Wexham Park Hospital

Health and care · Healthcare site

Pin Request correction

First report 21 Jan 2014•Latest report 21 Jan 2014

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Wexham Park Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Berkshire

    AI-generated summary

    Mrs Nutbeam · 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 Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.

    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 Wexham Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a procedure for transferring patient information between different Trusts

    Wider context from the report

    “(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were once aware that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wexham Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide patients with a letter accompanying them to subsequent appointments

    Wider context from the report

    “(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were once aware that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wexham Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate vomiting symptoms to the anaesthetist and surgeon

    Wider context from the report

    “(2) Despite clear evidence from the family that Mrs Nutbeam was vomiting on the ward shortly before her debridement procedure, there is no reference in the nursing notes and this information was not made known to the Anaesthetist nor Surgeon. The fact that she was vomiting prior to a surgical procedure should have been a matter of serious concern. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wexham Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to routinely ask patients about vomiting within the previous twenty-four hours before surgery

    Wider context from the report

    “(4) It was also given in evidence at the Inquest that, when the Anaesthetist visited Mrs Nutbeam prior to the surgery and explained the procedure, the risks and took her consent, he did not ask her if she had vomited within the last twenty four hours. The evidence was that this is not a standard question to ask of patients ahead of surgery. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wexham Park Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record vomiting symptoms in nursing notes

    Wider context from the report

    “(2) Despite clear evidence from the family that Mrs Nutbeam was vomiting on the ward shortly before her debridement procedure, there is no reference in the nursing notes and this information was not made known to the Anaesthetist nor Surgeon. The fact that she was vomiting prior to a surgical procedure should have been a matter of serious concern. ”
    Open source report
Back to top

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026