8 Dec 2023 Jasbir Pahal · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 3 Reliance on ad hoc voluntary interventional neuroradiologist availability for out-of-hours thrombectomy View source Failure of the nearest hyper-acute stroke hospital to offer a thrombectomy service View source Insufficient commissioned out-of-hours thrombectomy provision for stroke patients 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.
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AI-generated summary
Jasbir Pahal · 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
Jasbir Pahal suffered an acute left middle cerebral artery stroke on 13 November 2022 and was transferred between hospitals while arrangements for thrombectomy were being considered. Imaging later showed extensive infarction, active treatment was withdrawn on 27 November, and she died on 30 November 2022. The principal concern was that thrombectomy access for patients at Calderdale Royal Hospital was available only during limited weekday hours, leaving patients without reliable access to potentially life-saving treatment outside those hours and subjecting access to local arrangements.
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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 Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reliance on ad hoc voluntary interventional neuroradiologist availability for out-of-hours thrombectomy
Wider context from the report “(6) That this level of service is inadequate is illustrated by the historical practice of thrombectomies being performed at LGI outside of the stated hours on an occasional ad hoc basis, dependent (among other factors) upon the availability and willingness of an interventional neuroradiologist to attend on a voluntary basis when not on call , to perform a potentially life-saving procedure. Among other reasons, it being considered inappropriate that clinicians should be exposed to the moral dilemma of agreeing or declining to perform such a life-saving procedure outside of their working or on-call hours, LTHT has as from June 2023 stopped accepting such ad hoc referrals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the nearest hyper-acute stroke hospital to offer a thrombectomy service
Wider context from the report “(1) Calderdale Royal Hospital (CRH), the hospital with a hyper-acute stroke unit closest to Jasbir’s home address, does not offer a thrombectomy service, whether in or out of hours .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient commissioned out-of-hours thrombectomy provision for stroke patients
Wider context from the report “(3) In common with similar arrangements applying to other district general hospital NHS Trusts in West Yorkshire, NHS England has commissioned the provision of a thrombectomy service to Calderdale and Huddersfield NHS Foundation Trust (CHFT) stroke patients by Leeds Teaching Hospitals NHS Trust (LTHT), whereby stroke patients admitted to Calderdale Royal Hospital and potentially requiring thrombectomy can be transferred for this purpose to Leeds General Infirmary (LGI).
(4) No similar service has been commissioned for CHFT stroke patients from any other Trust.
(5) The existing arrangement between CHFT and LTHT (and between other Trusts within the Regional Integrated Stroke Delivery Network and LTHT) operates only between 0800 and 1500 hrs on weekdays (Monday to Friday), that is, for 35 out of 168 hours in a week (or 20.8%). Anyone who needs heart hyper-acute stroke unit is at a district general hospital in West Yorkshire and who suffers a stroke outside of those hours during the week, or between 1500 hrs on a Friday and 0800 hrs the following Monday, does not have access to a thrombectomy service .
” Open source report
20 Sep 2021 Uyapo Theodore Hayunga-Macha · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1 Failure to provide care and supervision while awaiting assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Uyapo Theodore Hayunga-Macha · 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
Uyapo Theodore Hayunga-Macha went missing from Arrowe Park Hospital on 4 December 2020 before he could be assessed for his mental health. He was found drowned on 9 March 2021, and it remained unclear how he ended up in the water. Concerns were raised about why he was not looked after and why he was left alone while waiting for assessment.
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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 Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide care and supervision while awaiting assessment
Wider context from the report “On 3 December 2020 Merseyside Police were called to Theo where it was apparent that he was suffering from poor mental health. An ambulance was called and Theo agreed to be taken to Arrowe Park Hospital. It is reported that whilst waiting for Triage that he left without being seen.
Why was he not being looked after? And why was he left alone when waiting for assessment?
” 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 online mental-health training for clinical support workers caring for patients in the Mental Health Unit.
Verbatim wording from the response “2. Further education and training for staff in relation to dealing with Mental Health patients and appropriate use of the Mental Health Unit (MHU). The Clinical support Workers who provide care and support for patients within the MHU have completed an online Mental Health training session” Source location 2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
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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 Take forward further staff education and training on caring for mental-health patients and appropriate use of the Mental Health Unit.
Verbatim wording from the response “2. Further education and training for staff in relation to dealing with Mental Health patients and appropriate use of the Mental Health Unit (MHU). The Clinical support Workers who provide care and support for patients within the MHU have completed an online Mental Health training session” Source location 2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
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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 Triage all ambulance-service arrivals on entry, document fit-to-sit rationales, and require verbal handover to the appropriate assessment or triage nurse.
Verbatim wording from the response “4. Ensure a standardised handover process to alert initial assessment / triage staff when a patient is placed in the waiting room as “fit to sit” by Ambulance Triage Nurse (ATN). All patients who arrive under the care of the North West Ambulance Service are now triaged by the ATN. This is a change in practice; previously, if patients were directed to the waiting room on arrival, as considered “fit to sit”, they would have been booked by the administrative team, at the main reception and would have waited to undergo initial triage assessment. The ATN now completes a triage assessment on arrival for all patients, including those presenting with a mental health concern. If this assessment finds the patient able to sit in the waiting room, the rationale for this decision is documented.” Source location 2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
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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 Escalate full Mental Health Unit capacity to the Tactical Commander and shift leader, with defined overnight senior-doctor and shift-leader decision-making, and communicate the process to staff.
Verbatim wording from the response “Unfortunately there are times when our MHU is full. A process has been developed to ensure that this is escalated to the Tactical Commander (TC) and the Shift leader, who are then responsible for decisions regarding either stepping someone out of MHU to create space, or where to place patients who are just arriving. Overnight if the TC is not on site, the decision is made by the senior Dr and Shift Leader. This process has been communicated to all staff.” Source location 2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly audits of 50 ambulance-service patients and share assessment, observation and triage findings with the Patient Safety and Quality Board.
Verbatim wording from the response “The Emergency Department leadership team have arranged for an audit of 50 patients per month to be undertaken to provide ongoing assurance around assessment/observations and triage of patients, who arrive via the ambulance service, the results of which are shared at the Trust’s Patient Safety and Quality Board.” Source location 2021-0314-Response-from-Wirral-University-Teaching-Hospital_Published
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17 Sep 2017 Paul James Maddox · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 3 Failure to act upon a reducing trend in a haemoglobin result View source Failure of the laboratory to ring through significant downward haemoglobin trends for urgent clinical review View source Failure to implement strategies to prevent recurrence of the identified failure 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
Paul James Maddox · 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 James Maddox was admitted to hospital with vomiting and subsequently developed severe internal bleeding after a fall in haemoglobin was not acted upon. He underwent emergency surgery after deteriorating, but died from massive gastrointestinal bleeding with disseminated intravascular coagulopathy. The principal concern was the missed opportunity to detect, investigate and treat the bleeding, with strategies to prevent recurrence still described as work in progress at the inquest.
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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 Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to act upon a reducing trend in a haemoglobin result
Wider context from the report “In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before 13th April 2017 the court has been told at inquest that strategies to avoid a repeated failure were still work in progress.
The missed opportunity was not acting upon a reducing trend in a haemoglobin result.
This is simply not good enough as this issue should have been fixed during the Root Cause analysis investigation and before the report was approved as soon as the error became evident.
During the course of the inquest evidence was heard from several doctors including a surgeon and it was suggested that “when there is a downward trend in haemoglobin of 10% or more the laboratory should always ring through the result as a potential surgical emergency for the urgent review of clinicians”
The court brings this to the attention of the Trust and for confirmation as to when a solution to this problem has been implemented
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the laboratory to ring through significant downward haemoglobin trends for urgent clinical review
Wider context from the report “In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before 13th April 2017 the court has been told at inquest that strategies to avoid a repeated failure were still work in progress.
The missed opportunity was not acting upon a reducing trend in a haemoglobin result.
This is simply not good enough as this issue should have been fixed during the Root Cause analysis investigation and before the report was approved as soon as the error became evident.
During the course of the inquest evidence was heard from several doctors including a surgeon and it was suggested that “when there is a downward trend in haemoglobin of 10% or more the laboratory should always ring through the result as a potential surgical emergency for the urgent review of clinicians ”
The court brings this to the attention of the Trust and for confirmation as to when a solution to this problem has been implemented
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement strategies to prevent recurrence of the identified failure
Wider context from the report “In spite of a Trust Root Cause Analysis Report identifying a missed opportunity before 13th April 2017 the court has been told at inquest that strategies to avoid a repeated failure were still work in progress .
The missed opportunity was not acting upon a reducing trend in a haemoglobin result.
This is simply not good enough as this issue should have been fixed during the Root Cause analysis investigation and before the report was approved as soon as the error became evident .
During the course of the inquest evidence was heard from several doctors including a surgeon and it was suggested that “when there is a downward trend in haemoglobin of 10% or more the laboratory should always ring through the result as a potential surgical emergency for the urgent review of clinicians”
The court brings this to the attention of the Trust and for confirmation as to when a solution to this problem has been implemented
” 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 Reduce the haemoglobin delta-check threshold from 25% to 20%.
Verbatim wording from the response “• The delta check value for Hb has changed from 25% to 20%. There is currently no delta check in the Royal College guidance.” Source location 2017-0220-Response-by-Wirral-University-Teaching-Hospital
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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 Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
Verbatim wording from the response “• Changes to the lab IT system have been made and an action notice has been issued to all staff informing them of the agreed changes to our standard operating procedure around Hb reporting” Source location 2017-0220-Response-by-Wirral-University-Teaching-Hospital
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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 a weekly Serious Incident meeting to review new incidents, report progress, and flag overdue actions.
Verbatim wording from the response “• A new Serious Incident meeting has been set up and meets on a weekly basis after the safety summit to review new incidents and the progress of reports. Any issues with out of date actions can be flagged at this meeting.” Source location 2017-0220-Response-by-Wirral-University-Teaching-Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise the haemoglobin telephone-alert threshold from below 70 g/L to below 75 g/L and audit its operation.
Verbatim wording from the response “• The telephone criteria for Hb has changed from less than 70g/l to less than 75g/l and continues to be audited.” Source location 2017-0220-Response-by-Wirral-University-Teaching-Hospital
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8 Jun 2014 James McArdle · Prevention of Future Deaths report Wirral
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Concerns raised 1 Lack of a replacement measure protecting elderly patients at risk of falls 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.
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AI-generated summary
James McArdle · 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 McArdle was an elderly independent man admitted to hospital on 24 November 2013 who suffered two falls on 5 December 2013, the second resulting in a non-survivable condition. The concern was that a coloured wristband system identifying patients at risk of falls had been withdrawn without replacement, potentially removing protection for elderly patients at risk of falling.
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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 Wirral University Teaching Hospital NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a replacement measure protecting elderly patients at risk of falls
Wider context from the report “That whatever the thinking was as regards the merits of the coloured wrist band system, the system has been withdrawn and not replaced , and in the process a level of protection against elderly patients at risk of falling suffering a fall has been removed . I am concerned that unless a review is undertaken and some new measure(s) introduced then patients such as the Deceased may be at a heightened risk of falls and future deaths may result .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations