24 Apr 2026 Michelle DAWES · Prevention of Future Deaths report Black Country
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Concerns raised 2 Failure to implement and embed identified patient-safety changes swiftly and effectively View source Lack of interim measures while identified patient-safety changes are being implemented View source
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Michelle DAWES · 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
Michelle Dawes was admitted to hospital with worsening symptoms and a large right-sided pleural effusion, but her transfer to the respiratory ward was delayed and a chest drain was never inserted. She deteriorated, suffered a cardiac arrest and died. The principal concerns were missed opportunities and delays in her care, including delayed implementation of changes identified by the Trust, leaving a continuing risk to patient safety.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and embed identified patient-safety changes swiftly and effectively
Wider context from the report “1. I am concerned about the fact that the Trust accept there were missed opportunities and delays in the care provided to Mrs Dawes and despite the fact they have identified changes required to improve the care being delivered to their patients, those changes are yet to be implemented and embedded at the Trust .
2. The failure to take swift action to implement change undermines the process of identifying learning from deaths, there is little point knowing what needs to be done to improve patient safety if steps are not taken to implement those changes swiftly and effectively .
3. In this case we are nine months after Mrs Dawes’ death and the evidence heard at inquest was that it could take another three months to implement the changes required . I am concerned that it is going to take the Trust a period of twelve months to implement the changes identified as required as a result of Mrs Dawes’ death and that the risk of future deaths continues in the absence of any interim measures being put in place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of interim measures while identified patient-safety changes are being implemented
Wider context from the report “1. I am concerned about the fact that the Trust accept there were missed opportunities and delays in the care provided to Mrs Dawes and despite the fact they have identified changes required to improve the care being delivered to their patients, those changes are yet to be implemented and embedded at the Trust.
2. The failure to take swift action to implement change undermines the process of identifying learning from deaths, there is little point knowing what needs to be done to improve patient safety if steps are not taken to implement those changes swiftly and effectively.
3. In this case we are nine months after Mrs Dawes’ death and the evidence heard at inquest was that it could take another three months to implement the changes required. I am concerned that it is going to take the Trust a period of twelve months to implement the changes identified as required as a result of Mrs Dawes’ death and that the risk of future deaths continues in the absence of any interim measures being put in place .
” 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 Incorporate incident learning into resident and registrar doctor induction and clinical supervisor discussions.
Verbatim wording from the response “• Learning incorporated into the Resident and Registrar doctors’ induction and clinical supervisor discussions.” Source location Response from Walsall Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete consultation and implementation of the amended specialty-transfer policy, including enhanced review and escalation for patients waiting seven or more days.
Verbatim wording from the response “Following learning from Mrs Dawes’ death we are acting on the principles of the right patient being cared for in the right clinical area and we have introduced a new formal process of patient referrals to specialty ward areas – based on urgency and clinical need. An amendment to the policy has been developed and is in draft format (whilst consultation process is completed).” Source location Response from Walsall Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a formal urgency- and clinical-need-based referral process for transferring patients to specialty wards.
Verbatim wording from the response “Following learning from Mrs Dawes’ death we are acting on the principles of the right patient being cared for in the right clinical area and we have introduced a new formal process of patient referrals to specialty ward areas – based on urgency and clinical need. An amendment to the policy has been developed and is in draft format (whilst consultation process is completed).” Source location Response from Walsall Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen the pleural procedures policy with senior escalation, competency-based referral routes, and guidance for bleeding risks and coagulopathy.
Verbatim wording from the response “A Standard Operating Procedure (SOP) aligned with the British Thoracic Society guidance ensuring clear escalation and senior involvement was already in place; following review of the incident learning has been undertaken since Mrs Dawes’s death. This means that amendments to the policy to further strengthen practice in undertaking pleural effusion drainage, has been carried out with the aim and objective being to ensure clear escalation and senior involvement, an amendment has been made to the policy to include guidance on pleural procedures when there is bleeding risk due to medications or coagulopathy (reference page 9 and 10 of the policy).” Source location Response from Walsall Healthcare NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing senior escalation, operational oversight, communication and specialist referral arrangements provide immediate safety controls while longer-term changes are embedded.
Verbatim wording from the response “3. Delays in implementation and lack of interim safety measures, leading to ongoing risk | Immediate senior escalation routes (ED Consultants, GIM rota, ICU team).” Source location Response from Walsall Healthcare NHS Trust
Open published response
7 Jan 2026 Joshua Lee Allcock · Prevention of Future Deaths report Black Country
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Concerns raised 4 Use of insensitive Capillary Refill Time testing for dehydration assessment View source Lack of clear national guidance on autism assessment View source Failure to provide onward referral to dieticians experienced in autism and ARFID View source Risk of dehydration among autistic children in similar circumstances View source See 1 more concern
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joshua Lee Allcock · 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
Joshua Lee Allcock, a five-year-old boy with complex medical needs and a limited diet, developed severe dehydration after entering foster care and died on 3 January 2023 despite hospital treatment. Concerns included the lack of a formal autism diagnosis and related dietary support, variation in autism assessment practice, and the potential for the capillary refill time test to provide misleading reassurance when assessing dehydration in children with similar circumstances.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Use of insensitive Capillary Refill Time testing for dehydration assessment
Wider context from the report “5. The expert evidence also indicated that the Capillary Refill Time (CRT) test used to assess dehydration by checking peripheral blood flow is a very insensitive test and can provide misleading reassurance . Therefore, my concern is that young children with similar circumstances to Joshua maybe at risk when assessing levels of dehydration . NHS England may wish to consider reviewing their guidance for health professionals.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear national guidance on autism assessment
Wider context from the report “2. My concern is that Joshua was never formally diagnosed with Autism and there appears to be nationally, a variation in practice before an assessment for autism can be made . Some areas specify 3 years of age or above but there is no clear national guidance .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide onward referral to dieticians experienced in autism and ARFID
Wider context from the report “3. Regrettably, without a formal diagnosis of autism being made, there was no onward referral to dieticians with experience of autism and therefore an understanding of the link between autism and Avoidant restrictive food intake disorder (ARFID) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of dehydration among autistic children in similar circumstances
Wider context from the report “4. In addition, I heard expert evidence that Joshua’s death wasn’t an isolated incident and another autistic child died in very similar circumstances by developing dehydration .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide an established autism pathway for children under five.
Verbatim wording from the response “Walsall Healthcare NHS Trust has in place an under 5’s pathway which has been in existence for many years. Archive records indicate that the under 5’s pathway was developed as early as 1991, this progressed to introduce a unique autism pathway from 2016. It is noted from the inquest records that your concerns are primarily with unclear national guidelines for the age at which autism can be reliably diagnosed. The pathways in use are attached for information.” Source location 2026-0012 - Response from Walsall Healthcare NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain an established pathway for assessing children under five.
Verbatim wording from the response “Walsall Healthcare NHS Trust has in place an under 5’s pathway which has been in existence for many years. Archive records indicate that the under 5’s pathway was developed as early as 1991, this progressed to introduce a unique autism pathway from 2016. It is noted from the inquest records that your concerns are primarily with unclear national guidelines for the age at which autism can be reliably diagnosed. The pathways in use are attached for information.” Source location 2026-0012 - Response from Walsall Healthcare NHS Trust
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing under-five and autism pathways are relied on alongside national guidance to address concerns about unclear autism diagnostic guidance.
Verbatim wording from the response “Walsall Healthcare NHS Trust has in place an under 5’s pathway which has been in existence for many years. Archive records indicate that the under 5’s pathway was developed as early as 1991, this progressed to introduce a unique autism pathway from 2016. It is noted from the inquest records that your concerns are primarily with unclear national guidelines for the age at which autism can be reliably diagnosed. The pathways in use are attached for information.” Source location 2026-0012 - Response from Walsall Healthcare NHS Trust
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18 Feb 2020 Zachary James Johnson · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 6 Failure to perform newborn resuscitation in accordance with resuscitation guidelines View source Lack of waterproof equipment for foetal heart rate auscultation during birthing pool births View source Failure to manage the newborn airway during transfer from ambulance to hospital View source Failure to restrict birthing pool use when correct foetal monitoring equipment is unavailable View source Failure to protect labouring mothers from being presented with an unsafe birthing option when foetal monitoring is unavailable View source Insufficient mandatory refresher training in newborn life support skills View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Zachary James Johnson · 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
Zachary James Johnson was born in a birthing pool on 15 October 2016 after his foetal heart rate could not be auscultated for approximately 38 minutes because no working waterproof sonicaid was available. He was born floppy and unresponsive, and problems occurred during resuscitation, including incorrect ventilation-to-compression ratios, a period without chest compressions, and an interruption in airway management during transfer to hospital. The concerns included the availability of appropriate monitoring equipment and insufficiently frequent mandatory refresher training in newborn life support skills.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform newborn resuscitation in accordance with resuscitation guidelines
Wider context from the report “(5) I heard evidence during the inquest that the resuscitation undertaken by the 2 midwives involved in Zachary’s resuscitation was incorrect and inadequate and not in accordance with the resuscitation guidelines . The ratio of inflation breaths to CC should have been 3:1 instead of 15:1 and there was a period where no chest compressions were being carried out immediately prior to the arrival of a 3rd midwife. I also heard evidence that having been taken to hospital there was a period where Zachary’s airway was not managed during the transfer from the ambulance to the hospital. I found both of these matters causative of Zachary’s death. The inquest heard evidence that the two midwives involved in Zachary’s resuscitation had attended a non-mandatory training course only a matter of weeks before Zachary’s death which included an update of Newborn Life Support (NBLS).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of waterproof equipment for foetal heart rate auscultation during birthing pool births
Wider context from the report “(1) During the course of the inquest, I heard evidence that Zachary’s mother was permitted to enter a birthing pool to give birth in the known absence of a waterproof sonicaid . The lack of such equipment prevented the auscultation of the foetal heart rate . This was a matter I found causative of Zachary’s death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to manage the newborn airway during transfer from ambulance to hospital
Wider context from the report “(5) I heard evidence during the inquest that the resuscitation undertaken by the 2 midwives involved in Zachary’s resuscitation was incorrect and inadequate and not in accordance with the resuscitation guidelines. The ratio of inflation breaths to CC should have been 3:1 instead of 15:1 and there was a period where no chest compressions were being carried out immediately prior to the arrival of a 3rd midwife. I also heard evidence that having been taken to hospital there was a period where Zachary’s airway was not managed during the transfer from the ambulance to the hospital . I found both of these matters causative of Zachary’s death. The inquest heard evidence that the two midwives involved in Zachary’s resuscitation had attended a non-mandatory training course only a matter of weeks before Zachary’s death which included an update of Newborn Life Support (NBLS).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict birthing pool use when correct foetal monitoring equipment is unavailable
Wider context from the report “(3) I also heard in evidence that the Walsall Healthcare NHS Trust had no specific policy or directive to prevent birthing mothers entering the birthing pool in the absence of the correct equipment and would still offer this as an option even if the correct equipment was not available .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to protect labouring mothers from being presented with an unsafe birthing option when foetal monitoring is unavailable
Wider context from the report “(4) I heard evidence that a foetal heartrate could not be monitored in the absence of the correct equipment to do so , yet birthing mothers in labour at a vulnerable time are having the responsibility about a potentially unsafe birthing option presented to 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 Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mandatory refresher training in newborn life support skills
Wider context from the report “(6) I also heard evidence that most midwives will go through their whole career without experiencing a situation requiring new born resuscitation. I heard evidence that the mandatory training on NBLS was valid for 4 years and whilst the Walsall Healthcare NHS Trust had provided annual refresher training this was not guaranteed to continue . My concern is that there is insufficient frequent mandatory refresher training in new born life support skills .
” Open source report
14 Jan 2020 Mr Madhavbhai Khushalbhai Patel · Prevention of Future Deaths report Black Country
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Concerns raised 3 Failure to advise families about eating with hands View source Failure to assess and advise on bread and bread products within dysphagia dietary guidance View source Failure to provide families with the IDDSI definition of ‘bite sized’ View source
Responses linked to these concerns
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AI-generated summary
Mr Madhavbhai Khushalbhai Patel · 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 Madhavbhai Khushalbhai Patel, a 95-year-old man living at home, choked on food during a meal on 13 May 2019 and died despite emergency treatment. Concerns included that the family had not been given the IDDSI definition of “bite sized”, and that there had been no specific assessment or advice concerning bread products or eating with his hands. The inquest did not find these matters causative or contributory to his death.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise families about eating with hands
Wider context from the report “(1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm.
(2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’.
(3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’.
(4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines.
(5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands.
The inquest did not find that any of the above matters were causative or contributory to death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and advise on bread and bread products within dysphagia dietary guidance
Wider context from the report “(1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm.
(2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’.
(3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’.
(4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines .
(5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands.
The inquest did not find that any of the above matters were causative or contributory to death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with the IDDSI definition of ‘bite sized’
Wider context from the report “(1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm.
(2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’.
(3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’.
(4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines.
(5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands.
The inquest did not find that any of the above matters were causative or contributory to death.
” 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 Complete a clinical audit 90 days after launching the revised risk assessment documents.
Verbatim wording from the response “5. We will be reviewing and revising our risk assessment and rating document, to specifically include questions about and advice regarding the mode of eating by patients (including the use of hands) to ensure that suitable advice is given to patients who use methods other than forks. This will be achieved as part of the policy review identified above but we endeavor to launch this assessment tool in advance of the ratification of our revised policy. The implementation of these documents will be assured through the completion of a clinical audit 90 days following launch.” Source location 2020-0006-Response-from-Walsall-NHS-Trust-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the risk assessment and rating document to address patients’ eating methods, including eating with hands.
Verbatim wording from the response “5. We will be reviewing and revising our risk assessment and rating document, to specifically include questions about and advice regarding the mode of eating by patients (including the use of hands) to ensure that suitable advice is given to patients who use methods other than forks. This will be achieved as part of the policy review identified above but we endeavor to launch this assessment tool in advance of the ratification of our revised policy. The implementation of these documents will be assured through the completion of a clinical audit 90 days following launch.” Source location 2020-0006-Response-from-Walsall-NHS-Trust-Redacted
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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 Replace internally developed patient documents with IDDSI guidance covering food, fluids, portion sizes, bite sizes and transitional foods.
Verbatim wording from the response “4. We will be replacing our current internally developed patient documents with those provided by IDDSI which provide clearer visual guidance to patients and their families / carers about the recommended food and fluid intake as well as the appropriate size of portions and the size of each bite. These documents also include specific reference to ‘transitional foods’, such as breads or similar products such as roti and chapatti, with guidance and an assessment criteria for their consumption. We aim to complete this transition on or before April 1st 2020.” Source location 2020-0006-Response-from-Walsall-NHS-Trust-Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the dysphagia policy to incorporate current IDDSI standards.
Verbatim wording from the response “3. We will be reviewing and updating our dysphagia policy to fully incorporate the current IDDSI standards to ensure our delivery of care to patients in all settings is undertaken in adherence to these international best practice guidelines by June 2020.” Source location 2020-0006-Response-from-Walsall-NHS-Trust-Redacted
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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 staff checklist in patient records prompting and evidencing distribution of supportive and advisory documents.
Verbatim wording from the response “6. A revised checklist for staff will be implemented to be included within patients records to assure that staff are prompted to handout all relevant supportive and advisory documents to patients and their family / carers and that this can be evidenced. This too will form part of a revised policy but we would anticipate this coming into use prior to the final ratification of the policy to ensure patients are supported.” Source location 2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Open published response
29 Mar 2018 Mrs Margaret Spencer · Prevention of Future Deaths report Black Country
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Concerns raised 2 Failure to implement sufficient staff training during introduction of a new IT system View source Failure to conduct further reviews of patients' access plans View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Margaret Spencer · 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 Margaret Spencer was treated for a prolapse with a pessary, but a change in IT systems meant that no follow-up review took place after May 2014. Her condition deteriorated, the pessary eroded through her bladder, and she died on 17 December 2017 after developing pneumonia and acute kidney injury. The principal concern was inadequate staff training and administrative failures during the introduction of the new IT system, which led to her follow-up being missed and placed patients at risk of harm.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement sufficient staff training during introduction of a new IT system
Wider context from the report “1. Evidence emerged during the inquest that there were failures to properly implement sufficient training for staff during the introduction of a new IT system (Lorenzo) . This resulted in the premature closing of her access plan and effectively no further review. This failure to conduct a review led to a number of patients including Mrs Spencer being placed at risk of harm.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct further reviews of patients' access plans
Wider context from the report “1. Evidence emerged during the inquest that there were failures to properly implement sufficient training for staff during the introduction of a new IT system (Lorenzo). This resulted in the premature closing of her access plan and effectively no further review . This failure to conduct a review led to a number of patients including Mrs Spencer being placed at risk of harm.
” 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 Run monthly data-quality reports, take corrective action and refer staff for training or support when necessary.
Verbatim wording from the response “Data Quality Metrics” Source location Margaret-Spencer-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement electronic outcome recording with alerts and audit trails for required follow-up appointments and incomplete clinician outcome forms.
Verbatim wording from the response “Outpatient processes have been improved across the Trust with the following measures being taken: –” Source location Margaret-Spencer-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure outpatient clinics are cashed up and monitor completion of patient outcomes daily through a central team.
Verbatim wording from the response “Outpatient processes Improvement” Source location Margaret-Spencer-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Validate overdue outpatient access plans and contact, discharge or arrange care for affected patients, continuing review of the remaining plans.
Verbatim wording from the response “It was agreed that a program of work to improve outpatient processes and validate the patients recorded as needing a follow up appointment.” Source location Margaret-Spencer-Response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver role-specific receptionist training and refresher sessions, retraining staff who fail the required assessment standard.
Verbatim wording from the response “The outpatient receptionists have specific modules for their role based training. Refresher sessions have been regularly delivered to all receptionists since go live to ensure staff remain up to date with the system, receive the same messages and provide further assurances of the required competencies. The training team monitor assessments that were completed during training sessions designed to equip staff with the required competencies to use the system safely and effectively. Any staff that failed to reach an 80% pass mark are re-trained.” Source location Margaret-Spencer-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 All historical patient access-plan closures cannot be reviewed and validated because approximately 500 closures occur daily.
Verbatim wording from the response “The Trust closes on average 500 patient access plans per day when the patients care is concluded. The scale of these closures means that it is not possible to review and validate all historical access plan closures.
Clinical Harm Group” Source location Margaret-Spencer-Response
Open published response
28 Jun 2016 Tommi-Ray Colin Vigrass · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 5 Inadequate preparation and care planning for the arrival of a premature baby View source Failure to consult the on-call consultant before making extubation decisions View source Failure to use the CO2 monitor early enough View source Inadequate handover for the arrival of a premature baby View source Delays and problems in contacting the tertiary unit through the switchboard View source See 2 more concerns
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AI-generated summary
Tommi-Ray Colin Vigrass · 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
Tommi-Ray Colin Vigrass was born prematurely at 28+2 weeks’ gestation and developed respiratory distress requiring ventilator support. Following difficulties with changing and re-inserting his endotracheal tube, he suffered a hypoxic episode and significant brain damage, and died on 13 January 2016. Concerns included the decision-making around extubation and intubation, delayed contact with the tertiary unit, and inadequate handover and preparation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate preparation and care planning for the arrival of a premature baby
Wider context from the report “3. There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consult the on-call consultant before making extubation decisions
Wider context from the report “1. Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that it was a mistake to extubate baby when he did. His words were: “What should have been a straight forward ET change turned into a nightmare”. He also confirmed that he should have consulted the Consultant on call prior to making the decision and earlier use of the CO2 monitor would have made a difference.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the CO2 monitor early enough
Wider context from the report “1. Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that it was a mistake to extubate baby when he did. His words were: “What should have been a straight forward ET change turned into a nightmare”. He also confirmed that he should have consulted the Consultant on call prior to making the decision and earlier use of the CO2 monitor would have made a difference .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate handover for the arrival of a premature baby
Wider context from the report “3. There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and problems in contacting the tertiary unit through the switchboard
Wider context from the report “2. In addition, it emerged that there were problems and delays in trying to contact the tertiary unit via the switchboard .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide relevant medical, neonatal practitioner and senior nursing staff access to the Maternal Badger System for antenatal, intrapartum and postnatal records.
Verbatim wording from the response “3. You may also wish to consider a review to ensure systems and procedures are in place to ensure that all relevant details/care plan are available for the Consultant in charge when a mother delivers a pre-term baby in an emergency” Source location 2016-0241-Response-by-Walsall-Healthcare-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an out-of-hours Regional Cot Locator service to facilitate contact with tertiary neonatal units.
Verbatim wording from the response “2. You may also wish to consider expediting the process to establish a system to contact tertiary units within our area to minimise any delays in contacting the relevant staff for advice.” Source location 2016-0241-Response-by-Walsall-Healthcare-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formalise neonatal handover processes.
Verbatim wording from the response “A Serious Incident investigation was carried out following Tommi-Ray’s death and a Root Cause Analysis report was formulated with a specific action plan. Actions including the development of a Standard Operating Procedure related to the difficult airway kit had been completed and handover processes formalised.” Source location 2016-0241-Response-by-Walsall-Healthcare-NHS-Trust
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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 Train neonatal staff in difficult-airway management, including CO2 detector use and associated airway equipment.
Verbatim wording from the response “Neonatal staff have now undergone training on ‘Difficult Airway Management’. This includes the use of:” Source location 2016-0241-Response-by-Walsall-Healthcare-NHS-Trust
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13 Jun 2016 Kinga Cieciorska · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4 Failure to consider medication details and the significance of diclofenac View source Failure to forward and make available GP medical notes for clinical examination View source Failure to record the identity of the specialist clinician giving advice View source Failure to investigate abnormal ECG findings and tachycardia through further testing and observation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Kinga Cieciorska · 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
Kinga Cieciorska, a 16-year-old girl with complex medical needs, was taken to hospital with abdominal pain and distension. She was diagnosed with constipation and discharged, but deteriorated overnight and died after being returned to hospital on 11 March 2016; the stated cause of death was peritonitis from a perforated gastric ulcer. Concerns included failure to investigate tachycardia and an abnormal ECG, failures in recording and transmitting clinical information, and failure to consider the significance of her medication.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider medication details and the significance of diclofenac
Wider context from the report “3. It also emerged during the inquest that details of her medication including the significance of the drug, Diclofenac was not considered . One of the contra-indications of this drug for long term users is gastric ulcers. Many people take NSAIDs without having any side effects, but there's always a risk the medication could cause problems, such as stomach ulcers, particularly if taken for a long time or at high doses.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to forward and make available GP medical notes for clinical examination
Wider context from the report “2. During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information. The Junior Doctor failed to record the name of the Specialist Paediatric Registrar giving advice. More worryingly the Paediatric Registrar at inquest could not recollect giving any advice in relation to the patient. It also emerged during the inquest that medical notes provided by the GP were given to reception staff by the parents on admission . Unfortunately these documents were not forwarded or seen by the Junior Doctor on examination of 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 Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record the identity of the specialist clinician giving advice
Wider context from the report “2. During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information. The Junior Doctor failed to record the name of the Specialist Paediatric Registrar giving advice . More worryingly the Paediatric Registrar at inquest could not recollect giving any advice in relation to the patient. It also emerged during the inquest that medical notes provided by the GP were given to reception staff by the parents on admission. Unfortunately these documents were not forwarded or seen by the Junior Doctor on examination of 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 Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate abnormal ECG findings and tachycardia through further testing and observation
Wider context from the report “1. Evidence emerged during the inquest that the abnormal ECG trace and tachycardia needed further investigation and she should have been subject to further tests and admitted for further observation to establish the cause of the tachycardia . This was effectively a missed opportunity to render basic medical care. On the balance of probability it is more likely than not, she may have survived or life may have been extended if tests had been done to confirm the diagnosis of peritonitis and appropriate treatment commenced.
” Open source report
21 Nov 2014 Tracey Bannister · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Failure to advise discharged patients to contact the treating department as well as their GP when pain or raised temperature continues for more than 24 hours 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
Tracey Bannister · 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
Tracey Bannister, aged 29, became unwell after an elective ERCP procedure on 24 June 2014, was admitted to hospital on 26 June with cyanosis, low blood pressure and acidosis, and died after cardiac arrest. The concern raised was that discharge advice should tell patients to contact both their GP and the department where surgery was performed if pain or a raised temperature continued for more than 24 hours.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Walsall Healthcare NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to advise discharged patients to contact the treating department as well as their GP when pain or raised temperature continues for more than 24 hours
Wider context from the report “My concern is that patients should be advised not only to contact their GP but also the department where surgery had been performed if symptoms of pain, raised temperature continue for more than 24 hours . In this case medical evidence suggested that she attended Hospital twenty four hours earlier then the outcome may have been different.
Therefore, you may consider that the information and advice given to patients on discharge may need to be altered to take into account the lessons learnt from this inquest.
” 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 Revise, approve, disseminate and implement the discharge leaflet with instructions to contact the treating department as well as a GP when symptoms persist.
Verbatim wording from the response “The Coroner’s concern is that patients should be advised not only to contact their GP but also the department where surgery had been performed if symptoms of pain, raised temperature continue for more than 24 hours. In this case medical evidence suggested that had she attended Hospital twenty four hours earlier then the outcome may have been different.” Source location 2014-0506-Response-by-Walsall-Healthcare-NHS-Trust
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations