24 Jun 2026 Jacqueline Frances O'BRIEN · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to follow up family concerns about a patient's condition View source Failure to carry out checks or observations on a deteriorating patient View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacqueline Frances O'BRIEN · 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
Jacqueline Frances O'Brien was treated for injuries from an accidental fall and later developed an intra-abdominal infection. She died in hospital on 4 November 2025 after deteriorating following transfer to a community hospital. The principal concerns were that staff failed to carry out checks or observations for about eight hours and failed to respond to family concerns about her worsening condition, resulting in a missed opportunity for earlier 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up family concerns about a patient's condition
Wider context from the report “It was agreed by the consultant who gave evidence at the inquest, and by the Trust's legal representative, that thereafter between 1230hrs and Mrs. O'Brien's departure for Pershore at 2025hrs that evening, there is no evidence of any further checks or observations being carried out.
In fact, when Mrs. O'Brien was seen on the PDU by family members that same afternoon, it was clear to them that she was in a great deal of pain and distress. They raised their concerns with staff on the PDU, who assured them that she was alright. No member of staff appears to have acted on those concerns, and ensured that Mrs. O'Brien was checked.
Those who transported Mrs. O'Brien to Pershore reported to staff there that she "had been in pain on transfer". On her arrival at Pershore at 2100hrs, it was clear to staff there and to an out of hours GP who was called to examine her, that she was in severe pain and very unwell, with a National Early Warning Score ( NEWS ) of 5. An ambulance was called to transfer her back to Worcester, and the paramedics recorded at 0111hrs that her NEWS score had risen to 10.
I am therefore concerned at how staff on the PDU at Worcestershire Royal Hospital failed:
(a) for some 8 hours to carry out any checks or observations on a patient who was clearly becoming very unwell; and
(b) to follow up concerns raised by Mrs. O'Brien's family about her condition on the afternoon/evening of her discharge .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out checks or observations on a deteriorating patient
Wider context from the report “It was agreed by the consultant who gave evidence at the inquest, and by the Trust's legal representative, that thereafter between 1230hrs and Mrs. O'Brien's departure for Pershore at 2025hrs that evening, there is no evidence of any further checks or observations being carried out .
In fact, when Mrs. O'Brien was seen on the PDU by family members that same afternoon, it was clear to them that she was in a great deal of pain and distress. They raised their concerns with staff on the PDU, who assured them that she was alright. No member of staff appears to have acted on those concerns, and ensured that Mrs. O'Brien was checked.
Those who transported Mrs. O'Brien to Pershore reported to staff there that she "had been in pain on transfer". On her arrival at Pershore at 2100hrs, it was clear to staff there and to an out of hours GP who was called to examine her, that she was in severe pain and very unwell, with a National Early Warning Score ( NEWS ) of 5. An ambulance was called to transfer her back to Worcester, and the paramedics recorded at 0111hrs that her NEWS score had risen to 10.
I am therefore concerned at how staff on the PDU at Worcestershire Royal Hospital failed:
(a) for some 8 hours to carry out any checks or observations on a patient who was clearly becoming very unwell ; and
(b) to follow up concerns raised by Mrs. O'Brien's family about her condition on the afternoon/evening of her discharge.
” 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 the discharge lounge SOP on patient capacity, deteriorating-patient management, and exclusion criteria for unsuitable patients.
Verbatim wording from the response “• We have identified and confirm that there were no documented observations in the discharge lounge, although the staff recall taking them but only on recording these on paper and not in the electronic patient record. We have reviewed the discharge lounge SOP as it lacked clarity around what we expect our staff and how often observations should be recorded whilst patients are in the discharge lounge.” Source location Response from Worcestershire Acute 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 Implement Martha’s Rule across the Trust as an alternative escalation pathway for patients, relatives, and staff concerned about a patient’s condition.
Verbatim wording from the response “• We can confirm there was no documentation of the family concerns in the patient's notes. Since the time of the case, Martha's Rule has been implemented across the trust, providing an alternative escalation pathway for both families and staff if there are concerns about a patient's condition, while it may not have been used in this specific case, it is now available to all patients, relatives and staff.” Source location Response from Worcestershire Acute 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 Complete the commissioned case review to identify system improvements and examine its findings for wider learning.
Verbatim wording from the response “An initial review has been undertaken and discussed in our Patient Safety incident Review Group (PSiRG) on 6th July 2026 and we have commissioned a case review to explore in more detail the events that day and what systems could be improved to aid our staff to care for patients safely and ensure records are accurate in a future scenario similar to this.” Source location Response from Worcestershire Acute 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 the discharge lounge team to record full observations electronically and use SBAR escalation for deterioration or medical emergencies.
Verbatim wording from the response “• in the event of a deterioration or medical emergency the patients consultant team will be contacted and arrangements made for the patient to be reviewed” Source location Response from Worcestershire Acute Hospitals NHS 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 patient was in the discharge lounge before transfer, not the PDU.
Verbatim wording from the response “In response to your specific concern listed above we would like firstly to clarify that Mrs O’Brien was on the discharge lounge prior to transfer to Pershore, we apologise for any misunderstanding that led you to believe it was PDU. Please find below the actions the trust have taken in relation to your concerns on her care before discharge:” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
1 Apr 2026 Lucy Jane PHELAN · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure of alarm monitoring equipment to allow new or different alarms to be distinguished audibly View source Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms 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
Lucy Jane PHELAN · 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
Lucy Jane Phelan was found unresponsive at home after taking prescribed medications with a significant amount of alcohol and was later treated in hospital for likely aspiration pneumonia. She subsequently vomited, suffered cardiopulmonary arrest, and died shortly after midnight on 14 May 2025; the inquest concluded that her death was contributed to by neglect. The principal concern was that latching on Emergency Department monitoring equipment may contribute to alarm fatigue and hinder recognition of new alarms, with its use in other hospitals in England and Wales unknown.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of alarm monitoring equipment to allow new or different alarms to be distinguished audibly
Wider context from the report “While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor.
The monitoring equipment has a facility known as “latching” which, if activated, means:
(a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly ; and
(b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm.
The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon ; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments.
It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of alarm monitoring equipment to record recurrent alarm conditions as new alarms
Wider context from the report “While in the resuscitation bay within the Emergency Department at the Alexandra Hospital, Redditch, Ms. Phelan was attached to equipment which monitored her physical observations. These observations are visible on a screen at the patient’s bedside and on a screen at the main nursing station. If a patient’s observations rise or fall outside acceptable parameters, the equipment generates notes both on audible alarm and a visual alarm ( red - higher priority; yellow – lower priority ) on each monitor.
The monitoring equipment has a facility known as “latching” which, if activated, means:
(a) an alarm will continue to be displayed and sounded even after the conditions which generated it have ended, until it is acknowledged on the monitor, meaning that any alarm for a new or different indication cannot be distinguished audibly; and
(b) if the alarm is not acknowledged on the monitor, and the same alarm condition occurs again, this new alarm is not listed in the alarm review or audit log as a new alarm .
The inquest heard evidence that “alarm fatigue” is a recognized phenomenon, and that in a busy environment like a hospital’s Emergency Department, particularly when patient numbers are high, staff find it increasingly difficult to react and respond to the many different types of alarm in use. The use of the “latching” facility on monitoring equipment is likely to contribute to this phenomenon ; this has been recognized by the equipment manufacturer which no longer recommends its use on Emergency Department monitors, and by Worcestershire Acute Hospitals NHS Trust who have switched it off on monitors in its Emergency Departments.
It is not known whether, and to what extent, the “latching” facility remains in use in Emergency Departments in other hospitals in England and Wales.
” Open source report
8 Jan 2026 Jean Alice WALDRON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Lack of adequate training on following advice from specialist doctors and nurses View source Lack of adequate training on the limits of care carers are able to provide 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 Alice WALDRON · 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 Waldron had a long-standing cervical spinal cord injury, vascular dementia and a sacral pressure ulcer, later developed a chest infection, and died at home in Worcester on 12 March 2025. Concerns were raised that a Team Leader carer removed wound dressings and attempted to clean the pressure sore despite instructions that carers were not licensed to provide wound care; the Tissue Viability Nurse said that using gauze was inappropriate and could have caused further complications. The report also questioned whether agency carers had received adequate training about the limits of their care and following specialist clinical advice.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate training on following advice from specialist doctors and nurses
Wider context from the report “In her evidence at the inquest a carer from your agency, who was a Team Leader, gave evidence that:
(a) she had read and understood an email from the District Nurse Clinical Lead, dated 15.1.25, which made clear that carers should not provide any care in relation to Mrs. Waldron's pressure sore as they did not have the correct licence to provide wound care; and
(b) despite that clear instruction, she had on 3 separate occasions thereafter removed soiled wound dressings from the pressure sore and attempted to clean the wound with saline and gauze because she felt that it was in the deceased's "best interests" so to do.
The lead Tissue Viability Nurse who gave evidence at the inquest said that the use of gauze was inappropriate and would have led to further adverse complications with the pressure sore.
It is particularly concerning that a carer who was a Team Leader acted in the way described, and suggests that carers employed by your agency may not have received adequate training about:
(a) the limits of the care which they are able to provide; and
(b) the need to accept and follow advice given by specialist doctors and nurses at all 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate training on the limits of care carers are able to provide
Wider context from the report “In her evidence at the inquest a carer from your agency, who was a Team Leader, gave evidence that:
(a) she had read and understood an email from the District Nurse Clinical Lead, dated 15.1.25, which made clear that carers should not provide any care in relation to Mrs. Waldron's pressure sore as they did not have the correct licence to provide wound care; and
(b) despite that clear instruction, she had on 3 separate occasions thereafter removed soiled wound dressings from the pressure sore and attempted to clean the wound with saline and gauze because she felt that it was in the deceased's "best interests" so to do.
The lead Tissue Viability Nurse who gave evidence at the inquest said that the use of gauze was inappropriate and would have led to further adverse complications with the pressure sore.
It is particularly concerning that a carer who was a Team Leader acted in the way described, and suggests that carers employed by your agency may not have received adequate training about:
(a) the limits of the care which they are able to provide ; and
(b) the need to accept and follow advice given by specialist doctors and nurses at all times.
” Open source report
26 Jun 2025 Jordanne Rose ROBERTS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to ensure that all locum doctors receive training to read both parts of CT scan reports View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jordanne Rose ROBERTS · 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
Jordanne Rose ROBERTS was assessed in hospital after falling down stairs, but was discharged before the full CT scan report was read. The final report identified a pulmonary embolism, and Jordanne collapsed and died at home two days later. The principal concern was that locum doctors might not have received or completed training on reading both parts of CT scan reports, creating a risk that life-threatening conditions could go undiagnosed.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all locum doctors receive training to read both parts of CT scan reports
Wider context from the report “1) Jordanne’s death arose because a locum doctor, said to be the most senior doctor on duty in the Emergency Department on 10.8.24, did not know that her CT scan taken that day would be reported in two parts. The initial report did not mention the presence of a pulmonary embolism, but did make clear that a second and final report was to follow. The doctor proceeded to make the decision to discharge Jordanne without reading the second and final report, which highlighted the pulmonary embolism;
2) In her evidence at inquest, ████████ ( Head of Patient Safety at the Trust ) confirmed:
(a) that all of the Trust’s own employed doctors receive training so that they ensure that both parts of any CT scan report are read;
(b) that all new locum doctors working for the Trust are provided with an induction pack, which highlights the requirement to read both parts of any CT scan report.
However, ████████ was unable to confirm that steps have been taken to ensure that all locum doctors already working at the Trust have received the equivalent training . She indicated that they have been invited to attend education sessions in which this topic has been covered, but that no record is kept of whether those doctors did in fact attend .
I am therefore concerned that unless and until the Trust is able to ensure that all locum doctors working at its hospitals have received training about the need to read both parts of a CT scan report , there remains a risk that ( as in this case ) life-threatening conditions may go undiagnosed, and consequently that patients’ lives may be put at risk.
” 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 Email investigation learning to regular doctors, including locum doctors.
Verbatim wording from the response “- The learning from this investigation via an anonymised case study was discussed in regular shop floor teaching and board rounds (i.e. teaching in the department with the staff on duty), done over a period of time to maximise saturation and to cover all staff.
- A email containing this learning was sent to all our regular doctors, including locums, at the time
- There was also a lesson of the week circulated post the completion of the report reminding staff of this fact (see attached)” Source location Response from Worcestershire Acute Hospital 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 Deliver anonymised investigation learning through regular shop-floor teaching and board rounds to reach staff, including locum doctors.
Verbatim wording from the response “- The learning from this investigation via an anonymised case study was discussed in regular shop floor teaching and board rounds (i.e. teaching in the department with the staff on duty), done over a period of time to maximise saturation and to cover all staff.
- A email containing this learning was sent to all our regular doctors, including locums, at the time
- There was also a lesson of the week circulated post the completion of the report reminding staff of this fact (see attached)” Source location Response from Worcestershire Acute Hospital 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 Circulate a lesson-of-the-week reminder about reading both parts of CT scan reports.
Verbatim wording from the response “- The learning from this investigation via an anonymised case study was discussed in regular shop floor teaching and board rounds (i.e. teaching in the department with the staff on duty), done over a period of time to maximise saturation and to cover all staff.
- A email containing this learning was sent to all our regular doctors, including locums, at the time
- There was also a lesson of the week circulated post the completion of the report reminding staff of this fact (see attached)” Source location Response from Worcestershire Acute Hospital NHS Trust
Open published response
6 Feb 2025 Katrina Veronica Francesca Insley · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Absence of a formal, documented handover system between hospital and Neighbourhood Team View source Failure to provide the Neighbourhood Team with direct access to hospital records for patients with pressure sores 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
Katrina Veronica Francesca Insley · 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
Katrina Insley died on 1 January 2024 at Alexandra Hospital, Redditch, from sepsis due to an infected pressure sore and pneumonia. The report identified concerns about the absence of a formal, documented handover system between hospital and the Neighbourhood Team, limited access to hospital records, and the resulting risk of delayed recognition and treatment of pressure sores, infection and sepsis.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a formal, documented handover system between hospital and Neighbourhood Team
Wider context from the report “(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient’s pressure sores when they are discharged from hospital and follow up to be delayed. This increases the risk of wound infection and consequent sepsis.
(2) I am informed (letter received from HWHT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to “formalise” the referral requirements between hospital and NT. I am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide the Neighbourhood Team with direct access to hospital records for patients with pressure sores
Wider context from the report “(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient’s pressure sores when they are discharged from hospital and follow up to be delayed. This increases the risk of wound infection and consequent sepsis.
(2) I am informed (letter received from HWHT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to “formalise” the referral requirements between hospital and NT. I am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed.
” Open source report
17 Jan 2025 Vauna LEEMING · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 6 Insufficient induction for agency nurses on completing important documentation View source Failure to complete documentation of Enoxaparin administration View source Insufficient nurse awareness of the duty to report documentation omissions View source Failure to complete documentation of compression stocking fitting and use View source Failure to report omissions in important documentation to a senior colleague View source Insufficient nurse awareness of the duty to complete important documentation 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
Vauna LEEMING · 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
Vauna Leeming was admitted to hospital after an accidental fall at home that caused a fractured right neck of femur. After surgery, her condition deteriorated, she tested positive for Covid-19, suffered a pulmonary embolism and died in hospital. Concerns included incomplete documentation of anticoagulation and compression-stocking measures, failures to report omissions, and insufficient awareness among employed and agency nurses of these duties.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient induction for agency nurses on completing important documentation
Wider context from the report “3) The inquest heard evidence that whilst in its induction to new nurse employees, the Trust emphasises the importance of completing documentation, it is still heavily reliant on agency nurses, for whom it cannot be expected to provide such an induction ;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete documentation of Enoxaparin administration
Wider context from the report “1) Following Mrs. Leeming’s surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication (Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between her surgery and Mrs. Leeming’s death:
(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered ;
(b) on a total of 15 days (including 5 consecutive days in one week ) no documentation was completed by nurses to show whether compression stockings had been fitted and were being worn;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nurse awareness of the duty to report documentation omissions
Wider context from the report “4) I am concerned that the evidence in this case highlights that there is still insufficient awareness among employed and agency nurses at the Trust’s hospitals of their professional duty :
(a) to complete important documentation such as prescription charts; and
(b) to report any omissions in the completion of such documentation to a senior colleague .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete documentation of compression stocking fitting and use
Wider context from the report “1) Following Mrs. Leeming’s surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication (Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between her surgery and Mrs. Leeming’s death:
(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered;
(b) on a total of 15 days (including 5 consecutive days in one week ) no documentation was completed by nurses to show whether compression stockings had been fitted and were being worn ;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to report omissions in important documentation to a senior colleague
Wider context from the report “2) It was of particular concern that for 5 consecutive days, no nurse had noticed or raised with a senior colleague that the prescription charts had not been completed to show that compression stockings had been fitted. This suggests either that there is little understanding of a nurse’s professional duty to report such omissions , or that the practice of not checking and completing such important documentation is commonplace;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient nurse awareness of the duty to complete important documentation
Wider context from the report “4) I am concerned that the evidence in this case highlights that there is still insufficient awareness among employed and agency nurses at the Trust’s hospitals of their professional duty :
(a) to complete important documentation such as prescription charts ; and
(b) to report any omissions in the completion of such documentation to a senior colleague.
” 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 and recirculate Trust-wide learning on mechanical thromboprophylaxis and signing prescriptions.
Verbatim wording from the response “ii. To update and re-circulate the lesson of the week Trust-wide on mechanical thromboprophylaxis and the importance of signing prescriptions” Source location Response from Worcestershire Acute 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 Reinforce requirements to sign prescription charts through daily safety huddles and team meetings.
Verbatim wording from the response “i. Ward managers and Matrons, in their daily safety huddles and team meetings, are reinforcing the direction that staff must sign prescription charts.” Source location Response from Worcestershire Acute 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 Increase VTE compliance monitoring through regular divisional audits of prescription-chart signing and monthly reports to the Improving Safety Action Group.
Verbatim wording from the response “• To increase the monitoring of VTE compliance via our Improving Safety Action Group (ISAG), chaired by the Chief Nursing Officer/CMO.” Source location Response from Worcestershire Acute 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 Request that the digital team ensure new electronic prescribing charts meet all requirements before launch.
Verbatim wording from the response “iii. The CMO will write to the digital team creating the electronic medical prescribing charts, formally requesting that they ensure that the new charts meet all requirements, prior to being launched (e.g. prescribing of TEDS)” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
14 Nov 2024 Teresa Auriemma · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3 Failure to ensure doctors are aware of and comply with electrolyte-monitoring policies View source Failure to ensure doctors understand the importance of U&E monitoring before prescribing intravenous fluids View source Failure to monitor electrolytes before prescribing intravenous fluids View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Teresa Auriemma · 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
Teresa Auriemma was admitted to hospital after becoming unwell and was treated for aspiration pneumonia, dehydration, acute kidney injury and deranged electrolytes. She received intravenous potassium based on an out-of-date and inaccurate blood test, was given further intravenous potassium without the required monitoring, and subsequently collapsed and died from a fatally high potassium level. The principal concerns were failures to monitor potassium and other electrolytes and to ensure that doctors understood and complied with relevant monitoring policies.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors are aware of and comply with electrolyte-monitoring policies
Wider context from the report “1) None of the doctors caring for Mrs. Auriemma from 11.3.24 onwards appear to have heeded the guidance of policy WAHT-PHA-020 for the treatment of hypokalaemia, and in particular that daily monitoring of urea and electrolytes (U&E) was required until the patient’s potassium levels had returned to normal levels. Mrs. Auriemma had been prescribed an oral potassium supplement from 11.3.24. A junior doctor assisting the consultant on the ward round on 15.3.24, when asked what Mrs. Auriemma’s potassium level was, gave the last reading taken on 11.3.24; that junior doctor appeared therefore not to have understood the need for daily U&E monitoring. The consultant accepted he should have checked the date of the reading given, but did not and instead assumed it was up-to-date. The consultant then proceeded to prescribe intravenous potassium on 15.3.24;
2) Once the intravenous potassium had been given on 15.3.24, further U&E monitoring should have been carried out before any more intravenous potassium was given. That U&E monitoring was not done, and instead further intravenous potassium was given on 16.3.24. No clear reason was provided to the inquest as to why the junior doctor responsible had not checked Mrs. Auriemma’s potassium levels before prescribing further intravenous potassium;
3) This is not the first inquest which has found shortcomings in the Trust’s monitoring of patients’ electrolyte levels. Only 2 months ago, this court heard evidence in another inquest concerning the death of a young woman at Worcestershire Royal Hospital in January 2024, who had died because staff at the hospital had failed to recognize and act upon an excessively low sodium level. In that case, like this, I found that there was a failure by doctors to ensure proper monitoring of electrolytes by checking blood results before prescribing IV fluids.
4) I am therefore concerned that the Trust has not ensured that its doctors:
(a) understand the importance generally of U&E monitoring before prescribing intravenous fluids; and
(b) are aware of, and comply with specific policies concerning this issue, such as that relating to the management of hypokalaemia ( WAHT-PHA-020 ).
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure doctors understand the importance of U&E monitoring before prescribing intravenous fluids
Wider context from the report “1) None of the doctors caring for Mrs. Auriemma from 11.3.24 onwards appear to have heeded the guidance of policy WAHT-PHA-020 for the treatment of hypokalaemia, and in particular that daily monitoring of urea and electrolytes (U&E) was required until the patient’s potassium levels had returned to normal levels. Mrs. Auriemma had been prescribed an oral potassium supplement from 11.3.24. A junior doctor assisting the consultant on the ward round on 15.3.24, when asked what Mrs. Auriemma’s potassium level was, gave the last reading taken on 11.3.24; that junior doctor appeared therefore not to have understood the need for daily U&E monitoring . The consultant accepted he should have checked the date of the reading given, but did not and instead assumed it was up-to-date. The consultant then proceeded to prescribe intravenous potassium on 15.3.24;
2) Once the intravenous potassium had been given on 15.3.24, further U&E monitoring should have been carried out before any more intravenous potassium was given. That U&E monitoring was not done, and instead further intravenous potassium was given on 16.3.24. No clear reason was provided to the inquest as to why the junior doctor responsible had not checked Mrs. Auriemma’s potassium levels before prescribing further intravenous potassium;
3) This is not the first inquest which has found shortcomings in the Trust’s monitoring of patients’ electrolyte levels. Only 2 months ago, this court heard evidence in another inquest concerning the death of a young woman at Worcestershire Royal Hospital in January 2024, who had died because staff at the hospital had failed to recognize and act upon an excessively low sodium level. In that case, like this, I found that there was a failure by doctors to ensure proper monitoring of electrolytes by checking blood results before prescribing IV fluids.
4) I am therefore concerned that the Trust has not ensured that its doctors:
(a) understand the importance generally of U&E monitoring before prescribing intravenous fluids ; and
(b) are aware of, and comply with specific policies concerning this issue, such as that relating to the management of hypokalaemia ( WAHT-PHA-020 ).
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor electrolytes before prescribing intravenous fluids
Wider context from the report “1) None of the doctors caring for Mrs. Auriemma from 11.3.24 onwards appear to have heeded the guidance of policy WAHT-PHA-020 for the treatment of hypokalaemia, and in particular that daily monitoring of urea and electrolytes (U&E) was required until the patient’s potassium levels had returned to normal levels. Mrs. Auriemma had been prescribed an oral potassium supplement from 11.3.24. A junior doctor assisting the consultant on the ward round on 15.3.24, when asked what Mrs. Auriemma’s potassium level was, gave the last reading taken on 11.3.24; that junior doctor appeared therefore not to have understood the need for daily U&E monitoring. The consultant accepted he should have checked the date of the reading given, but did not and instead assumed it was up-to-date. The consultant then proceeded to prescribe intravenous potassium on 15.3.24;
2) Once the intravenous potassium had been given on 15.3.24, further U&E monitoring should have been carried out before any more intravenous potassium was given. That U&E monitoring was not done , and instead further intravenous potassium was given on 16.3.24. No clear reason was provided to the inquest as to why the junior doctor responsible had not checked Mrs. Auriemma’s potassium levels before prescribing further intravenous potassium;
3) This is not the first inquest which has found shortcomings in the Trust’s monitoring of patients’ electrolyte levels. Only 2 months ago, this court heard evidence in another inquest concerning the death of a young woman at Worcestershire Royal Hospital in January 2024, who had died because staff at the hospital had failed to recognize and act upon an excessively low sodium level. In that case, like this, I found that there was a failure by doctors to ensure proper monitoring of electrolytes by checking blood results before prescribing IV fluids .
4) I am therefore concerned that the Trust has not ensured that its doctors:
(a) understand the importance generally of U&E monitoring before prescribing intravenous fluids; and
(b) are aware of, and comply with specific policies concerning this issue, such as that relating to the management of hypokalaemia ( WAHT-PHA-020 ).
” 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 Require all Trust doctors to undertake continuing professional development on electrolyte balance.
Verbatim wording from the response “iii. There are planned actions to get all of the doctors in the Trust to do some Continued Professional Development (CPD) on electrolyte balance” Source location Response from Worcestershire Acute 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 Use electronic prescribing technology, where appropriate, to prompt doctors to consider blood-test results before prescribing intravenous fluids.
Verbatim wording from the response “iii. As the Trust moves towards electronic prescribing, technology is used where appropriate to prompt medical staff to consider blood test results for patients requiring intravenous fluids.” Source location Response from Worcestershire Acute 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 Issue an advisory notice reminding doctors to follow NICE guidance when prescribing intravenous fluids and monitoring electrolytes.
Verbatim wording from the response “i. An advisory notice has gone out to all doctors to remind them to prescribe IV fluids and monitor electrolytes as per NICE guidance (which are printed on the reverse of every intravenous fluid prescription sheet).” Source location Response from Worcestershire Acute 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 Operate a working party to examine non-compliance with fluid-monitoring standards and address identified knowledge or skills gaps.
Verbatim wording from the response “ii. A working party has been set up to examine the reasons for non-compliance with these standards, and to address any knowledge or skills gap that is identified.” Source location Response from Worcestershire Acute 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 Improve the intranet’s policy visibility and search function so electrolyte-correction policies are readily available.
Verbatim wording from the response “ii. The Trust has improved the visibility and search function of the Trust’s intranet page so that policies are readily available on demand.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
24 Sep 2024 Kelly Marie STEVENS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Failure to perform regular electrolyte testing when prescribing intravenous fluids View source Failure to ensure overall consultant responsibility for patients receiving care from multiple teams View source Failure to properly record fluid intake and output on fluid balance charts View source Routine copying and pasting of out-of-date care plans into hospital notes 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
Kelly Marie STEVENS · 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
Kelly Stevens, who had profound learning and physical disabilities and received nutrition, hydration and medication via a PEG tube, was admitted to hospital on 28 December 2023. She suffered a seizure on 3 January 2024 caused by an excessively low, unrecognised sodium level, aspirated vomit, developed aspiration pneumonia and died in hospital later that night. Concerns included the absence of clear overall consultant responsibility, failure to monitor electrolytes and record fluid intake and output properly, and the copying of outdated care plans in her notes.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform regular electrolyte testing when prescribing intravenous fluids
Wider context from the report “2) No doctor providing care for Ms. Stevens followed the established principle that the prescription of intravenous fluids for a patient must be accompanied by regular testing of electrolytes . In Ms. Stevens’ case, this was particularly important because her baseline sodium level was low anyway, so the overprescription of fluids put her at greater risk of hyponatraemia;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure overall consultant responsibility for patients receiving care from multiple teams
Wider context from the report “1) Despite being under the care of the medical team, Ms. Stevens did also receive input from the surgical team. Her situation was further complicated by the fact that for most of her admission she was placed as a medical outlier on a surgical ward. In the event, no one consultant was in overall charge of her care , which meant that the issues identified in this case were not picked up on. I heard evidence that there was no policy in place at the Trust to give guidance as to how this sort of situation should be resolved , but instead that it was expected that consultants would liaise with each other in order to do so . That did not happen in this case ;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to properly record fluid intake and output on fluid balance charts
Wider context from the report “3) There was no proper recording of Ms. Stevens’ fluid intake and output on fluid balance charts for most of her hospital admission . For the reasons set out at 2) above, this was vitally important in her case;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Routine copying and pasting of out-of-date care plans into hospital notes
Wider context from the report “4) Ms. Stevens’ hospital notes revealed evidence of the routine “copying and pasting” of out-of-date care plans by previous doctors . This meant that the next person reading her notes would be left with an erroneous view of her current care plan .
” 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 blood monitoring training in the core medical curriculum.
Verbatim wording from the response “2) Blood monitoring training is included as part of the core medical curriculum covered within medical training.” Source location Response from Worcestershire Acute Hospitals NHS
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 Share Trust-wide learning and required actions to improve fluid-balance documentation in the electronic patient record.
Verbatim wording from the response “3) There have been multiple actions to improve fluid balance records:” Source location Response from Worcestershire Acute Hospitals NHS
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 Share, approve and implement the agreed policy for managing medical outliers and assigning overall responsibility for their care.
Verbatim wording from the response “1) At the time of the incident, there was no policy in place for the management of medical outliers. In the action plan of the report the Chief Medical Officer (CMO) has an action relating to the review of a patient outlier policy and to taking over patient care. These actions are almost completed. Meetings were held between the senior clinical leaders and the Chief Medical Officer on 11th October 2024 and the 4th November to review the policy. The policy has been agreed and will be shared through the Improving Safety Actions Group (ISAG) on 14th November 2024 and approved through Trust Management Board on 20th November 2024 with immediate implementation thereafter.” Source location Response from Worcestershire Acute Hospitals NHS
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 deliver a local training package addressing fluid-balance and electronic-record changes.
Verbatim wording from the response “• Additional opportunities for education around nutrition and hydration are included throughout the ward:
○ Local induction to the ward for Healthcare Assistants (HCA) covers MUST and fluid balance; this is an informal local training and is completed with the Band 6.
○ Fluid balance training provided by the Acute Kidney Injury nurse.
○ Rolling HCA study day programme which includes MUST and nutritional risk.
○ Due to changes with fluid balance and the introduction of EPR, the Division recognise there is a gap in training; the Division are currently formulating a training package to be delivered locally.” Source location Response from Worcestershire Acute Hospitals NHS
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 ward-based education on nutrition, hydration, MUST assessment and fluid-balance recording through induction, specialist training and HCA study days.
Verbatim wording from the response “• Additional opportunities for education around nutrition and hydration are included throughout the ward:
○ Local induction to the ward for Healthcare Assistants (HCA) covers MUST and fluid balance; this is an informal local training and is completed with the Band 6.
○ Fluid balance training provided by the Acute Kidney Injury nurse.
○ Rolling HCA study day programme which includes MUST and nutritional risk.
○ Due to changes with fluid balance and the introduction of EPR, the Division recognise there is a gap in training; the Division are currently formulating a training package to be delivered locally.” Source location Response from Worcestershire Acute Hospitals NHS
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 Remove the electronic-record copy-forward function from all clinical documents.
Verbatim wording from the response “4) The copy forward function on EPR was removed from 3 documents on 14th May 2024: Medical Clerking, Ward Round and Specialty Review. Copy forward was then removed from all documents within the EPR system on 4th September 2024.” Source location Response from Worcestershire Acute Hospitals NHS
Open published response
20 Sep 2024 Margaret Rose MAYCROFT · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to document falls prevention measures following falls risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Margaret Rose MAYCROFT · 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
Margaret Rose Maycroft was readmitted to Worcestershire Royal Hospital after falls and was found to have suffered an ischaemic stroke. During her admission, she sustained further falls resulting in a displaced fractured neck of femur, underwent surgery, and later died at Princess of Wales Community Hospital, Bromsgrove, while receiving palliative care. The principal concern was that, although falls risk assessments were completed, no falls prevention measures were documented or put in place, and there was no evidence that this issue had since been addressed.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document falls prevention measures following falls risk assessments
Wider context from the report “2) In respect of each of these falls, Matron ████████ gave evidence that whilst staff in the Emergency Department and the Acute Frailty Unit had completed falls risk assessments, no measures to mitigate that risk, such as might be found in a falls prevention, assessment and intervention plan, were documented in Ms. Maycroft’s notes . This meant that no documented falls prevention measures were put in place for her .
3) Furthermore, I heard no evidence at the inquest which satisfied me that the steps have now been taken to ensure falls prevention measures are now being properly considered and documented in both the Emergency Department and the Acute Frailty Unit at the hospital .
” 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 barriers to documenting falls interventions on the electronic patient record, take resulting actions and monitor them through the Improving Safety Action Group.
Verbatim wording from the response “• The barriers faced by staff in documenting falls interventions in place on EPR will be explored and actions taken and monitored through Improving Safety Action Group (ISAG)” Source location Response from Worcestershire Acute 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 Distribute guidance on documenting falls interventions in Sunrise.
Verbatim wording from the response “• The EPR team will distribute an update on how to document interventions on Sunrise.” Source location Response from Worcestershire Acute 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 Review the electronic post-fall record and intervention document and clarify completion expectations.
Verbatim wording from the response “• There are trust wide falls prevention measures in place and work is being undertaken to review the post fall record and intervention document on the electronic patient record and for the expectations around completion to be clarified.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
4 Jun 2024 Susan Lynne EDWARDS · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Lack of a system to ensure that mechanical thromboprophylaxis instructions are carried out View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Lynne EDWARDS · 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
Susan Edwards died in hospital on 7 October 2023 after a sudden deterioration, with post-mortem examination establishing that the cause was a large pulmonary embolus. The report raised concerns that an instruction for mechanical thromboprophylaxis was not carried out and that Worcestershire Royal Hospital had no apparent system to ensure such instructions were followed, potentially putting patients at risk.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system to ensure that mechanical thromboprophylaxis instructions are carried out
Wider context from the report “1) On 19 September 2023 a Venous Thromboembolism Risk Assessment made clear that Mrs. Edwards should be provided with mechanical thromboprophylaxis. This instruction was not entered on Mrs. Edwards’ anticoagulation drug card, and Mrs. Edwards was not provided with any form of mechanical thromboprophylaxis between that date and her death 18 days later on 7 October 2023. No nurse or reviewing doctor picked up on this omission.
Although I was satisfied that, in this case, the provision of mechanical thromboprophylaxis would probably not have prevented Mrs. Edwards’ death, I am concerned that:
(a) no system appears to be in place at Worcestershire Royal Hospital to ensure that such an instruction is carried out ; and
(b) as long as that remains the case, the lives of patients who require thromboprophylaxis during a hospital admission may be put at risk.
” 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 prescription-chart checks in matron audits to verify prophylaxis prescriptions are signed as in place.
Verbatim wording from the response “2. Monitoring:” Source location Response from Worcestershire Acute 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 Implement mechanical prophylaxis documentation on the electronic patient prescribing and administration system.
Verbatim wording from the response “3. Long term plan is this will be on the electronic patient medical prescribing / administration system.” Source location Response from Worcestershire Acute 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 Deliver weekly teaching on mechanical prophylaxis and reinforce signing prescription charts to confirm prophylaxis is in place.
Verbatim wording from the response “1. We have focussed on educating our staff in order to provide clear instructions around this area and will implement the following:” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
26 Jan 2024 Paul William BRADLEY · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Lack of a clear system for following up missed important urology appointments and meeting treatment targets View source Lack of a clear system for communication between teams about patient progress and missed appointments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Paul William 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
Paul William Bradley was diagnosed with renal cancer in July 2019 and died in hospital on 17 May 2023 after the tumour had become metastatic. The report identified missed follow-up after a urology appointment in March 2021, inadequate systems for tracking missed appointments, and insufficient communication between the urology and vascular teams as substantive concerns.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for following up missed important urology appointments and meeting treatment targets
Wider context from the report “(a) The Trust’s urology team had no clear system in place to try to ensure that a patient who missed an important urology appointment could be followed up, and his treatment targets met. That still appears to be the case;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for communication between teams about patient progress and missed appointments
Wider context from the report “(b) Where, as here, more than one team was involved in a patient’s care, there was no clear system in place to ensure that the teams involved communicated with each other about the progress they were making with the patient, and about any appointments missed by 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 Develop a risk-stratification process within clinical teams for patients who cancel appointments or do not attend.
Verbatim wording from the response “The following actions were agreed with named individuals responsible for their delivery: -” Source location Response from Worcestershire Acute 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 clear process for handing patients from Cancer Services to departmental teams when they leave active cancer tracking.
Verbatim wording from the response “The following actions were agreed with named individuals responsible for their delivery: -” Source location Response from Worcestershire Acute 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 standard operating procedure for monitoring potentially cancerous lesions, including information transfer between teams.
Verbatim wording from the response “The following actions were agreed with named individuals responsible for their delivery: -” Source location Response from Worcestershire Acute Hospitals
Open published response
26 Jan 2024 Michael Leslie PEGG · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3 Crowded and noisy treatment areas ill-suited to proper patient treatment View source Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency View source Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Michael Leslie PEGG · 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
Michael Leslie Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after two significant seizures and died there on 15 January 2023 following deterioration and pneumonia. The report raised concerns that steroid treatment fell far short of relevant NICE guidelines, that staff awareness and application of the guidelines were insufficient, and that crowded treatment areas created difficulties in providing appropriate care.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Crowded and noisy treatment areas ill-suited to proper patient treatment
Wider context from the report “3) For a substantial part of his time at Worcestershire Royal Hospital, Mr. Pegg was being treated in a bed in a corridor in the Emergency Department, and then in the Majors Overflow area, both busy, crowded and noisy areas ill-suited to the proper treatment of patients . In his evidence to the inquest about trying to ensure that the Trust’s staff are aware of these Guidelines, Dr Raven told the inquest:
“As long as we still have crowded settings, it is difficult to provide assurances that these guidelines will be followed , for example because we have a high turnover of locum clinicians and agency nursing staff.”
It is particularly concerning to hear that patients’ wellbeing may be put at risk because a hospital Trust may not be able properly to ensure that the staff it employs are aware of, and able to apply NICE Guidelines.
It is perhaps unfair to put responsibility for rectifying this situation solely at the door of the Worcestershire Acute Hospitals NHS Trust, which is why this report is also being sent to NHS England and Health Education England.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinician awareness and ability to apply NICE guidelines for adrenal insufficiency
Wider context from the report “2) Although in this case, I was unable to conclude that the above omissions in steroid treatment probably caused or contributed to Mr. Pegg’s death, it was nonetheless concerning to hear that none of those treating him had sufficient awareness of the NICE Guidelines as to be able to apply them properly in his case . Unless action is taken to ensure clinicians employed by the Trust are aware of, and able to apply these Guidelines , there remains a risk that another patient with adrenal insufficiency may die in similar circumstances ;
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to apply NICE steroid-treatment guidelines for adrenal insufficiency during intercurrent illness
Wider context from the report “1) Over the two days that Mr. Pegg was at Worcestershire Royal Hospital, those treating him failed to apply the NICE guidelines which relate to the treatment of those with adrenal insufficiency conditions who are being treated for intercurrent illness . ████████, who conducted the Trust’s serious incident investigation into these events, told the inquest:
“There was a policy in place for administering steroids, as per the 2020 NICE guidelines – this advises:
(a) double dosing of oral steroids in cases of intercurrent illness until 48 hours after recovery (also known as Sick Day rule 1);
(b) if [the patient has ] significant trauma, prolonged vomiting or diarrhoea, then 100mg IV hydrocortisone [ should be administered ];
(c) if suspected adrenal crisis, 100mg IV hydrocortisone immediately.”
In fact, the steroid treatment provided to Mr. Pegg during this admission fell far short of those Guidelines , in that:
(a) He only received one double dose of his oral hydrocortisone medication , which he was usually required to take twice a day;
(b) He received no doses at all ( double or standard ) of his oral prednisolone medication , which he was usually required to take once a day;
(c) Although he did eventually receive a 100mg dose of IV hydrocortisone on 14.1.23, this should have been given much earlier that day when his condition seriously deteriorated .
” 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 Highlight steroid replacement in Emergency Department handovers and repeat the messaging to maintain medical staff awareness.
Verbatim wording from the response “• Steroid replacement (and other time critical meds) has been highlighted in effective handover in ED in 2023 and will be repeated (appendix 4) to raise and maintain awareness for all medical staff working in the ED.” Source location Response from Worcestershire Acute 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 Prioritise adrenal insufficiency and steroid replacement for Medical Examiner review, triggering further case review when concerns are identified.
Verbatim wording from the response “• The Medical Examiners, at the request of the Trust, are working with Adrenal Insufficiency/Steroid Replacement as one of their high priority conditions which means that any concerns identified with steroid replacement will trigger further case review. The focus therefore remains on this area and will continue to be so until we are fully assured that our processes for identifying and managing this condition are effective.” Source location Response from Worcestershire Acute 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 Use the updated Emergency Department adult patient document, which automatically includes highlighted steroid replacement as a time-critical medication for all adults.
Verbatim wording from the response “several occasions since Mr Pegg’s sad death. Discussions included the importance of the adult patient document in the Emergency Department which was updated in June 2023. This now includes a time critical medications (highlighted steroid replacement) (please see appendix 1 attached). This is automatically included for all adults presenting to the Emergency Department.” Source location Response from Worcestershire Acute 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 Circulate steroid replacement safety materials to Emergency and Medical staff and display them in the Emergency Department handover area.
Verbatim wording from the response “• A “detect and reflect” document and “time critical medication safety flash” have been circulated to all Emergency and Medical staff to raise awareness of the need for steroid replacement therapy (appendix 2, 3). These are displayed in the Emergency Department handover area.” Source location Response from Worcestershire Acute 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 Have the Acting Chief Medical Officer highlight steroid replacement during induction for new doctors rotating into the hospitals.
Verbatim wording from the response “• The Acting Chief Medical Officer will be attending the Induction for new doctors in August in order to highlight this area of focus for the Trust for all junior doctors rotating into our hospitals.” Source location Response from Worcestershire Acute 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 Incorporate steroids and other time-critical medications into the Emergency Department electronic patient record.
Verbatim wording from the response “• The Trust is due to move to an electronic patient record in the Emergency Department in Autumn 2024 – time critical medications including steroids are due to be incorporated into this.” Source location Response from Worcestershire Acute 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 Close and discontinue use of the Emergency Department overflow area.
Verbatim wording from the response “• The “overflow area” of the ED is no longer being used, having closed in October 2023.” Source location Response from Worcestershire Acute 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 Participate in the Royal College of Emergency Medicine audit of prescribing and administration of time-critical medicines, including steroids.
Verbatim wording from the response “• The Emergency Departments on both sites are participating in a Royal College of Emergency Medicine audit looking at the prescribing and administration of time critical medicines, including steroids. This audit will provide a “benchmark” for the Trust and also highlight areas where further improvement is required. The audit is still in data collection phase but results will be available later in the year.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
15 Dec 2023 Terence Edward Hines · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3 Failure to carry out required routine MRSA screening View source Insufficient staff awareness of policies and procedures requiring MRSA screening and room cleaning View source Failure to carry out the required Red clean of a room before a subsequent occupant moves in 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
Terence Edward Hines · 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
Terence Edward Hines developed an MRSA infection after surgery for a fractured right neck of femur and died in hospital on 15 July 2023. The report identified failures to carry out the required Red clean of a hospital room and routine MRSA screening, and raised concerns about staff awareness of relevant policies and procedures.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required routine MRSA screening
Wider context from the report “5) On or about 24.6.23, because Mr. Hines had now been an inpatient for 28 days, he should have been screened for MRSA. That routine MRSA screen was not carried out. The Trust’s investigation was unable to explain why that routine screen had not been carried out;
6) On 26.6.23 Mr. Hines suffered an accidental fall in the room, and was found to have sustained a fractured right neck of femur. As a result, he was transferred to Worcestershire Royal Hospital where surgery to fix the neck of femur fracture was carried out on 1.7.23;
7) As a matter of established routine, Mr. Hines should again have been screened for MRSA prior to his surgery,. Once again, that routine MRSA screen was not carried out . The Trust’s investigation did not explore the question of why that routine MRSA screen had not taken 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff awareness of policies and procedures requiring MRSA screening and room cleaning
Wider context from the report “Although I was unable to be satisfied, on the balance of probabilities, that identification of the MRSA infection at either the missed routine 28 day screen on or about 24.6.23, or at the missed pre-surgery screen on 1.7.23, would have resulted in treatment which would likely have prevented Mr. Hines’ death, it is a matter of grave concern that these screens and the Red clean of the room, all routine measures designed to identify, treat and prevent the spread of such a serious pathogen, were not carried out.
These failures have led me to conclude that staff at both the Alexandra Hospital, Redditch, and Worcestershire Royal Hospital, do not have sufficient awareness of the Trust’s policies and procedures which require such measures to be taken .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out the required Red clean of a room before a subsequent occupant moves in
Wider context from the report “2) On 19.6.23 Mr. Hines was moved to side room 2, on ward 2 at the hospital. This room had been vacated that same day by another patient who had a known MRSA infection and an exfoliating skin condition which, taken together, represented a heightened risk of a subsequent occupant of the room developing an MRSA infection, and therefore ought to have triggered a Red ( hydrogen peroxide ) clean of the room before Mr. Hines moved into it ;
3) A Red clean of the room did not take place before Mr. Hines moved into the room – instead, an Amber ( chlorine ) clean was carried out in error ;
” Open source report
19 Apr 2023 DAVID ERNEST MASON · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 8 Call-handler pathway failing to consider adrenal crisis risk after trauma View source National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress View source Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress View source Absence of adrenal insufficiency prompts in emergency department and clerking documentation View source Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress View source Unclear NHS England monitoring of compliance with National Patient Safety Alerts View source Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy View source Failure of internal investigation coordination and learning from patient-safety incidents View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
DAVID ERNEST MASON · 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 Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Call-handler pathway failing to consider adrenal crisis risk after trauma
Wider context from the report “2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately . This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety-netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at WMAS .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation National treatment guidance failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress . Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. It is my understanding that a new guideline in respect of managing the treatment of adrenal insufficiency is currently being developed by NICE. Consideration of these matters should be included as part of guideline development.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of acute hospital clinicians to recognise the need for replacement steroid therapy after trauma or physiological stress
Wider context from the report “1) Evidence heard at the inquest demonstrated that no clinician involved in providing care to Mr Mason (in both the emergency department and the surgical trauma department) appreciated that , as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy , to prevent the development of an acute adrenal crisis.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of adrenal insufficiency prompts in emergency department and clerking documentation
Wider context from the report “4) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency . Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Guideline failing to emphasise replacement steroid therapy after trauma or physiological stress
Wider context from the report “2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are on the same page as advice to patients and families for long-term condition management) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear NHS England monitoring of compliance with National Patient Safety Alerts
Wider context from the report “2) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. It is not clear what follow-up action is taken by NHS England in relation to monitoring of compliance by NHS Trusts following National Patient Safety Alerts being issued.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient clinician knowledge of adrenal insufficiency and replacement steroid therapy
Wider context from the report “3) Evidence heard at the inquest (relating to the trauma/surgical department at WAHT) suggested that it is likely that many clinicians (including at consultant level) do not have a well-developed understanding of adrenal insufficiency and the crucial importance of administering replacement steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering an adrenal crisis .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigation coordination and learning from patient-safety incidents
Wider context from the report “4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle , which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason by WMAS.
” 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 Provide recurring adrenal insufficiency teaching to Trauma and Orthopaedic junior doctors through induction, three times annually.
Verbatim wording from the response “1. In order to raise awareness and educate clinicians, the following actions have been taken. Individual feedback was given and reflection undertaken by clinicians involved in July 2022 (appendix 1). On the 9th May 2023 at the Trauma & Orthopaedic (T&O) Governance meeting attended by 33 multidisciplinary staff including T&O Consultants this case was discussed and reflected upon (appendix 2). A teaching session was delivered by the Deputy Chief Medical Officer to 40+ Surgical trainees at a Regional Teaching Session on the 9th May 2023 (appendix 3). A teaching session highlighting the risk of adrenal insufficiency for T&O Junior Doctors delivered by a consultant Anaesthetist is now given three times per year as part of the induction programme (appendix 4).” Source location Response from Worcestershire Acute 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 Provide individual feedback and require reflection by clinicians involved in the case.
Verbatim wording from the response “1. In order to raise awareness and educate clinicians, the following actions have been taken. Individual feedback was given and reflection undertaken by clinicians involved in July 2022 (appendix 1). On the 9th May 2023 at the Trauma & Orthopaedic (T&O) Governance meeting attended by 33 multidisciplinary staff including T&O Consultants this case was discussed and reflected upon (appendix 2). A teaching session was delivered by the Deputy Chief Medical Officer to 40+ Surgical trainees at a Regional Teaching Session on the 9th May 2023 (appendix 3). A teaching session highlighting the risk of adrenal insufficiency for T&O Junior Doctors delivered by a consultant Anaesthetist is now given three times per year as part of the induction programme (appendix 4).” Source location Response from Worcestershire Acute 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 Deliver teaching on the case and adrenal insufficiency risks to surgical trainees at a regional teaching session.
Verbatim wording from the response “1. In order to raise awareness and educate clinicians, the following actions have been taken. Individual feedback was given and reflection undertaken by clinicians involved in July 2022 (appendix 1). On the 9th May 2023 at the Trauma & Orthopaedic (T&O) Governance meeting attended by 33 multidisciplinary staff including T&O Consultants this case was discussed and reflected upon (appendix 2). A teaching session was delivered by the Deputy Chief Medical Officer to 40+ Surgical trainees at a Regional Teaching Session on the 9th May 2023 (appendix 3). A teaching session highlighting the risk of adrenal insufficiency for T&O Junior Doctors delivered by a consultant Anaesthetist is now given three times per year as part of the induction programme (appendix 4).” Source location Response from Worcestershire Acute 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 Amend the Trust guideline to advise on additional steroid replacement for admitted Emergency Department patients at risk from physiological stress and pain.
Verbatim wording from the response “2. The Trust guideline, based on National guidance, has been amended to include clear advice for all patients in the Emergency Departments who require admission (appendix 6). Following discussion with our Endocrinology and Emergency Department teams, it was felt that this would be the most effective way of ensuring that clinicians were aware of the need for additional steroid replacement therapy for patients at risk of adrenal crisis due to physiological stress and pain.” Source location Response from Worcestershire Acute 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 Emergency Department admission-document prompts for time-critical steroid medications and consideration of increased steroid doses.
Verbatim wording from the response “4. Changes have been made to the ED admission documents, implemented 6th June 2023, to include prompts on time critical medications, including steroids, and to consider increasing the dose of steroids (appendix 7). The T&O admission document, as discussed at the Inquest, was updated in October 2022 to include Steroid Management prompts (appendix 8).” Source location Response from Worcestershire Acute 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 Share a Lesson of the Week on adrenal insufficiency through governance teams and Trust communication and incident-management channels.
Verbatim wording from the response “A Lesson of the Week was shared on 25th May 2023 (appendix 5), with Governance teams to disseminating it through Divisions, in the Trust “Worcestershire Weekly”, Datix Incident management system and the Trust Intranet page.” Source location Response from Worcestershire Acute 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 Update the Trauma and Orthopaedic admission document to include steroid-management prompts.
Verbatim wording from the response “4. Changes have been made to the ED admission documents, implemented 6th June 2023, to include prompts on time critical medications, including steroids, and to consider increasing the dose of steroids (appendix 7). The T&O admission document, as discussed at the Inquest, was updated in October 2022 to include Steroid Management prompts (appendix 8).” Source location Response from Worcestershire Acute Hospitals
Open published response
8 Jun 2022 Jack HURN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 4 Failure of investigations to examine relevant clinical care and record conclusions and their basis View source Failure of serious incident investigations to identify relevant guidance and explain departures from it View source Failure to make timely VITT specialist referral and transfer arrangements View source Lack of national or Trust guidance on managing VITT 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
Jack HURN · 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
Jack Hurn, aged 26, died after developing vaccine-induced immune thrombocytopenia and thrombosis with cerebral venous sinus thrombosis following an AstraZeneca COVID-19 vaccination. Concerns included the absence or non-use of guidance and pathways for timely specialist management of VITT, aspects of his care at Alexandra Hospital, and the apparent inadequacy of the investigation into his care.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to examine relevant clinical care and record conclusions and their basis
Wider context from the report “1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB.
- The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT).
- Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission.
2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination:
i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021
ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021
iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021
3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital.
4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case.
5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions.
6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients.
7. No adequate explanation was given in evidence to explain why the investigation was incomplete.
8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to identify relevant guidance and explain departures from it
Wider context from the report “1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB.
- The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT).
- Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission.
2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination:
i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021
ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021
iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021
3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital.
4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case.
5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions.
6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients.
7. No adequate explanation was given in evidence to explain why the investigation was incomplete.
8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make timely VITT specialist referral and transfer arrangements
Wider context from the report “1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB.
- The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT).
- Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission .
2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination:
i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021
ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021
iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021
3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital.
4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case.
5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions.
6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients.
7. No adequate explanation was given in evidence to explain why the investigation was incomplete.
8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national or Trust guidance on managing VITT
Wider context from the report “1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH , therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted , therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB.
- The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT).
- Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission.
2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH , there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination:
i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021
ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021
iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021
3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital.
4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case.
5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions.
6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients.
7. No adequate explanation was given in evidence to explain why the investigation was incomplete.
8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk.
” 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 Require investigators to use comprehensive literature and independent evidence reviews and address families’ concerns in investigation reports.
Verbatim wording from the response “We are ensuring investigators undertake more comprehensive literature and independent evidence reviews when indicated, rather than relying on internal expertise, and ensure that the concerns of patient’s family are sought and addressed in our reports. As part of our reflection we have recognised the need and actioned raising awareness of the Trust’s Library Services who can support literature searches for existing clinical guidelines and publications, to our investigators.” Source location Response from NHS Worcestershire Acute Hospital
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 Raise investigators’ awareness of Library Services support for searches of clinical guidelines and publications.
Verbatim wording from the response “We are ensuring investigators undertake more comprehensive literature and independent evidence reviews when indicated, rather than relying on internal expertise, and ensure that the concerns of patient’s family are sought and addressed in our reports. As part of our reflection we have recognised the need and actioned raising awareness of the Trust’s Library Services who can support literature searches for existing clinical guidelines and publications, to our investigators.” Source location Response from NHS Worcestershire Acute Hospital
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 a gap analysis of national patient-safety investigation standards against current practice.
Verbatim wording from the response “You may also be aware that NHS England is due to publish their Patient Safety Incident Response Framework (PSIRF), which describes how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Included as part of the framework are the National Standards for Patient Safety Investigation, published in 2020, designed to support improvement in the quality of patient safety investigation in NHS-funded care and specifies the basic requirements of reviews. The Trust completed a gap analysis of these standards against current practice, which is being used to inform the development of a revised investigation processes and report template as well as guidance for investigators. The Framework supports the National Patient Safety Strategy, to improve understanding of safety by drawing insights from patient safety incidents.” Source location Response from NHS Worcestershire Acute Hospital
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 regulators with assurance about appropriate referral of future patients to tertiary services.
Verbatim wording from the response “I confirm that we have discussed the concerns raised with the Care Quality Commission and Clinical Commissioning Group (as was), in particular providing assurance about the actions taken in order that any future patients presenting at our sites are referred appropriately to tertiary services.” Source location Response from NHS Worcestershire Acute Hospital
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 revised investigation processes, report templates and investigator guidance informed by the standards gap analysis.
Verbatim wording from the response “You may also be aware that NHS England is due to publish their Patient Safety Incident Response Framework (PSIRF), which describes how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Included as part of the framework are the National Standards for Patient Safety Investigation, published in 2020, designed to support improvement in the quality of patient safety investigation in NHS-funded care and specifies the basic requirements of reviews. The Trust completed a gap analysis of these standards against current practice, which is being used to inform the development of a revised investigation processes and report template as well as guidance for investigators. The Framework supports the National Patient Safety Strategy, to improve understanding of safety by drawing insights from patient safety incidents.” Source location Response from NHS Worcestershire Acute Hospital
Open published response
3 Nov 2021 RHIAN EMMA KATE ROSE · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Failure to give due weight to infection risk from retained foetus in delivery discussions following feticide View source Failure to record discussions about mode of delivery, maternal wishes and management-plan risks and benefits View source Lack of specific guidance for managing infection risk following feticide View source Failure to provide informed consent discussions and facilitate maternal wishes regarding mode of delivery 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.
×
AI-generated summary
RHIAN EMMA KATE ROSE · 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
Rhian Rose became unwell during a hospital admission for the second phase of medical termination of pregnancy following feticide for trisomy 21. Her condition deteriorated, leading to emergency caesarean section, hysterectomy and cardiac arrest; she died from multi-organ failure and sepsis on 25 November 2019. The principal concerns were insufficient consideration of informed consent and maternal choice regarding mode of delivery, and inadequate guidance on infection risks and delivery options following feticide.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to give due weight to infection risk from retained foetus in delivery discussions following feticide
Wider context from the report “2) Infection risk of retained foetus following feticide – I am concerned that a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical discussions when a mother is attending for delivery (following feticide) . There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach. Cases such as Rhian’s may well be rare, however consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record discussions about mode of delivery, maternal wishes and management-plan risks and benefits
Wider context from the report “1) Informed consent and material choice regarding mode of delivery – I am concerned that enough emphasis is not being given to maternal wishes regarding mode of delivery. This issue appears to be a recurring theme in obstetric practice, and I am concerned that the culture in this area appears to still not fully accepting of the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section) and of facilitating the wishes of pregnant women and holding full and frank discussions about the risks and benefits and the pros and cons of the different options. I am concerned that situations might arise, like it appeared happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussions held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk/benefits of differing management plans .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance for managing infection risk following feticide
Wider context from the report “2) Infection risk of retained foetus following feticide – I am concerned that a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical discussions when a mother is attending for delivery (following feticide). There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach . Cases such as Rhian’s may well be rare, however consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide informed consent discussions and facilitate maternal wishes regarding mode of delivery
Wider context from the report “1) Informed consent and material choice regarding mode of delivery – I am concerned that enough emphasis is not being given to maternal wishes regarding mode of delivery . This issue appears to be a recurring theme in obstetric practice, and I am concerned that the culture in this area appears to still not fully accepting of the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section) and of facilitating the wishes of pregnant women and holding full and frank discussions about the risks and benefits and the pros and cons of the different options . I am concerned that situations might arise, like it appeared happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussions held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk/benefits of differing management plans.
” Open source report
16 May 2019 Kevin John McDonald · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to retain discharge documentation View source Failure to provide clear discharge follow-up advice and guidance 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
Kevin John McDonald · 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
Kevin John McDonald was admitted to hospital after a spinal injury, was assessed and discharged with analgesia, apparently without follow-up. He later died by suicide, leaving a note indicating that he could no longer tolerate the pain. Concerns included unclear discharge advice and follow-up arrangements, with the family stating that he was left unsure what to do about his increasing pain and that no relevant hospital documentation had been found.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain discharge documentation
Wider context from the report “(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients.
The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain.
It appears that no documentation has been found within the hospital about this
The standardisation of discharge documentation would appear to be in need of review and I invite you to consider 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide clear discharge follow-up advice and guidance
Wider context from the report “(1) During the inquest the clinician giving evidence indicated that the discharge paperwork from the clinical decision-making unit is different to that from other wards/departments and it is not clear what a follow-up or advice/guidance is given to patients .
The family of the deceased contend that there was no advice or follow-up and that the deceased was left not knowing what to do about his increasing pain.
It appears that no documentation has been found within the hospital about this
The standardisation of discharge documentation would appear to be in need of review and I invite you to consider this.
” Open source report
30 Oct 2017 Michael Edward Giles · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 6 Failure to assign responsibility for carrying out and following up tests and investigations during crisis periods View source Failure to assign responsibility for complete and thorough handover View source Inadequate case notes and medical records View source Inadequate highlighting of particular patients' needs during handover View source Inconsistent handover processes failing to ensure adequate information sharing View source Absence of senior review of patients over weekends 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
Michael Edward Giles · 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
Michael Edward Giles became unwell, was admitted to hospital, underwent a diagnostic surgical procedure, then deteriorated and died. The report identified concerns about inconsistent shift handovers, lack of senior review at weekends, inadequate clinical and nursing leadership during a crisis, and inadequate case notes and medical records.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for carrying out and following up tests and investigations during crisis periods
Wider context from the report “(3) There was an acknowledgement within the Trusts investigation that, during the crisis period of this patient's admission there was a lack of leadership from both clinicians and nurses with no one taking responsibility to ensure that tests and investigations were in fact carried out and followed 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign responsibility for complete and thorough handover
Wider context from the report “(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared.
It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion .
The highlighting of the needs of particular patients who were the subject of the handover was inadequate.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate case notes and medical records
Wider context from the report “4 The case notes and medical records were (again) inadequate . I have been told on many occasions that the importance of good record-keeping is emphasised to clinicians - sadly in this case yet again the lessons do not appear to be being learned .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate highlighting of particular patients' needs during handover
Wider context from the report “(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared.
It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion.
The highlighting of the needs of particular patients who were the subject of the handover was inadequate .
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent handover processes failing to ensure adequate information sharing
Wider context from the report “(1) The handover process between shifts was expressed to be different throughout the hospital on different wards . This potentially leads to inconsistency with inadequate information being shared .
It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion.
The highlighting of the needs of particular patients who were the subject of the handover was inadequate.
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of senior review of patients over weekends
Wider context from the report “(2) The absence of a senior review of patients over the weekend was a factor in the suboptimal care given to this 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 Reorganize consultant working practices to increase the proportion of patients receiving review at least every 24 hours.
Verbatim wording from the response “There is already an expectation that all patients need to be reviewed 7 days per week. For those patients with high dependency needs the expectation is that they are seen and reviewed by a consultant twice daily (including acutely ill patients directly transferred and other who deteriorate). An audit of our practice from March 2017 shows that we were able to meet this requirement 93% of occasions. The overall proportion of patients who required a daily consultant review and were reviewed by a consultant was 68%. In order to improve this further working practice by consultants has been reorganised to facilitate a higher proportion of patients being seen at least once every 24 hours.
In order to keep the risks to a minimum for patients undergoing invasive procedures we are already reviewing where these can be done, i.e.” Source location 2017-0309-Response
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 clinical record-keeping video with the communications team to improve documentation standards.
Verbatim wording from the response “We recognise the importance of good clinical record note keeping. As part of this, we have undertaken an audit to assess our baseline and thereby assess the impact of interventions to improve this. I have attached the audit which demonstrates areas of good practice as well as areas in need of improvement. We’re also working with the communications team to develop a clinical records keeping video to drive up standards. I anticipate that this will be available in February. I’ve also attached a leaflet that will be forwarded to all in the Trust that utilise patient’s notes. The attached has yet to be finalised and is merely to provide an indication of the direction of travel. I anticipate that this will be available in February 2018.” Source location 2017-0309-Response
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 an audit establishing baseline clinical record-keeping performance and assessing improvement interventions.
Verbatim wording from the response “We recognise the importance of good clinical record note keeping. As part of this, we have undertaken an audit to assess our baseline and thereby assess the impact of interventions to improve this. I have attached the audit which demonstrates areas of good practice as well as areas in need of improvement. We’re also working with the communications team to develop a clinical records keeping video to drive up standards. I anticipate that this will be available in February. I’ve also attached a leaflet that will be forwarded to all in the Trust that utilise patient’s notes. The attached has yet to be finalised and is merely to provide an indication of the direction of travel. I anticipate that this will be available in February 2018.” Source location 2017-0309-Response
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 Finalize and distribute a clinical record-keeping leaflet to Trust staff who use patient notes.
Verbatim wording from the response “We recognise the importance of good clinical record note keeping. As part of this, we have undertaken an audit to assess our baseline and thereby assess the impact of interventions to improve this. I have attached the audit which demonstrates areas of good practice as well as areas in need of improvement. We’re also working with the communications team to develop a clinical records keeping video to drive up standards. I anticipate that this will be available in February. I’ve also attached a leaflet that will be forwarded to all in the Trust that utilise patient’s notes. The attached has yet to be finalised and is merely to provide an indication of the direction of travel. I anticipate that this will be available in February 2018.” Source location 2017-0309-Response
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 a standardized SBAR structure for clinical handovers across the hospital.
Verbatim wording from the response “1. You’ve invited the Trust to consider standardising the handover process across the hospital and to put in place a protocol whereby the identity of the person responsible for ensuring the handover takes place is clearly recognised.” Source location 2017-0309-Response
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 existing SBAR handover structure and ward board rounds are considered robust arrangements for transferring clinical information.
Verbatim wording from the response “The events surrounding this tragic case and your regulation 28 letter was discussed with the trainees in early November 2017. The conclusion from the trainees was that they were confident that the processes now in place were robust and they had not experienced any near misses as a consequence of inadequate handover. There is a standardised structure for handover which follows SBAR. This is an acronym for Situation, Background, Assessment, Recommendation. With reference to identifying a responsible person is a little more fraught. Handover takes place at multiple levels whilst the patient remains an inpatient.” Source location 2017-0309-Response
Open published response
22 Apr 2015 Noel Owen JONES · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Unavailability of an out-of-hours interventional radiology service View source Unavailability of an out-of-hours vascular surgery service View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Noel Owen JONES · 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
Noel Owen JONES underwent surgery on 2 October 2014 and was later admitted to Hereford County Hospital severely unwell with an internal haemorrhage. He was ultimately transferred by ambulance to Worcestershire Royal Hospital, where he died shortly after arrival, following an apparent four-hour delay in acceptance. Concerns included evidence that earlier acceptance might have enabled survival and that Worcestershire Royal Hospital had no out-of-hours vascular surgery or interventional radiology service.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an out-of-hours interventional radiology service
Wider context from the report “(2) Evidence was given that there is within Worcestershire Royal Hospital no out of hours service for vascular surgery or interventional radiology
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an out-of-hours vascular surgery service
Wider context from the report “(2) Evidence was given that there is within Worcestershire Royal Hospital no out of hours service for vascular surgery or interventional radiology
” 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 Review out-of-hours and on-call arrangements for vascular surgery or interventional radiology transfers involving critically ill patients.
Verbatim wording from the response “I am writing with reference to your letter dated 22 April 2015 in which you raised two concerns regarding Trust procedures following evidence which you heard at the inquest into the death of Mr Jones. As a result of your letter I confirm that I have reviewed the Trust’s processes in respect of the following action:” Source location 2015-0155-Response-by-Worcestershire-NHS-Trust
Open published response
13 Feb 2013 Francoise Simone Annabel SNAPE · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to complete VTE assessments View source Lack of knowledge and consideration of NICE guidance on mechanical anti-DVT devices 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
Francoise Simone Annabel SNAPE · 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 Snape was admitted to Worcestershire Royal Hospital on 2 August 2014 after an infarcted stroke and later developed a massive pulmonary embolus. Thromboembolic medication caused a catastrophic bleed resulting in her death. Concerns included the absence of a VTE assessment and failure to consider relevant NICE guidance on mechanical anti-DVT devices, which represented a lost opportunity for informed care and may have changed the outcome.
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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete VTE assessments
Wider context from the report “(1) No VTE assessment was ever made of Mrs Snape . The explanation given by ████████ was that staff were too busy to complete the form and that because she had had a stroke heparin could not be given and therefore the paperwork was unnecessary .
(2) NICE guidelines regarding the use of mechanical anti DVT devices instead of heparin in high risk cases was not considered. ████████ indicated in his evidence that the guidance on such matters was to be found in "general" guidance regarding DVTs and not in "stroke" guidance. The clear difference was that he was not aware of the content of the general guidance despite it being specifically referred to as involving stroke patients.
It was clear in the Inquest that the absence of a formally completed VTE assessment and lack of knowledge of NICE guidelines amounted to a lost opportunity to make informed decisions for the care of Mrs Snape which may (but only may) have changed the outcome for her.
(3)
” 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 Worcestershire Acute Hospitals NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge and consideration of NICE guidance on mechanical anti-DVT devices
Wider context from the report “(1) No VTE assessment was ever made of Mrs Snape. The explanation given by ████████ was that staff were too busy to complete the form and that because she had had a stroke heparin could not be given and therefore the paperwork was unnecessary.
(2) NICE guidelines regarding the use of mechanical anti DVT devices instead of heparin in high risk cases was not considered . ████████ indicated in his evidence that the guidance on such matters was to be found in "general" guidance regarding DVTs and not in "stroke" guidance. The clear difference was that he was not aware of the content of the general guidance despite it being specifically referred to as involving stroke patients .
It was clear in the Inquest that the absence of a formally completed VTE assessment and lack of knowledge of NICE guidelines amounted to a lost opportunity to make informed decisions for the care of Mrs Snape which may (but only may) have changed the outcome for her.
(3)
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations