an inquest, which concluded with a narrative conclusion. The concerns identified were serious failings in the use of NEWS and a failure to identify a mesenteric thrombus, apparently while a junior radiologist was working overnight under pressure.
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 identify mesenteric thrombi in overnight radiology practice
Wider context from the report “(2) There was a failure to identify a mesenteric thrombus (see Record of Inquest) This appears to have occurred when the junior radiologist was working overnight and under pressures . What lessons have been learned from this?
” Open source report × Source evidence
How this 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 appropriately
Wider context from the report “(1) Once again I must write concerning the serious failings in the use of NEWS . Please see the Record of Inquest for details. When you respond to this Regulation 28 report will you please explain why it is that I regularly send you reports on the misuse of NEWS . Am I to assume that no lessons are being learnt?
” 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 Remind radiologists and trainees to specifically assess the superior mesenteric artery when investigating suspected ischaemic bowel.
Verbatim wording from the response “1. All Radiologists including trainees have been reminded to look specifically at the SMA when the request is for a queried ischemic bowel.” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 Enable discretionary next-morning Consultant review of scans reported overnight by post-FRCR Part 2b trainees.
Verbatim wording from the response “4. Any scans reported by post FRCR Part 2b trainees can be reviewed the following morning by a Consultant at the trainee's discretion.” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 electronic patient observations to the Maternity Department and Emergency Department.
Verbatim wording from the response “We cannot agree that lessons have not been learnt in relation to NEWS within the Trust. During his evidence at the inquest, ████████ described how electronic patient observations (Patientrack) are now embedded in the Trust and are working very well. The roll out of electronic patient observations began in July 2019 and to date, all Adult and Paediatric inpatient areas now have the system in place. Later this month the system will be put into the Maternity Department and then to the Emergency Department in May (following other digital changes we are making).” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 electronic patient observations with automated NEWS calculation, escalation prompts, and clinical visibility across adult and paediatric inpatient areas.
Verbatim wording from the response “We cannot agree that lessons have not been learnt in relation to NEWS within the Trust. During his evidence at the inquest, ████████ described how electronic patient observations (Patientrack) are now embedded in the Trust and are working very well. The roll out of electronic patient observations began in July 2019 and to date, all Adult and Paediatric inpatient areas now have the system in place. Later this month the system will be put into the Maternity Department and then to the Emergency Department in May (following other digital changes we are making).” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-present the case through the REAL radiology learning and case-review meeting.
Verbatim wording from the response “5. Mrs Gibb’s case has been re-presented in our REAL (Radiology Events and Learning through case review) meeting.” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 training for new ward staff on NEWS and escalation of care.
Verbatim wording from the response “10. All new staff to the ward have received training on both NEWS and the importance of escalation of care.” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 Change radiology protocols to use thinner two-plane reconstructions for improved regional visualisation.
Verbatim wording from the response “2. The Protocol has changed so the reconstructions are thinner in two planes to enable better visualisation of the region.” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 next-morning Consultant review of overnight scans reported by pre-FRCR Part 2b trainees.
Verbatim wording from the response “3. All overnight scans are reviewed by a Consultant the following morning for those reported by pre Fellowship of the Royal College of Radiologists (FRCR) Part 2b trainees overnight.” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 missed embolus was difficult to diagnose, perception errors can occur, and no particular reporting pressure, interruption or distraction was identified.
Verbatim wording from the response “Radiology
As confirmed in ████████ statement for the inquest, the initial CT report missed an embolus lodged in the superior mesenteric artery which was not causing radiological bowel changes at the time. ████████ confirmed that this was not an easy diagnosis to make and, having shown the scans to some of his Consultant Radiological colleagues, not all of them identified the embolus on the imaging. As acknowledged by ████████ in his statement for the inquest, perception errors such as these unfortunately do occur in the field of radiology and any misses are discussed by the team in regular discrepancy meetings. ████████ did not state that he was under any particular pressure when he reported Mrs Gibb’s scan, and he could not recall any particular interruption or distraction that night.” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
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 Trust disputes that lessons were not learned about NEWS, citing effective implementation of electronic observations and escalation prompts.
Verbatim wording from the response “We cannot agree that lessons have not been learnt in relation to NEWS within the Trust. During his evidence at the inquest, ████████ described how electronic patient observations (Patientrack) are now embedded in the Trust and are working very well. The roll out of electronic patient observations began in July 2019 and to date, all Adult and Paediatric inpatient areas now have the system in place. Later this month the system will be put into the Maternity Department and then to the Emergency Department in May (following other digital changes we are making).” Source location 2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Open published response
Concerns raised 3 Failure to use transfer assessment tools View source Failure to follow the transfer policy View source Unnecessary and inappropriate inter-hospital 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
Jean Evelyn WAGHORN · 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
Jean Evelyn WAGHORN fell at home and sustained fractures to her neck, after which she was transferred between hospitals three times in just over 48 hours. She developed pneumonia while receiving conservative care in hospital and died on 29 June 2019. The substantive concerns were that two transfers were inappropriate, the relevant transfer policy was effectively ignored, and previous recommendations concerning the policy had not been implemented for Mrs Waghorn.
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 transfer assessment tools
Wider context from the report “(3) I have made two recent previous regulation 28 reports concerning the Transfer Policy on 12 July 2018 and 20 July 2018. The response to the former included the assurance that a trust wide transfer policy working group was convened, led by ████████, three extra assessment tool sheets were created. None of these were used for Mrs Waghorn. Why not? What is the point of the Regulation reports if the trust ignores them?
” Open source report × Source evidence
How this 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 transfer policy
Wider context from the report “(2) The Brighton and Sussex University Hospital NHS Trust policy for transfer was effectively ignored .
” Open source report × Source evidence
How this 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 and inappropriate inter-hospital transfers
Wider context from the report “(1) Unnecessary and inappropriate transfers between the Royal Sussex County Hospital, the Princes Royal Hospital and the Royal Sussex County Hospital.
” Open source report
2 Oct 2019 Richard Lester Ridout · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 4 Failure to carry out cervical spine imaging after distracting injury and neck pain View source Failure to put out a trauma call for high-energy road traffic collisions View source Failure to escalate assessment and treatment after a serious road traffic collision View source Failure to carry out trauma series CT scans after high-energy injury View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Richard Lester Ridout · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Lester Ridout was involved in a single-vehicle road traffic collision on 20 January 2019 and was later readmitted with respiratory failure, where cervical fractures and pulmonary contusions were discovered. The inquest concluded that he died from Influenza A and streptococcal pneumonia causing sepsis and multiple organ failure. Concerns were raised that the assessment and escalation of treatment after the collision did not include a trauma call, trauma CT scan, or cervical spine imaging despite the reported collision circumstances, injuries, neck pain and medication use.
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 carry out cervical spine imaging after distracting injury and neck pain
Wider context from the report “(3) There was evidence available to the medical staff involved in his treatment that Richard had consumed diazepam and buprenorphine prior to his arrival at hospital. Despite this information being available, the distracting injury to his shoulder and a complaint of neck pain no imaging of his c-spine was carried out .
” Open source report × Source evidence
How this 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 put out a trauma call for high-energy road traffic collisions
Wider context from the report “(1) I heard evidence that a trauma call would be put out if certain circumstances arose. These included where a high speed was involved in an RTC. In this inquest it was clear that inconsistent information was given about the speed and the junior doctor was informed that the speed was 50-60mph. Despite this inconsistency and evidence of a high speed collision no trauma call was put out.
(2) I heard evidence that no trauma series CT scan was carried out or trauma call put out despite Richard suffering an injury requiring a high degree of force (fractured scapula) and having been involved in a roll-over RTC .
” Open source report × Source evidence
How this 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 assessment and treatment after a serious road traffic collision
Wider context from the report “(4) Whilst the undiagnosed condition did not contribute to Richard Ridouts death I am concerned that the failure to escalate the assessment and treatment of a person involved in such a road traffic collision could lead to deaths in the future .
” Open source report × Source evidence
How this 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 carry out trauma series CT scans after high-energy injury
Wider context from the report “(1) I heard evidence that a trauma call would be put out if certain circumstances arose. These included where a high speed was involved in an RTC. In this inquest it was clear that inconsistent information was given about the speed and the junior doctor was informed that the speed was 50-60mph. Despite this inconsistency and evidence of a high speed collision no trauma call was put out.
(2) I heard evidence that no trauma series CT scan was carried out or trauma call put out despite Richard suffering an injury requiring a high degree of force (fractured scapula) and having been involved in a roll-over RTC.
” 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 fractured-scapula management protocol advising cervical-spine and chest X-rays and a lower threshold for clinically indicated CT scanning.
Verbatim wording from the response “While there was no clear clinical indication for a full trauma CT scan on this occasion, we are currently developing a protocol for the management of patients who have sustained a fractured scapula. The protocol will advise that these patients should now have x-rays of their cervical spine and chest, with a lower threshold to perform a CT scan if clinically indicated. The work on protocols is taking place across the two hospital sites and will be complete within 3 months.” Source location 2019-0331-Response-by-Western-Sussex-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 Develop a trauma-management protocol addressing differing collision-speed accounts, reduced clinical signs in patients using opiates or sedatives, and consideration of trauma calls.
Verbatim wording from the response “We can confirm that a protocol is being developed for the management of patients who have sustained trauma where there are differing accounts of the speed involved as well as emphasising that patients who are on long term opiates or sedatives, whether prescribed or not, will often have reduced clinical signs so the level of clinical suspicion needs to be increased. The need to give consideration to instigating a trauma call when there is an unclear account of the collision and, in particular, potential of a high speed impact, is included as part of the protocol.” Source location 2019-0331-Response-by-Western-Sussex-Hospitals
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 There was no clear clinical indication for a full trauma CT scan in this case.
Verbatim wording from the response “While there was no clear clinical indication for a full trauma CT scan on this occasion, we are currently developing a protocol for the management of patients who have sustained a fractured scapula. The protocol will advise that these patients should now have x-rays of their cervical spine and chest, with a lower threshold to perform a CT scan if clinically indicated. The work on protocols is taking place across the two hospital sites and will be complete within 3 months.” Source location 2019-0331-Response-by-Western-Sussex-Hospitals
Open published response
Concerns raised 6 Failure to accurately and contemporaneously record NEWS observations View source Failure to follow NICE guidance for the diagnosis and management of allergy View source Lack of communication of allergy information within the hospital and to patients, families and GPs View source Insufficient nursing and medical staffing capacity View source Failure to act on NEWS observations and escalate deteriorating patients View source Failure to prevent prescribing and administration of a documented allergenic medication View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ioannis AVGOUSTI · 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
Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.
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 accurately and contemporaneously record NEWS observations
Wider context from the report “(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him.
I saw evidence of a poorly documented, from the point of view of time, NEWS observation . Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours.
The observations were added up to 9. In fact the total was 13.
NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care.
This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty)
If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative.
Whilst I cannot say categorically that this would have been the case I believe it is highly likely.
NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018.
” Open source report × Source evidence
How this 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 NICE guidance for the diagnosis and management of allergy
Wider context from the report “(1) On the 2nd September 2017 the NICE Guidance for the Diagnosis and Management of Allergy was not followed.
It was suggested to me that following the episode of anaphylaxis on the 27th July 2018 the NICE protocol was followed and therefore lessons had been learned to protect future patients however, I found that that was not the case.
Whilst two Mast Cell Tryptase tests had been carried out and there had been some rather sporadic marking of a possibility of allergy in some of the hospital documentation, there had been no proper communication either immediately following the incident or later on within the hospital itself nor to the GP nor to Mr. Avgousti himself or his family. This was simply not good enough.
” Open source report × Source evidence
How this 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 communication of allergy information within the hospital and to patients, families and GPs
Wider context from the report “(1) On the 2nd September 2017 the NICE Guidance for the Diagnosis and Management of Allergy was not followed.
It was suggested to me that following the episode of anaphylaxis on the 27th July 2018 the NICE protocol was followed and therefore lessons had been learned to protect future patients however, I found that that was not the case.
Whilst two Mast Cell Tryptase tests had been carried out and there had been some rather sporadic marking of a possibility of allergy in some of the hospital documentation, there had been no proper communication either immediately following the incident or later on within the hospital itself nor to the GP nor to Mr. Avgousti himself or his family . This was simply not good enough.
” Open source report × Source evidence
How this 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 nursing and medical staffing capacity
Wider context from the report “(3) On the same night the nurses and the doctors were working 12½ hour “weekend” shifts”. The day nursing shift was one nurse short and so far as the doctors were concerned they were, as I understand they always are at weekends, too few in number and as a result all staff in hospital are thoroughly stretched and stressed and under resourced .
This is no way to run a hospital service.
Exacerbating factors in Mr. Avgousti’s case were that his rapid deterioration took place at around handover for both doctors and nurses, thus adding even more pressure to the situation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act on NEWS observations and escalate deteriorating patients
Wider context from the report “(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him.
I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours.
The observations were added up to 9. In fact the total was 13.
NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care.
This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty)
If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative.
Whilst I cannot say categorically that this would have been the case I believe it is highly likely.
NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018.
” Open source report × Source evidence
How this 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 prevent prescribing and administration of a documented allergenic medication
Wider context from the report “(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him .
I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours.
The observations were added up to 9. In fact the total was 13.
NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care.
This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty)
If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative.
Whilst I cannot say categorically that this would have been the case I believe it is highly likely.
NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018.
” 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 Deliver bespoke Acute Admissions Unit training on penicillin allergy risks and co-amoxiclav use.
Verbatim wording from the response “To supplement this trial, the Acute Admissions Unit team have put in a place a bespoke training programme for staff in order to highlight the risk of penicillin allergy and the use of co-amoxiclav. I am delighted to say that over the last month there have been no penicillin related incidents on the Acute Floor at the Royal Sussex County Hospital. These improvements will then be extended to other areas of the Trust.” Source location 2019-0135-Response-by-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 Roll out an electronic system for recording NEWS observations and nursing assessments.
Verbatim wording from the response “I agree with you that NEWS is a very important tool and should be used and followed correctly. I regret the NEWS documentation was not to the standard we expect. The ward team have reflected at length and the case was discussed by the wider team at the Medicine Division’s Clinical Governance meeting on 17 May 2019. I am pleased to say, after a successful trial, the Trust has purchased an electronic system for recording NEWS and nursing assessments. This system is currently rolling out electronic recording of observations, and NEWS scores of all patients will therefore be available to view by the” Source location 2019-0135-Response-by-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 Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.
Verbatim wording from the response “Critical Care Outreach service, of which we are expanding, so escalation will be immediate rather than reliant on staff on the ward calculating the scores and putting out a MET call.” Source location 2019-0135-Response-by-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 Undertake medicines reconciliation for every patient as soon as possible after admission.
Verbatim wording from the response “Medicines reconciliation is now undertaken for every patient as soon as possible after they have been admitted to hospital.” Source location 2019-0135-Response-by-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 Implement redesigned prescription charts displaying medication, reaction and allergy-safety decision information.
Verbatim wording from the response “████████ Head of Nursing for Quality Improvement has undertaken work in conjunction with the Pharmacy team to ensure that the Trust is fully compliant with these NICE guidelines. ████████ has confirmed that the Trust is currently compliant with most of the guidelines and has produced an action plan for the remaining guidelines. This includes a tool, to describe reactions and to determine actual allergy status, which has been developed and this tool will be incorporated into the new design of the Trust’s Prescription chart. The next print run of our newly designed Prescription charts will include:” Source location 2019-0135-Response-by-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 Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
Verbatim wording from the response “All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work.” Source location 2019-0135-Response-by-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 Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
Verbatim wording from the response “We have undertaken extensive investigation into the use of red allergy wrist bands, led by the Head of Nursing - Quality Improvement. We have conducted three audits of the appropriate use of red wristbands since January 2019 and there has been 10% improvement on compliance. In addition, our Acute Admissions Unit and Emergency Department are trialing a single coloured wristband system whereby if a patient has an allergy, they will only wear a red wristband with their details on it, and not an additional white wristband. The aim of this trial is to see if it reduces the risk of the red wristband not being seen when checking patients’ details prior to medication administration and our patients like Mr Avgousti who I gather did not like wearing multiple wristbands and would sometimes pull them off, being more comfortable and reducing the risk of removal.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
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 Purchase of the EPMA package cannot proceed until NHS England decides its funding allocation.
Verbatim wording from the response “All of the above will be incorporated into the EPMA (Electronic Prescribing and Medicines Administration) system. The business case for this package has been approved and the specification is currently being finalised. We are waiting for an imminent NHS England allocation of funding decision in order to purchase the EPMA package. Once commenced we our aim is for 80% of wards to have EPMA within 2 years. The Chief of Pharmacy and his team are leading on this work.” Source location 2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Open published response
Concerns raised 7 Failure to check disconnected epidurals in response to increasing pain View source Failure of the postoperative pathway to provide safe urinary catheter removal guidance View source Lack of postoperative urinary catheter management instructions View source Unnecessary Junior Doctor attendance requirement delaying operations View source Incomplete discharge documentation for handover to doctors View source Lack of continuity between operating surgeons and postoperative consultants View source Failure to deliver prescribed blood transfusions as scheduled 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
Kenneth George Alfred WHITTINGTON · 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
Kenneth George Alfred Whittington died following an operation, but the supplied text does not provide further circumstances of his death beyond referring to the Record of Inquest. The principal concerns included inadequate instructions and handover about management of his urinary catheter after bladder repair, failure to check a disconnected epidural despite increasing pain, incomplete blood transfusion and discharge documentation, and a delay to the initial operation because no Junior Doctor was present.
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 check disconnected epidurals in response to increasing pain
Wider context from the report “(3) Immediately post operatively Mr. Whittington’s epidural became disconnected.
He complained of increasing pain over the ensuing night and in spite of this nobody, not even the most senior Nurses, ever checked his epidural!
It was not until some hours later in the early morning that the cause for his increasing pain was ascertained.
At that stage his pain control was optimised however, this is not a situation which should have occurred. During his period of increased pain he developed a pneumonia.
” Open source report × Source evidence
How this 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 postoperative pathway to provide safe urinary catheter removal guidance
Wider context from the report “(4) Following the operation Mr. Whittington’s last contact with his Consultant was immediately post operatively.
Due to the system operated at the Royal Sussex County Hospital (along with many other hospitals as I understand it) the situation is that the operative surgeon will not see the patient again unless there is some specific reason to do so.
Instead the patient will be seen by the on call surgical team for that particular day or part of the day.
Mr. Whittington therefore saw a Consultant who did not know him and who did not understand either the condition that Mr. Whittington had come in to hospital with (Colovesical Fistula) or the fact that he needed an operation which had included a bladder repair as I have already pointed out (2 above).
The surgeon wanted the urinary catheter to remain in situ for at least two weeks to allow the bladder repair that had been made at Mr. Whittington’s operation to heal.
This was absolutely crucial and yet no specific instructions were given and the post-operative pathway which was being followed gave very little help in that respect either, save to suggest that the catheter should always be removed early, well prior to discharge.
Had there been post-operative instructions and had there been a checklist for the Consultant picking up the ward rounds following the operation, the catheter would not have been removed and Mr. Whittington would not have died.
If the Trust is insistent on perpetuating this lack of continuity between the Surgeon and the post-operative Consultant care there must be sufficient handover and sufficient clear instructions from the Surgeon doing the operation as to the post-operative care so as to protect 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 Lack of postoperative urinary catheter management instructions
Wider context from the report “(2) Most importantly post operation ‘paperwork’ contained no instructions regarding the management of his urinary catheter or how long it was to remain in situ.
████████ said that he had expected to be in place for at least two weeks post operatively and very likely longer because at the operation he had had to make a bladder repair and therefore did not want to remove the urinary catheter until such time as the bladder had healed.
Had he made this requirement clear I have no doubt that this matter would not have come to Inquest.
” Open source report × Source evidence
How this 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 Junior Doctor attendance requirement delaying operations
Wider context from the report “(1) Mr. Whittington’s initial operation was abandoned because on his pre operation assessment on the 23rd March 2018 there was no Junior Doctor present.
It became apparent that the presence of a Junior Doctor was not imperative by any means.
I gather that since this situation occurred and caused a delay in Mr. Whittington’s operation the presence of a Junior Doctor in these circumstances is really no longer required . Although the delay neither caused nor contributed to Mr. Whittington’s death it must nonetheless have caused him considerable anxiety and inconvenience.
” Open source report × Source evidence
How this 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 discharge documentation for handover to doctors
Wider context from the report “(6) Mr. Whittington was due to be discharged on the 4th May. His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable.
” Open source report × Source evidence
How this 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 between operating surgeons and postoperative consultants
Wider context from the report “(4) Following the operation Mr. Whittington’s last contact with his Consultant was immediately post operatively.
Due to the system operated at the Royal Sussex County Hospital (along with many other hospitals as I understand it) the situation is that the operative surgeon will not see the patient again unless there is some specific reason to do so.
Instead the patient will be seen by the on call surgical team for that particular day or part of the day.
Mr. Whittington therefore saw a Consultant who did not know him and who did not understand either the condition that Mr. Whittington had come in to hospital with (Colovesical Fistula) or the fact that he needed an operation which had included a bladder repair as I have already pointed out (2 above).
The surgeon wanted the urinary catheter to remain in situ for at least two weeks to allow the bladder repair that had been made at Mr. Whittington’s operation to heal.
This was absolutely crucial and yet no specific instructions were given and the post-operative pathway which was being followed gave very little help in that respect either, save to suggest that the catheter should always be removed early, well prior to discharge.
Had there been post-operative instructions and had there been a checklist for the Consultant picking up the ward rounds following the operation, the catheter would not have been removed and Mr. Whittington would not have died.
If the Trust is insistent on perpetuating this lack of continuity between the Surgeon and the post-operative Consultant care there must be sufficient handover and sufficient clear instructions from the Surgeon doing the operation as to the post-operative care so as to protect 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 deliver prescribed blood transfusions as scheduled
Wider context from the report “(5) On the 2nd May Mr Whittington’s haemoglobin was low. Mr. Whittington needed and was written up to receive two units of blood on the 2nd May. In fact he received one unit on the 3rd May.
There is absolutely no rationale for what happened or exploration thereof. This is unsatisfactory
” 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 Use documentation audits to review discharge-documentation quality.
Verbatim wording from the response “Discharge documentation was poor in Mr Whittington’s records; we have now appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning. We have also revised the two band 7 nurse roles on the ward so one of these nurses is in their role will focus on discharges (and admissions) and make sure the discharge planning is on track and the accompanying discharge paperwork is complete. The discharge planner template is being revised to make it clearer and easier to use and record the key information. The documentation audits will review the quality of discharge documentation.” Source location 2019-0049-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 Revise the Enhanced Recovery Programme booklet to include post-operative urinary-catheter management guidance.
Verbatim wording from the response “In addition, the Division of Surgery have reviewed the Enhanced Recovery Programme booklet and have amended this to include a section on the management of post operative urinary catheters. An order for the amended booklets has been placed with the printers. When the new booklets have been printed we will roll these out for use.” Source location 2019-0049-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 mandatory daily morning Board Rounds across all wards and specialties to coordinate patient acuity, investigations, interventions and communication.
Verbatim wording from the response “We do operate a system of a consultant surgeon being the consultant for the week, this allows us to ensure our patients are seen by a consultant each day. To improve continuity of care and ensure the team are aware of each patient on the ward, on 25 February 2019 we introduced mandatory Board Rounds to take place in the morning, before the ward rounds, on all wards and in all specialities to facilitate improved communication between ward teams (doctors, nurses and allied health professionals). The principles of the Board Round are to confirm the patient acuity (how unwell they are), have they had any test results which require review, do they need any tests to progress their care, what interventions/actions need to be taken and when e.g. removal of catheter. The meeting occurs every morning.” Source location 2019-0049-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 Print and roll out the amended Enhanced Recovery Programme booklets for use.
Verbatim wording from the response “In addition, the Division of Surgery have reviewed the Enhanced Recovery Programme booklet and have amended this to include a section on the management of post operative urinary catheters. An order for the amended booklets has been placed with the printers. When the new booklets have been printed we will roll these out for use.” Source location 2019-0049-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 Require documented medical instructions before nursing staff remove urinary catheters on surgical wards.
Verbatim wording from the response “Our practice has changed and Nursing staff no longer remove urinary catheters on the Surgical wards, without clear documented instruction in the records from the doctors to do so.” Source location 2019-0049-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 a nurse-led pre-operative assessment model and continue work to improve identification and escalation of abnormal blood results.
Verbatim wording from the response “There was no junior doctor present at the pre operative assessment appointment to see Mr Whittington. This resulted in his atypical antibodies not being identified and therefore the surgery did not take place on the original date planned. For this I apologise. A General Medical Council (GMC) and Health Education England Kent Surrey and Sussex (HEEKSS) Deanery review of the Digestive Diseases Directorate in the Trust was undertaken. This review was critical of our use of junior doctors in pre-operative assessment processes and they recommended that these tasks should be nurse delivered as is the case in most NHS Trusts now. A Working Group was convened to change the pre operative assessment process and a new model is being developed. Nursing Staff are responsible for flagging pre operative abnormal blood test results. Mr Threfall is in contact with the Pre Operative” Source location 2019-0049-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 Add a pre-printed urinary-catheter prompt to daily ward-round sheets.
Verbatim wording from the response “To strengthen awareness and recording, the daily ward round sheets now include a pre printed prompt on urinary catheters. An audit is underway of documentation in surgery measured against National Guidelines. ████████ is leading on this audit.” Source location 2019-0049-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 Revise the discharge-planner template to clarify recording of key information.
Verbatim wording from the response “Discharge documentation was poor in Mr Whittington’s records; we have now appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning. We have also revised the two band 7 nurse roles on the ward so one of these nurses is in their role will focus on discharges (and admissions) and make sure the discharge planning is on track and the accompanying discharge paperwork is complete. The discharge planner template is being revised to make it clearer and easier to use and record the key information. The documentation audits will review the quality of discharge documentation.” Source location 2019-0049-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 Revise the Trust Epidural Policy with clear guidance on disconnected and failed epidurals, including epidural failure.
Verbatim wording from the response “Wendy Caddye, Nurse Consultant for Pain Management, has reviewed and revised the Trust’s Epidural Policy to provide robust and clear guidance for all staff on the management of disconnected and failed epidurals. A section has been added to the policy titled epidural failure. To supplement this, all Level 9A nurses have attended, or are in the process of booking to attend, an Acute Pain Study Day which includes specific training on epidural management. All nurses in charge of a shift on the ward are fully epidural trained.” Source location 2019-0049-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 Provide Acute Pain Study Day epidural-management training to Level 9A nurses and ensure shift-leading nurses are epidural trained.
Verbatim wording from the response “Wendy Caddye, Nurse Consultant for Pain Management, has reviewed and revised the Trust’s Epidural Policy to provide robust and clear guidance for all staff on the management of disconnected and failed epidurals. A section has been added to the policy titled epidural failure. To supplement this, all Level 9A nurses have attended, or are in the process of booking to attend, an Acute Pain Study Day which includes specific training on epidural management. All nurses in charge of a shift on the ward are fully epidural trained.” Source location 2019-0049-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 Appoint a discharge facilitator and refocus a band 7 nursing role on admissions, discharges and complete discharge-planning documentation.
Verbatim wording from the response “Discharge documentation was poor in Mr Whittington’s records; we have now appointed a discharge facilitator to work with the Level 9A staff and to assist with patient discharges and in turn with the documentation of discharge planning. We have also revised the two band 7 nurse roles on the ward so one of these nurses is in their role will focus on discharges (and admissions) and make sure the discharge planning is on track and the accompanying discharge paperwork is complete. The discharge planner template is being revised to make it clearer and easier to use and record the key information. The documentation audits will review the quality of discharge documentation.” Source location 2019-0049-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
Concerns raised 12 Failure to obtain an ordered CT scan View source Failure to review clinical notes during ward transfer and overnight review View source Failure to provide clinical review and monitoring after ward transfer View source Failure to provide prescribed intravenous fluids View source Failure to obtain repeat blood tests for clinical comparison View source Failure to maintain an accurate fluid balance chart and measure urine output View source Failure to review and identify abnormal ECG results View source Failure to administer prescribed potassium View source Life-threatening perforated gastric ulcer View source Failure to implement prescribed intravenous fluid treatment View source Failure to provide prescribed Cyclazine View source Failure to obtain a second ECG when clinically indicated View source See 9 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
Kalma RAM-HENMAN · 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
Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned 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 obtain an ordered CT scan
Wider context from the report “(4) On the morning of the 7th at around 10.30 am. the attending Doctor wanted Mrs RAM-HENMAN to be given Cyclazine, intravenous fluids and for her to have a CT scan. None of this was achieved before her death two hours later .
She should have at least received the intravenous fluids and the Cyclazine.
Again it seems that at this stage there was a failure to realise that she had not been given the Potassium she had been written up for in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review clinical notes during ward transfer and overnight review
Wider context from the report “(3) Opportunities to realise that sodium and fluids had not been administered were missed overnight when Mrs RAM-HENMAN was transferred from A&E to Bristol Ward and was seen in the early hours of the 7th. It seems her notes were not read so the failure to give fluids and potassium was missed.
” Open source report × Source evidence
How this 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 clinical review and monitoring after ward transfer
Wider context from the report “(6) It may be that her transfer from A&E to Bristol Ward at around 5.30 – 6.30pm on the afternoon of the 6th June (a Thursday) coincided with a time of hiatus on the ward but there should not have been an assumption that she should simply be put in a bed and left until the morning ward round and as I say it seems there was an opportunity missed when she deteriorated in the night and a doctor was asked to see 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 prescribed intravenous fluids
Wider context from the report “(4) On the morning of the 7th at around 10.30 am. the attending Doctor wanted Mrs RAM-HENMAN to be given Cyclazine, intravenous fluids and for her to have a CT scan. None of this was achieved before her death two hours later .
She should have at least received the intravenous fluids and the Cyclazine.
Again it seems that at this stage there was a failure to realise that she had not been given the Potassium she had been written up for in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain repeat blood tests for clinical comparison
Wider context from the report “(5) Mrs RAM-HENMAN only had one set of bloods done . At Inquest I was told that she should have had more bloods for comparison . These would undoubtedly have shown her deteriorating condition and would have acted as an additional reminder of the failings in her care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an accurate fluid balance chart and measure urine output
Wider context from the report “(1) This lady arrived in A&E in a “precarius” state as the blood test results revealed and there were several failings:-
The attending Doctor required an accurate fluid chart. This was started. It was incompletely filled out and showed no output and no attempts were made to measure urine output . As a result, Doctors and Nurses were unaware of just how dehydrated Mrs RAM-HENMAN was becoming.
” Open source report × Source evidence
How this 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 review and identify abnormal ECG results
Wider context from the report “(2) An ECG was ordered which showed abnormalities likely associated with her low potassium level. This was not seen by the doctor who requested it. The signature on it is illegible.
A second ECG should have been requested. It was not.
She was written up for potassium in A&E as well as intravenous fluids but was given no potassium and only half a litre of intravenous fluids in her entire 24 hour admission.
It was the view of the Doctors giving the evidence that she should have received at least four litres to deal with her depleted state. So instructions given within three to four hours of her arrival in A&E (at 12.12pm on 6/6/2018) were not implemented.
Why not?
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed potassium
Wider context from the report “(2) An ECG was ordered which showed abnormalities likely associated with her low potassium level. This was not seen by the doctor who requested it. The signature on it is illegible.
A second ECG should have been requested. It was not.
She was written up for potassium in A&E as well as intravenous fluids but was given no potassium and only half a litre of intravenous fluids in her entire 24 hour admission.
It was the view of the Doctors giving the evidence that she should have received at least four litres to deal with her depleted state. So instructions given within three to four hours of her arrival in A&E (at 12.12pm on 6/6/2018) were not implemented.
Why not?
” Open source report × Source evidence
How this 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 Life-threatening perforated gastric ulcer
Wider context from the report “(7) It transpires that Mrs RAM-HENMAN had a large gastric ulcer which perforated . This in itself is a life threatening emergency and her presentation was unusual.
From the evidence I heard it was clear that although there is no guarantee that she would have survived the perforation, had she been optimised in terms of fluids and Potassium her cardio vascular reserve would have been considerably better.
” Open source report × Source evidence
How this 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 implement prescribed intravenous fluid treatment
Wider context from the report “(2) An ECG was ordered which showed abnormalities likely associated with her low potassium level. This was not seen by the doctor who requested it. The signature on it is illegible.
A second ECG should have been requested. It was not.
She was written up for potassium in A&E as well as intravenous fluids but was given no potassium and only half a litre of intravenous fluids in her entire 24 hour admission .
It was the view of the Doctors giving the evidence that she should have received at least four litres to deal with her depleted state. So instructions given within three to four hours of her arrival in A&E (at 12.12pm on 6/6/2018) were not implemented .
Why not?
” Open source report × Source evidence
How this 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 prescribed Cyclazine
Wider context from the report “(4) On the morning of the 7th at around 10.30 am. the attending Doctor wanted Mrs RAM-HENMAN to be given Cyclazine, intravenous fluids and for her to have a CT scan. None of this was achieved before her death two hours later .
She should have at least received the intravenous fluids and the Cyclazine.
Again it seems that at this stage there was a failure to realise that she had not been given the Potassium she had been written up for in A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to University Hospitals Sussex NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain a second ECG when clinically indicated
Wider context from the report “(2) An ECG was ordered which showed abnormalities likely associated with her low potassium level. This was not seen by the doctor who requested it. The signature on it is illegible.
A second ECG should have been requested. It was not.
She was written up for potassium in A&E as well as intravenous fluids but was given no potassium and only half a litre of intravenous fluids in her entire 24 hour admission.
It was the view of the Doctors giving the evidence that she should have received at least four litres to deal with her depleted state. So instructions given within three to four hours of her arrival in A&E (at 12.12pm on 6/6/2018) were not implemented.
Why not?
” 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 Add a drug-chart front-page prompt reminding staff to prescribe infusions in the normal section.
Verbatim wording from the response “The SI investigation also showed that it has been habitual for some staff to use the “once-only” section of the drug prescription chart, when prescribing fluid/drug infusions. This section was designed to be used by ED clinicians who may need to prescribe antibiotics for patients with a suspected chest infection or who need pain relief, who are then discharged from ED. It is not appropriate to use this section for IV infusions and a Trust Safety Alert has been issued, instructing all staff not to use this section of the drug chart for infusions and that any such prescription should be completed in the normal section of the drug chart. A prompt will also be added to the front of the drug chart, reminding staff of this requirement.” Source location 2018-0306-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 Implement an Electronic Prescribing System to prevent recurrence of fluid and potassium administration problems.
Verbatim wording from the response “As you will see, we have implemented a new SBAR telephone handover form (copy attached for reference) as part of the revision of the Emergency Department Safety Booklet. The form includes prompts for staff on drains and lines present, and medication issues. In the longer term, the implementation of an Electronic Prescribing System will ensure that the problems that” Source location 2018-0306-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 Implement separate Acute Medicine Consultant cover for telephone calls while another consultant sees requested patients.
Verbatim wording from the response “Finally, ████████, Consultant in Acute Medicine and Clinical Lead for Ambulatory Care, has implemented a new system whereby an Acute Medicine Consultant will cover telephone calls whilst another Acute Medicine Consultant sees patients when requested. This will ensure that the Consultant seeing patients is released from answering calls and will allow more time for review and follow up of clinical plans.” Source location 2018-0306-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 Issue a Trust Safety Alert instructing staff to prescribe infusions in the normal drug-chart section rather than the once-only section.
Verbatim wording from the response “The SI investigation also showed that it has been habitual for some staff to use the “once-only” section of the drug prescription chart, when prescribing fluid/drug infusions. This section was designed to be used by ED clinicians who may need to prescribe antibiotics for patients with a suspected chest infection or who need pain relief, who are then discharged from ED. It is not appropriate to use this section for IV infusions and a Trust Safety Alert has been issued, instructing all staff not to use this section of the drug chart for infusions and that any such prescription should be completed in the normal section of the drug chart. A prompt will also be added to the front of the drug chart, reminding staff of this requirement.” Source location 2018-0306-Response-by-Brighton-and-Sussex-University-NHS-Trust
Open published response
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Request correction
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