8 Sep 2017 Terence Ryan · Prevention of Future Deaths report Manchester West
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Concerns raised 4 Lack of alerts for new medications subject to repeat prescription View source Failure to notify relevant support services and contacts after patient self-discharge View source Failure to record externally requested new medications on repeat prescriptions View source Lack of a protocol for patients self-discharging from hospital without necessary medication View source See 1 more concern
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Terence Ryan · 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 Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of alerts for new medications subject to repeat prescription
Wider context from the report “i. On the 15th July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22nd July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10th November 2016.
The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:-
a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment.
b. In respect of discharge letters directing new medication – the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time.
However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription , bearing in mind that the deceased had seen a General Practitioner on the 13th September 2016, the 30th September 2016 and the 14th October 2016 without the omission being checked .
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to notify relevant support services and contacts after patient self-discharge
Wider context from the report “ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient.
There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication .
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record externally requested new medications on repeat prescriptions
Wider context from the report “i. On the 15th July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22nd July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10th November 2016.
The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:-
a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment.
b. In respect of discharge letters directing new medication – the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time.
However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription, bearing in mind that the deceased had seen a General Practitioner on the 13th September 2016, the 30th September 2016 and the 14th October 2016 without the omission being checked.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for patients self-discharging from hospital without necessary medication
Wider context from the report “ii. The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital , particularly where they may be receiving necessary medication in the form of anticoagulation treatment . At the Inquest the deceased was identified as an vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient.
There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self-discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the electronic hospital information system to provide ward managers with daily lists of missing discharge summaries and promptly rectify failures or delays in sending them to GPs.
Verbatim wording from the response “As you will be aware the Trust has now implemented a Hospital Information System (HIS) which is an electronic patient records system. Discharge letters are generated electronically through this system. I have been informed that as part of the audit of this system, the Ward Manager will receive a daily list of the patients for whom a discharge summary has not been completed. This is a real time audit so action can be taken to rectify this issue immediately and a discharge summary can be sent to the patient’s GP as the patient is being discharged/shortly after their discharge from the hospital.” Source location 2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue communicating self-discharge policy requirements to clinical and nursing staff through bulletins, meetings, induction, briefings and read-and-sign materials.
Verbatim wording from the response “I have been informed that a bulletin with the key requirements of the Policy for Self-Discharge Against Medical Advice has been prepared for both clinicians and for the nursing staff to heighten awareness of the policy and ensure compliance. This information has been and will be shared/communicated in the following ways:” Source location 2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a more sophisticated audit of hospital information system records to assess information quality and identify discharge-summary failures or delays in real time.
Verbatim wording from the response “The HIS system is audited and work is currently being undertaken to develop a more sophisticated audit system to assess the quality of the information recorded on HIS. As such the Trust is continually seeking to improve its systems to ensure the best care possible for its patients.” Source location 2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign self-discharge codes and conduct monthly audits to verify that discharge letters are sent to patients’ GPs, urgently rectifying omissions.
Verbatim wording from the response “In addition, I believe that the Trust’s medical coders, who attach a code to each patient to help categorise patients to enable data to be collated, now assign a code to any patient who has self-discharged. At the end of each month an audit is conducted of the patients with a self-discharge code to check that a discharge letter has been sent to each patient’s GP. For any patients without a discharge letter, the Division is notified and a letter is sent to the patient’s GP urgently.” Source location 2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing self-discharge policy and electronic discharge system require GP discharge letters for all patients, addressing discharge communication.
Verbatim wording from the response “Please can I assure you that the Trust does have a Policy for “Self-discharge Against Medical Advice”. I enclose a copy of this policy for your information. This version of the Policy was approved in November 2014 and was in place at the time that Mr Ryan was treated at the Trust.” Source location 2017-0225-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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8 Sep 2017 Patricia Forshaw · Prevention of Future Deaths report Manchester West
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Concerns raised 5 Failure to escalate Emergency Department incidents for Serious Incident Review View source Failure to communicate relevant preliminary examination information to Doctors View source Failure to record telephone calls and advice concerning discharged patients View source Ambiguous discharge contact numbers and lack of deterioration advice on appointment cards View source Lack of a formal policy for routine observations and blood investigations during wound review View source See 2 more concerns
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Patricia Forshaw · 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
Patricia Forshaw fell at home, sustaining a full-thickness wound to her right leg, which developed signs of infection. She died in hospital after suffering a cardiac arrest at home. Concerns included unclear discharge information and telephone advice, failures to record or communicate clinical information, lack of routine observations and blood investigations, and inadequate escalation for review.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate Emergency Department incidents for Serious Incident Review
Wider context from the report “iv. The evidence at the Inquest confirmed that there had been a discussion between Consultants in the Emergency Department in relation to the treatment and care of Mrs Forshaw but the treatment and care of Mrs Forshaw had not been escalated as a formal report for consideration of a Serious Incident Review . Accordingly, a Serious Incident Review had not taken place in relation to Mrs Forshaw’s death, although it was accepted that, in retrospect, a Review should have taken place to enable any recommendations to be formalised within the Governance framework.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate relevant preliminary examination information to Doctors
Wider context from the report “ii. The telephone call from the deceased’s husband to the Hospital in the early hours of the 20th October 2016 and the advice to give paracetamol was not recorded in any Hospital records.
Furthermore, the consultation with the Nurse who removed the dressing and who was aware of the deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not bring the information to the attention of the Doctor at the time of his consultation with the deceased.
The evidence at the Inquest indicated that the nurse would not be expected to make a note relating to the above information but she would be expected to mention the information to the Doctor .
████████ commented in his evidence that there had been a “gross miscommunication” in the care of Mrs Forshaw.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record telephone calls and advice concerning discharged patients
Wider context from the report “ii. The telephone call from the deceased’s husband to the Hospital in the early hours of the 20th October 2016 and the advice to give paracetamol was not recorded in any Hospital records.
Furthermore, the consultation with the Nurse who removed the dressing and who was aware of the deceased requiring a blanket because she was cold and also aware of the offensive smelling discharge from the wound, did not record that information in the notes and did not bring the information to the attention of the Doctor at the time of his consultation with the deceased.
The evidence at the Inquest indicated that the nurse would not be expected to make a note relating to the above information but she would be expected to mention the information to the Doctor.
████████ commented in his evidence that there had been a “gross miscommunication” in the care of Mrs Forshaw.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ambiguous discharge contact numbers and lack of deterioration advice on appointment cards
Wider context from the report “i. The telephone number on the card given to the deceased when she was discharged from the Hospital related to appointments only but the purpose of the number is ambiguous and when the deceased’s husband telephoned the number on the card in the early hours of the 20th October 2016 he believed he was speaking to the Emergency Department, particularly in view of the fact that he was given advice to give paracetamol to the deceased.
Evidence was given at the Inquest that the appointment card was the only documentation given to the deceased when she was discharged and the card does not have any information as to the action to be taken if there is a deterioration in a patient’s condition after discharge . The evidence given by ████████ a Consultant in Emergency Medicine at the Hospital was that if there is a deterioration in condition the patient should not be given treatment advice by telephone and the patient should be advised to telephone 111 or return to the Hospital but ████████ accepted that there is no reference to such action on the card .
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a formal policy for routine observations and blood investigations during wound review
Wider context from the report “iii. ████████ accepted that, having heard the evidence of the family at the Inquest, routine observations (pulse, blood pressure, respiratory rate, temperature) and blood investigations should have been conducted when the deceased presented to the Out Patient appointment on the 21st October 2016. ████████ gave evidence that there had been some discussion between Consultants in the Emergency Department and there was mention that there should be a policy for checking routine observations in patients attending Clinic for wound review, particularly where there was an indication of infection . However ████████ confirmed that there was no formal policy in place .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce nurses’ recording of relevant care and notification of reviewing clinicians, including through local nursing induction.
Verbatim wording from the response “All of our nurses are aware of their duty to ensure patient records are accurate and to document relevant information as appropriate. However I understand that a notification has been circulated to all nursing staff by the Matron for Unscheduled Care to reiterate the requirement for nurses to document in the patient’s notes any relevant care or treatment provided. The Clinical Director for Emergency Care will inform all the Consultants of this issue and this matter will also be discussed at the Clinical Governance Meeting. I have also been informed that this notification will be incorporated into the ongoing local induction for nursing staff.” Source location 2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update outpatient appointment cards with advice to contact NHS 111 or a GP if the patient’s condition deteriorates.
Verbatim wording from the response “information to be ambiguous. I am aware that the Trust’s outpatient appointment card is to be updated to include advice for patients to contact NHS 111 or their GP if their condition deteriorates.” Source location 2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss wound infection and sepsis awareness with Emergency Care Consultants and incorporate their feedback on routine observations.
Verbatim wording from the response “████████ has discussed Mrs Forshaw’s care at a meeting of the Emergency Care Consultants to heighten awareness of wound infection and sepsis and to gather feedback from the senior Consultants in relation to routine observations; this senior opinion has been incorporated into this response.” Source location 2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A formal outpatient policy for routine observations cannot be implemented because patients and symptoms do not fit clearly defined categories.
Verbatim wording from the response “to implement a formal policy or standard operating procedure for conducting routine observations on patients in the Outpatients Clinic. Unfortunately patients and their symptoms do not fit into clearly defined categories as to when observations are required and when they are not. Patients attend with a vast range of symptoms and as such, the standard practice at WWL is for the clinician to examine the patient, consider their presentation and determine the treatment and advice to be given on the basis of their clinical judgment. I do not believe this is out of line with the procedure followed at all other NHS Trusts.” Source location 2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinical judgment, sepsis guidelines and observations or blood investigations where appropriate are considered sufficient for outpatient patients showing clear infection signs.
Verbatim wording from the response “to implement a formal policy or standard operating procedure for conducting routine observations on patients in the Outpatients Clinic. Unfortunately patients and their symptoms do not fit into clearly defined categories as to when observations are required and when they are not. Patients attend with a vast range of symptoms and as such, the standard practice at WWL is for the clinician to examine the patient, consider their presentation and determine the treatment and advice to be given on the basis of their clinical judgment. I do not believe this is out of line with the procedure followed at all other NHS Trusts.” Source location 2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The clinician did not consider the patient’s presentation to show clear infection warranting routine observations and blood tests.
Verbatim wording from the response “████████ has confirmed that he did not, in his clinical judgment based on Mrs Forshaw’s presentation on 22 October, consider her to be showing clear signs of infection which warranted routine observations and blood to be taken. ████████ impression of Mrs Forshaw’s presentation was one of localised wound infection. I have been assured that the clinical staff in the Outpatient Clinic are very aware of the Trust’s sepsis guidelines and trigger the sepsis pathway whenever required.” Source location 2017-0262-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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23 Nov 2016 Patrick Richard Steer · Prevention of Future Deaths report Manchester West
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Concerns raised 1 Failure of communication between specialist teams caring for patients under shared care View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Patrick Richard Steer · 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
Patrick Richard Steer was admitted with abdominal pain, found to have a cancerous bowel tumour, and underwent surgery. He subsequently suffered a myocardial infarction and developed a right sub hepatic abscess before his condition deteriorated and he died. The principal concern was poor communication between the Surgical and Coronary Care teams when patients were under shared care, which could affect treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between specialist teams caring for patients under shared care
Wider context from the report “I have concerns with regard to the following:
i. That in circumstances where a patient is under the care of both the Surgical and Coronary Care teams, communication between the Doctors of those teams does not work well and could affect the treatment a patient receives which could lead to a future death.
” Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the shared-care actions through the Quality and Safety Committee with updates every two months.
Verbatim wording from the response “Continued Monitoring” Source location 2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a shared-care guidance note reminding clinical staff of their communication responsibilities.
Verbatim wording from the response “However it is accepted that there are occasions when shared care is not as easy, particularly when important changes to a daily basis. This can be challenging in terms of communication between teams, and it is then crucial that teams agree some fundamental principles such as ceilings of care, and who communicates directly with the patient and families.” Source location 2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss shared-care communication concerns at the Trust’s Clinical Advisory Board.
Verbatim wording from the response “The concerns you raised in respect of shared care were also discussed at the Trust’s Clinical Advisory Board (CAB) on 7 December 2016 by senior members of the Medical Directors and is attended by senior representatives from the various clinical areas.” Source location 2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute the approved shared-care guidance to clinical staff and upload it to the Trust’s policy library.
Verbatim wording from the response “In that respect the ████████ Responsible Officer, ████████ was asked to draft a guidance note in respect of shared care that could be circulated within the Trust to remind clinical staff of their responsibilities. I enclose a draft guidance note that is being discussed at the next Clinical Advisory Board on 18 January 2017.” Source location 2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Daily reviews and documented management plans provided sufficient shared-care communication, so direct discussion was not indicated.
Verbatim wording from the response “I however confirmed that Mr Ster received daily reviews from both teams (surgical and cardiac), however no direct communication took place between the two teams. The documentation to indicate that either team had encountered any difficulties in attempting to communicate with the other. Both teams were able to review and comment on each others’ documented management plans.” Source location 2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The absence of direct communication between surgical and cardiology teams did not contribute to the deceased’s death.
Verbatim wording from the response “Having reviewed the clinical records, ████████ is satisfied that the absence of direct communication between the two clinical teams did not contribute to the deceased’s demise; it appears that both teams were satisfied with each other’s management plans and documentation, and therefore there was no indication to have direct discussion.” Source location 2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Much shared-care communication responsibility rests with clinicians’ obligations under the GMC’s Good Medical Practice guidance.
Verbatim wording from the response “Following discussions at the Trust’s Clinical Advisory Board, it was agreed that much of the requirement for communication within shared care falls under the remit of the GMC’s (General Medical Council) Good Medical Practice which clinicians are required to adhere to. Under section 11, in respect of communication within and between the GMC states as follows:” Source location 2016-0427-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
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15 Jul 2016 Margaret Mary Gleeson · Prevention of Future Deaths report Manchester West
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Concerns raised 3 Lack of understanding of MEWS tool use View source Insufficient weekend staffing capacity View source Failure to accurately score MEWS tools on medical charts View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Margaret Mary Gleeson · 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 Mary Gleeson underwent elective incisional hernia repair and sustained a tear to her mesentery, after which her condition deteriorated and she developed sepsis. She suffered a cardiac arrest during further surgery and died on 4 October 2015; concerns included weekend staffing levels and inaccurate or poorly understood use of the MEWS tool.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of MEWS tool use
Wider context from the report “2. The scoring of the MEWS tool on the medical charts had been done inaccurately, and the use of the MEWS tools did not appear to be clearly understood . It would appear that refresher training would assist
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient weekend staffing capacity
Wider context from the report “1. At the weekend on the call team had to do the job of 4 teams and that it was not possible to provide patients with the care they deserve . In those circumstances, I consider that staffing levels should be reviewed.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately score MEWS tools on medical charts
Wider context from the report “2. The scoring of the MEWS tool on the medical charts had been done inaccurately , and the use of the MEWS tools did not appear to be clearly understood. It would appear that refresher training would assist
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a monthly Task and Finish Group to oversee MEWS use, audit findings, compliance and scoring accuracy.
Verbatim wording from the response “In addition to this, the Trust’s Director of Nursing, ████████, has established since the inquest, and is currently chair of, a dedicated Task and Finish Group to oversee the use of the MEWS Tool. The Group meets on a monthly basis to discuss the audit findings and to monitor compliance and accuracy of scoring.” Source location 2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monthly deterioration, MEWS and fluid-balance training for staff involved in patient care.
Verbatim wording from the response “Since the conclusion of the inquest in June 2016 the Trust has provided extensive training programmes both in the accuracy and recording of MEWS and fluid balance, but also in recognising and responding appropriately to the early signs of deterioration in patients, including sepsis. The enclosed Action Plan provides extensive evidence of the training sessions held to date, and those sessions will continue on a monthly basis for all Trust staff involved in patient care.” Source location 2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide extensive staff training on accurate MEWS and fluid-balance recording and recognition and response to patient deterioration, including sepsis.
Verbatim wording from the response “Since the conclusion of the inquest in June 2016 the Trust has provided extensive training programmes both in the accuracy and recording of MEWS and fluid balance, but also in recognising and responding appropriately to the early signs of deterioration in patients, including sepsis. The enclosed Action Plan provides extensive evidence of the training sessions held to date, and those sessions will continue on a monthly basis for all Trust staff involved in patient care.” Source location 2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct monthly audits of nursing compliance with MEWS standards and feed results back to ward and nursing managers.
Verbatim wording from the response “Firstly, with regards to training of the MEWS tool this has been led by the Trust’s Critical Care Outreach Lead, ████████, through the QUEST programme. This programme trains nursing staff on the use of the MEWS tool, and highlights the importance of accurate scoring. A dedicated Critical Care Outreach Nurse also undertakes monthly audits of compliance with MEWS standards. Copies of these audits are embedded within the enclosed Action Plan and the results are fed back to Ward Managers and Heads of Nursing for action to be taken, wherever necessary. They are also monitored through the Trust’s Harm Free Care Board.” Source location 2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit two clinical fellows to provide sufficient clinicians for the additional weekend ward rounds.
Verbatim wording from the response “To ensure there are sufficient clinicians to cover the additional ward rounds, the Trust is in the process of recruiting 2 clinical fellows. One appointment has already been made, and it is hopeful the second appointment will be filled in the upcoming weeks.” Source location 2016-0255-Response-by-Wrighton-Wigan-and-Leigh-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 the QUEST programme to train nursing staff in MEWS use and accurate scoring.
Verbatim wording from the response “Firstly, with regards to training of the MEWS tool this has been led by the Trust’s Critical Care Outreach Lead, ████████, through the QUEST programme. This programme trains nursing staff on the use of the MEWS tool, and highlights the importance of accurate scoring. A dedicated Critical Care Outreach Nurse also undertakes monthly audits of compliance with MEWS standards. Copies of these audits are embedded within the enclosed Action Plan and the results are fed back to Ward Managers and Heads of Nursing for action to be taken, wherever necessary. They are also monitored through the Trust’s Harm Free Care Board.” Source location 2016-0255-Response-by-Wrighton-Wigan-and-Leigh-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 Provide four-hour weekend ward rounds by middle-grade surgeons for elective surgical patients, with concerns reported to on-call consultants.
Verbatim wording from the response “During the inquest evidence was heard that at weekends the surgical on call team were extremely busy which led to patients, on occasions, not always receiving the standard of treatment they should expect. The Directorate of General Surgery recognised the variation in patient care that existed between weekends and weekdays, and action has been taken accordingly.” Source location 2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Open published response
7 Apr 2016 Joyce Carney · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Lack of agreed police-hospital protocols for joint risk assessments and liaison View source Failure of police-hospital liaison and communication during risk assessment of police-supervised hospital patients View source Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff View source Failure of senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital 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
Joyce Carney · 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
Joyce Carney, who had diabetes and dementia, was knocked to the floor in a hospital corridor by another patient running away from Police Officers. She sustained a fractured neck of femur, underwent surgery, developed infections and deteriorated before dying on 11 February 2015. The principal concerns were the lack of communication and joint risk assessment between Police and Hospital staff, and the absence of protocols to protect other patients, visitors, the public and staff when patients are supervised by Police Officers.
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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of agreed police-hospital protocols for joint risk assessments and liaison
Wider context from the report “iv. There are no agreed protocols, policies or procedures between the Greater Manchester Police and the Royal Albert Edward Infirmary, Wigan in relation to joint risk assessments for patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers. Furthermore there is no protocol, in relation to liaison and consultation between the Greater Manchester Police and the Hospital to formulate risk assessments in relation to patients detained at the Hospital under arrest or in the presence of or supervised by Police Officers.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of police-hospital liaison and communication during risk assessment of police-supervised hospital patients
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of risk assessments for police-supervised hospital patients to protect other patients, visitors, members of the public and staff
Wider context from the report “i. When the Patient was moved to Lowton Ward in the Hospital the risk assessment conducted by the Hospital in relation to the location of the Patient in the Ward involved the Bed Manager, the Ward Manager and the Nurses treating the Patient. The risk assessment did not involve, nor include, the Police Officers who were observing a patient. The risk assessment conducted by the Hospital focussed on the safety of the Patient and did not extend to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and members of staff employed in the Hospital.
ii. The risk assessment conducted by Police Officers, in relation to the Patient at the Hospital, focussed on the Patient and the fact that the Patient may seek to leave the Hospital but the assessment did not include any discussions or liaison with Hospital staff. The risk assessment did not include the protection of other patients in the Hospital, visitors to the Hospital, members of the public or staff employed in the Hospital.
iii. There was no liaison or communication between the Police Officers observing the Patient and the Hospital treating the Patient in relation to the layout of the Hospital or with regard to the safety of other patients in the Hospital, visitors to the Hospital, members of the public and staff employed in the Hospital.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of senior police officers to reassess risk after concerns about an agitated patient threatening to leave hospital
Wider context from the report “Furthermore the Officers at the Hospital raised concerns with their Supervising Officer, namely a Sergeant at the Police Station, in relation to the Patient being agitated and threatening to leave the Hospital during the afternoon of the 21st December 2014 but neither the Sargent nor any other senior Officer attended the Hospital to conduct any further risk assessment or to reassess the situation .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and finalise a joint Patient Under Escort Record with GMP, incorporating shared risk assessment and patient management information for escorted patients.
Verbatim wording from the response “Following the conclusion of Mrs Carney’s inquest, ████████ contacted ████████ (Detective Inspector) of GMP and it was agreed that both organisations would work jointly to address the actions outlined at points 1–3 above. The Trust already has a very good relationship with GMP and this would be utilised to formulate the required protocols, policies and procedures for the protection of patients, staff and visitors to the hospital.” Source location 2016-0140-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
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 Roll out training on using the Patient Under Escort Record to staff in A&E and assessment areas.
Verbatim wording from the response “The “Patient Under Escort Record” will be completed by the police officer when they attend the hospital site with the patient. The document will then be completed jointly by GMP and hospital staff throughout the course of the patient’s stay, and will remain with them until discharge. Upon discharge the document will become the property of GMP who will hold it on file to form part of their intelligence of that patient (should it be required in the future).” Source location 2016-0140-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust_Redacted
Open published response
28 Sep 2015 Harry Pryal · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 8 Failure to record advice on medical treatment and care View source Failure of Lakeside Unit clinical notes to identify actions, times and clinicians View source Lack of triage procedures for urgent or unexpected significant x-ray findings View source Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements View source Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement View source Unavailability of electronic access to WWL x-rays for 5BP clinicians View source Unavailability of physiotherapy and occupational therapy for Lakeside Unit patients View source Failure of nominated officers to review the operation and performance of Service Agreements 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
Harry Pryal · 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
Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.
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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record advice on medical treatment and care
Wider context from the report “i. 5BP contact WWL for advise in relation to medical treatment for patients at the Lakeside Unit on a regular basis as a matter of protocol. The Doctors in psychiatry at the Lakeside Unit, are dependent upon such advice for the treatment and care of patients.
The evidence identified that there is no note of the advice in the records maintained by WWL, neither to identify the Doctor giving advice nor the content of the advice . Furthermore evidence was given that this was a situation arising on a nationwide scale. The absence of any notes prevents a record of the advice for the purpose of continuity of treatment and any subsequent referrals , particularly in a case when the Doctor giving the advice is no longer available and further advice is requested by the referring Doctor for medical treatment.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Lakeside Unit clinical notes to identify actions, times and clinicians
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note . The notes were inadequate , particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of triage procedures for urgent or unexpected significant x-ray findings
Wider context from the report “iii. The evidence given by WWL was that there were no time lines in relation to the reporting of x-ray performed at the Leigh Infirmary, other than national timelines , although it was accepted that the Service Agreement provided that “urgent or unexpected significant clinical findings will be communicated to referring clinicians at the time of the Consultant Radiological reporting”. It was accepted if there was an unexpected significant clinical finding it would be necessary to communicate the finding to the referring clinician without delay.
WWL do not have any triage procedures in relation to x-ray examinations so that any “urgent or unexpected significant clinical finding” would not be reported to the referring clinician for some time after the examination . An early triage of the x-ray examination within a short period of the examination would allow any urgent or unexpected significant clinical finding to be communicated to the referring clinician without delay.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Lakeside Unit clinicians to understand x-ray request and urgency requirements
Wider context from the report “v. The evidence at the Inquest revealed that the notes completed by clinicians at the Lakeside Unit, failed to identify the times of actions by them and in one note failed to identify the identity of the clinician making the note. The notes were inadequate, particularly the notes which accompanied Mr Pryal on his transfer from the Lakeside Unit, to RAEI.
The details to be included in a request for x-ray examination and the fact that an urgent x-ray examination required either a telephone call to the Radiologist or a note of priority on the x-ray form did not appear to be understood by clinicians at the Lakeside Unit, and demonstrated a lack of liaison and understanding between the two Trusts, which would be necessary to allow the terms of the Service Agreement to be operated and performed.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 5BP and WWL to maintain a shared understanding and interpretation of the Service Agreement
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1 .
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement. Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place.
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship , even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of electronic access to WWL x-rays for 5BP clinicians
Wider context from the report “iv. 5BP accepted that the Service Agreement provided for web viewing of the x-rays but accepted that the software operated by 5BP does not allow web viewing of x-rays and 5BP did not have network connections to view the x-rays electronically by access to the WWL network . In any event the Consultant Psychiatrist from the Lakeside Unit indicated that the Doctors in her team based at the Lakeside Unit, may not have the expertise to interpret the x-rays on web view and the Doctors would be dependent upon a formal report, either verbal or written, from the Radiologist.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of physiotherapy and occupational therapy for Lakeside Unit patients
Wider context from the report “vi. Evidence was given at the Inquest that there was no physiotherapy or occupational therapy at the Lakeside Unit to deal with the physical health needs of any patients on the Unit . There was no Service Agreement for the provision of physiotherapy and occupational therapy and no understanding as to who would provide such services . The evidence indicated that the Clinical Commissioning Group in Wigan would provide the services and 5BP were not in a position to enter into agreements for the provision of services from elsewhere. Evidence was given by 5BP that the Clinical Commissioning Group in Wigan had not provided services so that the physical health needs of patients in the Lakeside Unit, were not being satisfied in relation to physiotherapy and occupational therapy .
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of nominated officers to review the operation and performance of Service Agreements
Wider context from the report “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1.
The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement . Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place .
The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship, even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh.
During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff that Lakeside Unit patients must be treated as inpatients and update CRIS to reflect that status.
Verbatim wording from the response “In the case of Mr Pryal, the x-rays undertaken by 5BP at Leigh Infirmary were treated the same as if he were based at an out-patient facility. It is acknowledged that there was a lack of understanding by health professionals at the Trust that Lakeside Unit is an inpatient facility. Mr Pryal’s x-rays should have been reviewed as if he was an inpatient, and then they would have been reported sooner.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a standardised transfer proforma recording medical background, referral reasons and prior discussions for transfer between the Trusts.
Verbatim wording from the response “In addition, the Trust has been working with 5BP to create a standardised proforma for use on transfers between the two organisations (please see Appendix 1). The proforma, setting out the patient’s medical background, reason for referral, and any prior discussions, would be sent upon transfer and kept within the medical records. Both Trusts are looking to pilot these proformas following approval from the respective clinical committees.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-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 Train reporting radiographers to interpret chest x-rays and expand specialist radiographer reporting capacity.
Verbatim wording from the response ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-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 a joint review of the Radiology Service Agreement to place patient safety at the centre of its specification.
Verbatim wording from the response “Shortly following the conclusion of Mr Pryal’s inquest, discussions were held regarding the interpretation of the Service Agreement for Radiology between the two organisations. Leading on these discussions for the Trust has been ████████ (Associate Director of Finance) and Andrew Beatty (Radiology Directorate Manager), with ████████ (Contract Manager for 5BP).” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-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 Provide weekday hot reporting of x-rays as soon as possible after examination.
Verbatim wording from the response ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-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 Grant secure web-based access to diagnostic reports for authorised 5BP health professionals.
Verbatim wording from the response “Following discussions with 5BP, it was agreed that the Trust would grant secure web based viewing for all diagnostic reports via a secure system which can be accessed by an agreed username and password. It will be decided by 5BP which of their health professionals has access to this system. This is an interim measure until further developments can be made via the Trust’s HIS system which is due to be implemented next year.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-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 5BP will decide which of its health professionals receive access to the secure system for viewing diagnostic reports.
Verbatim wording from the response “Following discussions with 5BP, it was agreed that the Trust would grant secure web based viewing for all diagnostic reports via a secure system which can be accessed by an agreed username and password. It will be decided by 5BP which of their health professionals has access to this system. This is an interim measure until further developments can be made via the Trust’s HIS system which is due to be implemented next year.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-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 Hot reporting is not available at weekends because of resource constraints.
Verbatim wording from the response ““Hot reporting” has also been in place since early 2015 during week days. This means that x-rays are reported “as close to immediately as possible following the x-ray being undertaken” (unless the referring clinician is able to review and interpret them directly). This is currently not in place at weekends due to lack of resources. However reporting radiographers are currently being trained to interpret chest x-rays. One has already been trained and funding is in place for another.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-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 health professional seeking advice is responsible for ensuring a full and accurate record of the clinical advice received.
Verbatim wording from the response “According to the General Medical Council, and Royal College guidance, there is a duty on the health professional seeking the advice to ensure a full and accurate record is kept. I note a directive has been given to clinicians within 5BP to ensure all clinical advice received is fully recorded, and for the documentation to include the health professional’s name, grade and contact details.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Documenting external referral discussions contemporaneously is difficult because calls occur during clinical duties and patients often lack accessible Trust records.
Verbatim wording from the response “I am advised that the Trust’s Medical Registrar on-call receives approximately 60 to 70 bleeps a day during his 12 hour shift. The majority of those relate to internal queries; however around 5-10% are telephone referrals from external providers, (such as 5BP, GPs, and other NHS hospitals). Often these calls are taken whilst the health professional is on a ward undertaking clinical duties, therefore making it difficult for a note to be made of that discussion, especially as these calls do not relate to patients currently being treated within the Trust.” Source location 2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
Open published response
19 Dec 2013 Kenneth Smalley · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 6 Handset emergency stop buttons failing to operate independently when other handset parts are damaged View source Inadequate staff training and auditing of pre-operative equipment checks View source Pre-operation checks failing to assess handset function, condition, seals and position View source Inspection procedures failing to identify handset damage and secure immediate replacement View source Failure to share investigation information with interested agencies promptly View source Failure to review operating tables and handsets used at the Hospital 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
Kenneth Smalley · 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
Kenneth Smalley died after surgery to remove an infected aortic graft and repair an aortoduodenal fistula. During the surgery, an operating table moved uncontrollably and its emergency stop button did not work; later, bleeding from splenic lacerations required a splenectomy, and he deteriorated and died. Concerns included the safety, inspection, maintenance, positioning and checking of operating-table handsets, staff training and auditing, and the sharing of investigation findings between relevant organisations.
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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Handset emergency stop buttons failing to operate independently when other handset parts are damaged
Wider context from the report “(3) I have concerns with regard to the Eschmann Group in relation to a review of the operation of handsets attached to operating tables in view of the number of unexplained and uncontrolled movements of operating tables with particular reference to the isolation of the emergency stop button on the handsets to ensure that the emergency stop button operates in all circumstances when there is damage to other parts of the handset .
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training and auditing of pre-operative equipment checks
Wider context from the report “(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to
i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013.
ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress.
iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets.
iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections .
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Pre-operation checks failing to assess handset function, condition, seals and position
Wider context from the report “(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to
i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013.
ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress.
iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets.
iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inspection procedures failing to identify handset damage and secure immediate replacement
Wider context from the report “(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to
i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013.
ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress.
iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets .
iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections.
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share investigation information with interested agencies promptly
Wider context from the report “(4) I have concerns with regard to the Medicines and Healthcare Products Regulatory Agency in relation to contact with all interested Agencies following an investigation to ensure the sharing of information with all interested Agencies particularly to enable lessons to be learned and corrective action to be taken as soon as possible .
” 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 Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to review operating tables and handsets used at the Hospital
Wider context from the report “(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to
i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013.
ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress.
iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets.
iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold the arranged discussion with the MHRA to strengthen future communication and information sharing.
Verbatim wording from the response “We note in your letter your concerns about communications between the Medicines and Healthcare Products Regulatory Agency and the Trust. We have contacted the MHRA to request a discussion to strengthen communication and sharing of information in the future. We are pleased to confirm that this has been arranged for Monday 10 February 2014.” Source location 2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and disseminate a theatre-preparation procedure requiring operating-table checks before daily lists.
Verbatim wording from the response “A Standard Operating Procedure for the preparation of Theatres prior to commencement of their daily list was ratified and disseminated in December 2013. Checks on the theatre tables must be performed as part of this SOP.” Source location 2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a daily checklist for critical equipment across all theatres, with sign-off and monthly auditing.
Verbatim wording from the response “In addition we have developed a daily checklist for all critical equipment, in all theatres across the trust, which must be signed by the person performing the checks and audited on a monthly basis. The disciplinary procedure for non compliance is quite clear within the ‘Preparation of RAEI & Leigh Theatres SOP’. This policy is currently under review to include Wrightington Theatres.” Source location 2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a theatre-staff training system and matrix covering medical-device competence, compliance records, assessments and manufacturer guidance.
Verbatim wording from the response “We have reviewed our staff training and now have a more robust system and matrix for training theatre staff maintaining records of training compliance. Building on the self assessment packs developed within the Trust for medical devices we have expanded our data base within theatres to cover all medical devices including medium and low risk items. Staff are assessed on competence and knowledge of devices and further training given as required. The medical device packs also include manufacturer’s user instructions and cleaning instructions.” Source location 2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and complete safety checks of all operating tables using Trust checklists based on manufacturer manuals.
Verbatim wording from the response “The Trust has four different types of powered operating theatre tables in use and a total of twenty-four units. All theatre tables are maintained via external maintenance contracts. Since this incident, the Trust has developed its own checklist for each type of table based on the Manufacturers User Manuals. The Trusts own qualified Medical Engineering Technicians have undertaken thorough checks of all operating tables against these checklists to confirm their safety for use. The completed checklists will be attached to work orders as evidence of the findings should remedial actions be required.” Source location 2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the theatre-preparation procedure to extend it to Wrightington Theatres.
Verbatim wording from the response “In addition we have developed a daily checklist for all critical equipment, in all theatres across the trust, which must be signed by the person performing the checks and audited on a monthly basis. The disciplinary procedure for non compliance is quite clear within the ‘Preparation of RAEI & Leigh Theatres SOP’. This policy is currently under review to include Wrightington Theatres.” Source location 2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing maintenance contracts and theatre preparation checks are considered sufficient to identify damage to operating tables and handsets.
Verbatim wording from the response “As outlined above, all operating tables are covered by external maintenance contracts. The two RX Eschmann tables have been serviced since the incident by the contracted provider, Eschmann Group in addition to the Trusts own inspection outlined previously.” Source location 2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations