Woodland Hospital

Health and care · Healthcare site

Pin Request correction

First report 16 Jun 2017•Latest report 16 Jun 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
10

Described in responses

Concerns and recipient responses

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

  1. Northamptonshire

    AI-generated summary

    Mrs Macrae · 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 Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.

    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 Woodland Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to seek attendance by the attending spinal surgeon for postoperative instability

    Wider context from the report

    “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this 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 Woodland Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery

    Wider context from the report

    “1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ”
    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

    Share the hospital's learning from the case with all consultants through the Consultant Newsletter.

    Verbatim wording from the response

    “• The spinal neuro surgeons and Consultant anaesthetists working at the hospital are very aware of this case and now have a high suspicion to exclude post-operative internal bleeding. The hospital learning from this case will be shared with all Consultants following the Medical Advisory Committee meeting on the 20th September 2017 via our Consultant Newsletter.”

    Source location

    2017-0193-Response-by-Woodlands-Hospital
    Page 2 · response
    Published 15 September 2017

    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

    Install a bedside Haemocue machine in recovery for haemoglobin testing by recovery staff.

    Verbatim wording from the response

    “• A bed side Haemocue machine has been installed in recovery, to allow patient bedside testing of haemoglobin by recovery staff. This enables recovery staff to initiate this test as part of their observations to inform attending clinicians of the haemoglobin level in the instance of a deteriorating patient.”

    Source location

    2017-0193-Response-by-Woodlands-Hospital
    Page 2 · response
    Published 15 September 2017

    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 both the Consultant Surgeon and Consultant Anaesthetist to attend when either is recalled or a deteriorating patient requires escalation.

    Verbatim wording from the response

    “• As standard practice now since this tragic outcome, if an anaesthetist or surgeon is re-called to the hospital, both Consultant Surgeon and Consultant Anaesthetist are asked to attend. The Senior Management Team (SMT) who provide on call support 24/7 are all very clear on this and ensure this happens as part of the escalation process for any deteriorating patient, or when a Consultant is asked to return to the hospital.”

    Source location

    2017-0193-Response-by-Woodlands-Hospital
    Page 1 · response
    Published 15 September 2017

    Open published response
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