11 Mar 2026 Malcolm WELCH · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 1 Inconsistent provision of assessed mobility aids during hospital admissions View source
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AI-generated summary
Malcolm WELCH · 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
Malcolm WELCH, who had a history including prostate cancer, pulmonary fibrosis and falls, suffered an unwitnessed fall in hospital on 22 January 2025, sustaining right-sided rib fractures. He developed pneumonia and deteriorated after discharge, dying at home on 22 February 2025. The principal concern was inconsistent provision of mobility aids when patients were transferred between hospital wards, creating a risk of future deaths.
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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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent provision of assessed mobility aids during hospital admissions
Wider context from the report “During the course of the inquest, evidence was heard from Ward Manager ████████ the Ward Manager from Ward 35. She confirmed that it was unlikely that the deceased had been provided with his allocated walking frame on admission to Ward 35; the clinical notes did not refer to him having been provided with that mobility aid. The evidence of ████████ was that even if a walking frame had been allocated to a patient at an earlier stage in the hospital admission process, that walking frame would not automatically follow the patient on their onward journey onto other wards or other areas of the hospital . The evidence was that a reassessment would be undertaken on admission to a new ward and a decision would then be taken in relation to the provision of such mobility aids. In this case, it is likely that the deceased had been on Ward 35 for around 2 hours and 40 minutes and he still had not been provided with an allocated walking frame for his own use. Whilst it cannot be said that this lack of a walking frame contributed to the deceased’s fall, given that he likely used a frame belonging to someone else, it is a matter of concern that a patient could be admitted onto a ward without being provided with the mobility aids that they had been previously assessed as needing at the hospital and which had been allocated to that patient at an earlier stage in the hospital admission process . I am therefore concerned about the consistency of the provision of such mobility aids during the course of a patient’s admission . I am concerned that this creates a risk of future deaths to other patients in circumstances where they are transferred onto wards without them having the mobility aids which they have been assessed as requiring, and with which they have already been provided at an earlier stage whilst in hospital .
” 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 Deliver and disseminate a Learning from Falls briefing on walking-aid provision, including discussion with Falls Champions.
Verbatim wording from the response “In response to this case the monthly Learning from Falls briefing focused on the provision of” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
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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 Ward-level walking-aid stocks and access on each ward are relied on to manage mobility needs without transferring aids between wards.
Verbatim wording from the response “Across York & Scarborough NHS Foundation Trust, each inpatient ward has their own stock of walking aids (mix of rollator frames and walking sticks) which are available for their patients to use during their inpatient stay. When a patient is assessed as needing a walking aid to support their mobility in the hospital, this is initially provided by each ward from the ward stock. The aid will then be accessible within the bay and in reach for the patient whilst they are on that ward.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
Open published response
Concerns raised 3 Failure to undertake interval cardiac scans or echocardiograms to check for deterioration View source Lack of a standard operating process for referring HOCM patients View source Failure to recognise the greater role of heart failure in deterioration View source
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Thomas Colin Morrell · 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
Thomas Colin Morrell had hypertrophic obstructive cardiomyopathy and was admitted to hospital in October 2024 after initially being treated for abdominal issues before being found to be in heart failure. He underwent heart transplantation, which was complicated by massive bleeding and irreversible failure of the transplanted heart; support was withdrawn and he died on 3 December 2024. Concerns included delayed recognition of heart failure and the absence of a standard operating process for referring HOCM patients, as well as a lack of cardiac imaging between 2021 and 2024 to monitor deterioration.
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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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake interval cardiac scans or echocardiograms to check for deterioration
Wider context from the report “(2) In 2019 an echocardiogram showed no changes to Mr Morrell's heart but by 6 July 2021 a cardiac MRI scan showed focal hypertrophy and patchy scarring within the heart, with functional impairment in the mild to moderate range. On 16 October 2024 an echocardiogram showed severe biventricular failure. There were no scans / echocardiograms undertaken between those dates to check for deterioration . Had the deterioration been detected sooner, I was told in evidence that there may have been an earlier opportunity to intervene prior to deterioration into end stage heart failure, which may have improved the prospects of surgical intervention.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard operating process for referring HOCM patients
Wider context from the report “(1) Following Mr Morrell's emergency admission to Scarborough Hospital on 8 October 2024, heart failure (as opposed to abdominal issues) played a greater role in his deterioration than was initially recognised by the treating clinicians. Had this been recognised sooner, Mr Morrell could have been transferred to the Freeman Hospital more quickly. There was not a standard operating process in place for Hypertrophic Obstructive Cardiomyopathy (HOCM) patients covering when to refer patients in such 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the greater role of heart failure in deterioration
Wider context from the report “(1) Following Mr Morrell's emergency admission to Scarborough Hospital on 8 October 2024, heart failure (as opposed to abdominal issues) played a greater role in his deterioration than was initially recognised by the treating clinicians . Had this been recognised sooner, Mr Morrell could have been transferred to the Freeman Hospital more quickly . There was not a standard operating process in place for Hypertrophic Obstructive Cardiomyopathy (HOCM) patients covering when to refer patients in such circumstances.
” 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 Circulate guidance to relevant clinicians emphasising timely referral of appropriate patients to a transplant centre.
Verbatim wording from the response “We recognise that timely referral of appropriate patients to a transplant centre is an important step in management and have circulated this message to relevant clinicians. We have a well-established working relationship with the transplant centre in Newcastle including open communication on cases where we have concerns. For example, as part of this relationship, members of the Newcastle team presented to our cardiology governance meeting in autumn 2025.” Source location Response from York Scarborough Hospital
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25 Sep 2025 Pamela Ann HONEYBONE · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 12 Failure to check CT scan outcomes before patient discharge View source Failure to identify and preserve the accounts of staff directly involved in errors View source Failure to positively identify patients during treatment encounters View source Continuing risk from patient misidentification View source Unavailability of radiology transfer checklists at the York site View source Failure to positively identify patients before radiology transfer and CT scanning View source Delays in conveying recognised scanning errors to treating teams View source Lack of designated responsibility for radiology transfer checklists out of hours View source Delays in auditing compliance with patient identification processes View source Failure of investigations to identify and question relevant medical team members View source Delays in commencing investigations and after-action reviews of recognised errors View source Delays in responding to identified errors View source See 9 more concerns
Responses linked to these concerns
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AI-generated summary
Pamela Ann HONEYBONE · 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
Pamela Ann Honeybone was admitted to Scarborough General Hospital after a fall and died there on 19 October 2024 after being moved to end-of-life care. Another patient with the same first name underwent her required CT scan in error, delaying diagnosis of an abdominal mass suggestive of lymphoma; the inquest concluded that it was not possible to determine whether this contributed to her death. The report identified continuing patient-safety risks from patient misidentification, delayed responses to recognised errors, incomplete investigation, and gaps in patient-identification processes.
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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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to check CT scan outcomes before patient discharge
Wider context from the report “1. It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question. No transfer checklist was completed, and the patient was not asked to complete and/or sign the CT scanning questionnaire herself. No member of staff inquired as to the outcome of this patient's CT scan prior to her discharge a few hours later .
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and preserve the accounts of staff directly involved in errors
Wider context from the report “3. As a result of the delay at 2 above, a Trust investigation did not commence until late November 2024. No prompt after action review therefore occurred in the hours and days after the error was recognised. When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events .
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to positively identify patients during treatment encounters
Wider context from the report “5. An Action Plan was drawn up as a result of the Trust investigation, but for various reasons no audit of compliance with patient identification processes commenced until early August 2025, some ten months after Mrs Honeybone's death. The results of the audit thus far were made available to me at inquest and indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified .
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Continuing risk from patient misidentification
Wider context from the report “7. I consider the above represent a continuing risk to others from misidentification and delayed responses to identified errors, with clear implications for patient safety.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of radiology transfer checklists at the York site
Wider context from the report “6. I heard evidence that while radiology transfer checklists are routinely completed 'in hours' at Scarborough Hospital when a dedicated HCA is on duty to perform this task, no such checklist is in use at the Trust's York site at any time of the day . Mrs Honeybone's misidentification occurred 'out of hours' at Scarborough when no designated person assumes responsibility for this task at that site.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to positively identify patients before radiology transfer and CT scanning
Wider context from the report “1. It was accepted in evidence that neither the doctor who escorted the wrong patient from the Emergency Department to radiology, nor the radiographer who undertook the CT scan on her, checked the identity of the patient in question . No transfer checklist was completed , and the patient was not asked to complete and/or sign the CT scanning questionnaire herself . No member of staff inquired as to the outcome of this patient's CT scan prior to her discharge a few hours later.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in conveying recognised scanning errors to treating teams
Wider context from the report “2. The scanning error was recognised by a radiologist on the 15th of October 2024, but was not conveyed to Mrs Honeybone's treating team until late October , by which time she had died and her death had been scrutinised by the Medical Examiner and certified by her treating doctor as wholly natural and not requiring referral to the Coroner.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of designated responsibility for radiology transfer checklists out of hours
Wider context from the report “6. I heard evidence that while radiology transfer checklists are routinely completed 'in hours' at Scarborough Hospital when a dedicated HCA is on duty to perform this task, no such checklist is in use at the Trust's York site at any time of the day. Mrs Honeybone's misidentification occurred 'out of hours' at Scarborough when no designated person assumes responsibility for this task at that site .
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in auditing compliance with patient identification processes
Wider context from the report “5. An Action Plan was drawn up as a result of the Trust investigation, but for various reasons no audit of compliance with patient identification processes commenced until early August 2025, some ten months after Mrs Honeybone's death . The results of the audit thus far were made available to me at inquest and indicate that 1 in 5 audited treatment encounters between staff of all grades and specialisms still occur without the patient being positively identified.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of investigations to identify and question relevant medical team members
Wider context from the report “4. Despite hearing evidence that it was a doctor who would have escorted the wrong patient to scanning, the Trust investigation focused on nursing involvement with the patients in question and did not seek to identify and question medical team members .
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in commencing investigations and after-action reviews of recognised errors
Wider context from the report “3. As a result of the delay at 2 above, a Trust investigation did not commence until late November 2024 . No prompt after action review therefore occurred in the hours and days after the error was recognised . When the Trust investigation did commence, staff directly involved either could not be identified or had no recollection of events.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to identified errors
Wider context from the report “7. I consider the above represent a continuing risk to others from misidentification and delayed responses to identified errors , with clear implications for patient safety.
” 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 Audit compliance with the patient identification policy regularly.
Verbatim wording from the response “In addition, it is reassuring to note, in relation to the audit results presented at inquest by Matron ████████, there has been a significant improvement in positive patient identification in more recent audits following Trust wide communication reminding staff of the importance of positive patient identification. This policy is also subject to regular audit to confirm compliance.” Source location Response from York and Scarborough 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 Embed the Patient Safety Incident Response Framework within Trust processes.
Verbatim wording from the response “We acknowledge that there was some delay in further investigations being carried out into the circumstances of the radiological error and this meant valuable witness evidence was not included. At the time of Mrs Honeybone’s death the Trust was in the early stages of implementing the Patient Safety Incident Response Framework (PSIRF). This framework is now embedded and if a similar incident occurred it would be likely that a hot debrief or after-” Source location Response from York and Scarborough 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 Review the patient identification policy and strengthen adherence using learning from the case.
Verbatim wording from the response “The Trust has an Identification of Patients policy in place. This has recently been reviewed and findings from this case have been used to strengthen adherence to the identification process.” Source location Response from York and Scarborough NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete development and governance review of a standardised checklist for all radiological transfers.
Verbatim wording from the response “The action in the Patient Safety Incident Investigation (PSII) report to standardise the radiology transfer checklist is almost complete. It was acknowledged that the CT transfer checklist in place at the time of Mrs Honeybone’s admission was not robust and not in place across the Trust. It was agreed that a transfer checklist was needed for all radiological investigations, not just CT scans. The checklist has been drafted and reviewed in consultation with the wider Radiology and nursing team and a final draft is awaiting sign off at the Radiology Governance Board. The checklist is due to be published and deployed for use at the end of November 2025.” Source location Response from York and Scarborough 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 Monitor checklist compliance through Radiology clinical governance meetings and escalate issues to the Care Group Board.
Verbatim wording from the response “Radiographers will be empowered to decline investigations if the checklist is not complete. This will be monitored at the Radiology clinical governance meetings and escalated to the Cancer Specialist & Support Services Care Group Board.” Source location Response from York and Scarborough 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 Obtain approval, publish and deploy the standardised radiology transfer checklist for use.
Verbatim wording from the response “The action in the Patient Safety Incident Investigation (PSII) report to standardise the radiology transfer checklist is almost complete. It was acknowledged that the CT transfer checklist in place at the time of Mrs Honeybone’s admission was not robust and not in place across the Trust. It was agreed that a transfer checklist was needed for all radiological investigations, not just CT scans. The checklist has been drafted and reviewed in consultation with the wider Radiology and nursing team and a final draft is awaiting sign off at the Radiology Governance Board. The checklist is due to be published and deployed for use at the end of November 2025.” Source location Response from York and Scarborough NHS Trust
Open published response
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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 Report identified discrepancies through Datix within 24 hours and ensure daily governance review alerts the relevant clinical team.
Verbatim wording from the response “Going forward, where a discrepancy is identified, this will be reported via Datix ideally within 24 hours. Incidents are reviewed daily by Care Group governance teams and therefore can ensure the relevant clinical team will be made aware of a potential issue within 24hrs during the working week and 72hrs, at worst, over the weekend period. This will alert to the need for multidisciplinary discussion and investigation.” Source location Response from York and Scarborough 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 Empower radiographers to decline radiological investigations when the transfer checklist is incomplete.
Verbatim wording from the response “Radiographers will be empowered to decline investigations if the checklist is not complete. This will be monitored at the Radiology clinical governance meetings and escalated to the Cancer Specialist & Support Services Care Group Board.” Source location Response from York and Scarborough NHS Trust
Open published response
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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 Communicate Trust-wide reminders to staff about the importance of positive patient identification.
Verbatim wording from the response “In addition, it is reassuring to note, in relation to the audit results presented at inquest by Matron ████████, there has been a significant improvement in positive patient identification in more recent audits following Trust wide communication reminding staff of the importance of positive patient identification. This policy is also subject to regular audit to confirm compliance.” Source location Response from York and Scarborough NHS Trust
Open published response
30 Jul 2025 Joanne Louise STONES · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 6 Failure to document consideration of relevant diagnoses in treatment plans View source Failure to liaise with relevant specialist clinicians View source Failure to prioritise and place seriously ill pre-alerted patients in Resus on arrival View source Delays in administering fluids View source Delays in treating hypoglycaemia View source Failure to identify and make visible patients’ relevant diagnoses to the treating team View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joanne Louise STONES · 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
Joanne Louise Stones, who had Anti-Phospholipid Syndrome and Addison’s Disease, was admitted with abdominal pain and diagnosed with acute cholecystitis with gallstones. Her condition deteriorated and she died in intensive care on 17 September 2023. Concerns included delays in prioritisation, treatment with fluids and antibiotics, recognition of her Addison’s Disease, and consideration of her underlying conditions in her treatment plan.
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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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document consideration of relevant diagnoses in treatment plans
Wider context from the report “(3) It was not clear from the medical notes that staff treating Joanne had considered the relevance of her APS and AD in her treatment plan.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to liaise with relevant specialist clinicians
Wider context from the report “(1) The ambulance service pre-alerted the hospital regarding Joanne’s serious condition but this did not result in her being prioritised and placed in Resus on arrival. Joanne was wearing two medic alert bracelets to draw attention to her diagnoses of APS and AD but these were not observed by the treating team. There were no visible ‘red flags’ on Joanne’s medical records, highlighting her APS and AD diagnoses to the treating team. The treating doctor relied on a very sick patient to confirm any underlying medical conditions. There was no liaison with Rheumatology, who had extensive knowledge and experience of Joanne and how to treat her conditions.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise and place seriously ill pre-alerted patients in Resus on arrival
Wider context from the report “(1) The ambulance service pre-alerted the hospital regarding Joanne’s serious condition but this did not result in her being prioritised and placed in Resus on arrival. Joanne was wearing two medic alert bracelets to draw attention to her diagnoses of APS and AD but these were not observed by the treating team. There were no visible ‘red flags’ on Joanne’s medical records, highlighting her APS and AD diagnoses to the treating team. The treating doctor relied on a very sick patient to confirm any underlying medical conditions. There was no liaison with Rheumatology, who had extensive knowledge and experience of Joanne and how to treat her conditions.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in administering fluids
Wider context from the report “(2) There was delay in Joanne receiving fluids , which led to hypoglycaemia which was then not treated promptly.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in treating hypoglycaemia
Wider context from the report “(2) There was delay in Joanne receiving fluids, which led to hypoglycaemia which was then not treated promptly .
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and make visible patients’ relevant diagnoses to the treating team
Wider context from the report “(1) The ambulance service pre-alerted the hospital regarding Joanne’s serious condition but this did not result in her being prioritised and placed in Resus on arrival. Joanne was wearing two medic alert bracelets to draw attention to her diagnoses of APS and AD but these were not observed by the treating team. There were no visible ‘red flags’ on Joanne’s medical records, highlighting her APS and AD diagnoses to the treating team. The treating doctor relied on a very sick patient to confirm any underlying medical conditions. There was no liaison with Rheumatology, who had extensive knowledge and experience of Joanne and how to treat her conditions.
” 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 through the learning-on-a-postcard system to check electronic alerts and patients’ medic-alert bracelets.
Verbatim wording from the response “The action that we will take to resolve these issues going forward is two-fold: we have reminded all staff of the importance of checking alerts on CPD and medic-alert bracelets on the patient by means of our “learning on a postcard” system. In addition, we are in the process of implementing a new electronic patient record system (known as Nervecentre) and we will ensure that the alerts on this system have improved visibility, in order to maximise the chance of clinicians seeing and acting on these alerts.” Source location Response from York and Scarborough Teaching Hospitals
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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 Automatically transfer point-of-care blood glucose results into the electronic patient record and Emergency Department whiteboard.
Verbatim wording from the response “It was identified in the Serious Incident Investigation report that the failure to identify Ms Stones’ hypoglycaemia was a significant failing when she presented acutely on her final attendance. The Trust has already implemented two actions designed to reduce the risk of a low blood sugar being missed/not actioned in future patients. These actions are to:” Source location Response from York and Scarborough Teaching Hospitals
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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 Operate the new Urgent and Emergency Care Centre with four resuscitation rooms and an expanded five-bay First Assessment area.
Verbatim wording from the response “In terms of potential risk for future patients, the Emergency Department at Scarborough now occupies a new Urgent and Emergency Care Centre which has been designed with 4 resuscitation room spaces, rather than the 3 that were available in the old department. In addition, the First Assessment space has been expanded to allow 5 bays in the old build. This significantly reduces the risks of delays to initial assessment and treatment of patients arriving in the department from the ambulance service.” Source location Response from York and Scarborough Teaching Hospitals
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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 Implement the Nervecentre electronic patient record with improved visibility of clinical alerts.
Verbatim wording from the response “The action that we will take to resolve these issues going forward is two-fold: we have reminded all staff of the importance of checking alerts on CPD and medic-alert bracelets on the patient by means of our “learning on a postcard” system. In addition, we are in the process of implementing a new electronic patient record system (known as Nervecentre) and we will ensure that the alerts on this system have improved visibility, in order to maximise the chance of clinicians seeing and acting on these alerts.” Source location Response from York and Scarborough Teaching Hospitals
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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 Include clinical alerts in the Emergency Department’s two-day departmental induction.
Verbatim wording from the response “In addition, the subject of alerts is discussed in detail in the ED two-day departmental induction.” Source location Response from York and Scarborough Teaching Hospitals
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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 Reorder blood-gas printout results so blood glucose appears higher and low readings are more readily identified.
Verbatim wording from the response “It was identified in the Serious Incident Investigation report that the failure to identify Ms Stones’ hypoglycaemia was a significant failing when she presented acutely on her final attendance. The Trust has already implemented two actions designed to reduce the risk of a low blood sugar being missed/not actioned in future patients. These actions are to:” Source location Response from York and Scarborough Teaching Hospitals
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 Add a learning-on-a-postcard prompt for clinicians to contact relevant teams for advice in complex cases.
Verbatim wording from the response “It has been identified that there would have been benefit of liaising with Ms Stones’ parent clinical team in Rheumatology (including Dr Morvely) in order to guide her ongoing treatment. Although that would not have been achievable when she presented at the weekend, or at the time of her final attendance on the following weekend (because there is not an out of hours Rheumatology service within the Trust), it would have been possible to get Rheumatology input into Ms Stones’ care during the week. The proposed completed action was to add this to the “learning on a postcard” general message to clinical staff as a prompt to contact other relevant clinicians for advice in complex cases.” Source location Response from York and Scarborough Teaching Hospitals
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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 Adherence to existing Trust Sepsis guidance will ensure fluids are prioritised in unwell patients.
Verbatim wording from the response “Regarding giving fluids, adherence to the Trust Sepsis guidance will ensure that fluids are prioritised in unwell patients such as Ms Stones.” Source location Response from York and Scarborough Teaching Hospitals
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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 Treatment in the First Assessment area was a reasonable alternative because airway management was not required on arrival.
Verbatim wording from the response “At the time of Ms Stones attendance at Scarborough the resuscitation room was full. This sometimes occurs at times of pressure and the “overflow” to the resuscitation room is the First Assessment area. Medical care that is provided in the resuscitation room can be provided to the same level in the First Assessment area, with the exception of airway management and anaesthesia (breathing for the patient if required). Ms Stones did not have a requirement for breathing support at time of arrival in the hospital. Therefore, although the resuscitation room” Source location Response from York and Scarborough Teaching Hospitals
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 Out-of-hours Rheumatology input was not achievable because the Trust had no out-of-hours Rheumatology service.
Verbatim wording from the response “It has been identified that there would have been benefit of liaising with Ms Stones’ parent clinical team in Rheumatology (including Dr Morvely) in order to guide her ongoing treatment. Although that would not have been achievable when she presented at the weekend, or at the time of her final attendance on the following weekend (because there is not an out of hours Rheumatology service within the Trust), it would have been possible to get Rheumatology input into Ms Stones’ care during the week. The proposed completed action was to add this to the “learning on a postcard” general message to clinical staff as a prompt to contact other relevant clinicians for advice in complex cases.” Source location Response from York and Scarborough Teaching Hospitals
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 The hospital computer alert for antiphospholipid syndrome and steroid treatment was present and visible when the patient attended, but was not noted.
Verbatim wording from the response “The only time that Ms Stones’ medical history was referenced in the clinical notes was in the nursing notes when she was referred to the Emergency Assessment Unit for further investigation of her chest (which was subsequently identified as abdominal) pain. The assumption therefore is that the bracelet wasn’t seen, or if it was, its importance wasn’t recognised. The CPD system is designed to remove the computer APD/steroid treatment alert if a patient dies (because of the need to remove the individual from the locality steroid register) and so can’t be seen on CPD at present. However, we are confident that the alert was present and visible when Ms Stones presented at the time, but unfortunately not noted by the treating clinicians. The alerts on CPD are not as obvious as they could be (they are displayed on a tab at the top of the screen in a light blue colour).” Source location Response from York and Scarborough Teaching Hospitals
Open published response
14 Oct 2024 Janet Kathleen SEDDON · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 4 Absence of completed learning and actions following reporting errors View source Delays in clear disclosure of reporting errors to families and the Coroner View source Significant delays in investigating missed radiology reporting errors View source Absence of proper assessment of harm caused by reporting errors View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Janet Kathleen SEDDON · 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
Janet Kathleen Seddon underwent surgery after a CT scan was re-reviewed and found to show abdominal pathology that had not been identified in the initial report. She deteriorated with signs of sepsis and died in hospital on 9 February 2023. Concerns included the delay in identifying the pathology, the absence of a proper assessment of harm, and delays in disclosing the reporting error to her family and the Coroner.
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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of completed learning and actions following reporting errors
Wider context from the report “1. The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs Seddon’s CT scan was initially reported on the 30th of January 2023. I found at inquest that there had been significant progression of Mrs Seddon’s bowel obstruction in the period between the initial report and the subsequent review, and that the delay in identifying her condition more than minimally contributed to her death.
2. The Trust referred Mrs Seddon’s death to the Coroner on the basis that her family was concerned about possible omissions in primary care. Despite the Trust becoming aware of the missed pathology on the 7th of February 2023, it does not appear to have set in motion any process of investigation of the case until approximately September 2023. I was advised that a radiology case could be concluded in October 2023 that there had been a reporting error and that a reasonable body of radiologists would have identified the concerning pathology on the CT scan. This finding was referred to the clinical care group responsible for Mrs Seddon’s care for them to assess whether the error had caused harm to Mrs Seddon, but no such definitive assessment took place and the Trust closed the investigation . As a result, no disclosure was made to Mrs Seddon’s family of the error in accordance with the Trust’s statutory Duty of Candour. The report of the closed investigation, indicating that an error had occurred in the reporting of the scan but no assessment of harm had been made, was not received by the court until February 2024, more than a year after Mrs Seddon’s death.
3. My concerns relate to –
a) the very significant delay in addressing whether the missed abdominal pathology was the result of a reporting error;
b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of the error;
c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner;
d) the absence of evidence that all relevant learning arising from the above has occurred and any actions arising from
such learning have been completed;
e) the potential risk of death to others in the event of a recurrence of any of the above.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in clear disclosure of reporting errors to families and the Coroner
Wider context from the report “1. The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs Seddon’s CT scan was initially reported on the 30th of January 2023. I found at inquest that there had been significant progression of Mrs Seddon’s bowel obstruction in the period between the initial report and the subsequent review, and that the delay in identifying her condition more than minimally contributed to her death.
2. The Trust referred Mrs Seddon’s death to the Coroner on the basis that her family was concerned about possible omissions in primary care. Despite the Trust becoming aware of the missed pathology on the 7th of February 2023, it does not appear to have set in motion any process of investigation of the case until approximately September 2023. I was advised that a radiology case could be concluded in October 2023 that there had been a reporting error and that a reasonable body of radiologists would have identified the concerning pathology on the CT scan. This finding was referred to the clinical care group responsible for Mrs Seddon’s care for them to assess whether the error had caused harm to Mrs Seddon, but no such definitive assessment took place and the Trust closed the investigation. As a result, no disclosure was made to Mrs Seddon’s family of the error in accordance with the Trust’s statutory Duty of Candour . The report of the closed investigation, indicating that an error had occurred in the reporting of the scan but no assessment of harm had been made, was not received by the court until February 2024, more than a year after Mrs Seddon’s death.
3. My concerns relate to –
a) the very significant delay in addressing whether the missed abdominal pathology was the result of a reporting error;
b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of the error;
c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner ;
d) the absence of evidence that all relevant learning arising from the above has occurred and any actions arising from
such learning have been completed;
e) the potential risk of death to others in the event of a recurrence of any of the above.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Significant delays in investigating missed radiology reporting errors
Wider context from the report “1. The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs Seddon’s CT scan was initially reported on the 30th of January 2023. I found at inquest that there had been significant progression of Mrs Seddon’s bowel obstruction in the period between the initial report and the subsequent review, and that the delay in identifying her condition more than minimally contributed to her death.
2. The Trust referred Mrs Seddon’s death to the Coroner on the basis that her family was concerned about possible omissions in primary care. Despite the Trust becoming aware of the missed pathology on the 7th of February 2023, it does not appear to have set in motion any process of investigation of the case until approximately September 2023 . I was advised that a radiology case could be concluded in October 2023 that there had been a reporting error and that a reasonable body of radiologists would have identified the concerning pathology on the CT scan. This finding was referred to the clinical care group responsible for Mrs Seddon’s care for them to assess whether the error had caused harm to Mrs Seddon, but no such definitive assessment took place and the Trust closed the investigation. As a result, no disclosure was made to Mrs Seddon’s family of the error in accordance with the Trust’s statutory Duty of Candour. The report of the closed investigation, indicating that an error had occurred in the reporting of the scan but no assessment of harm had been made, was not received by the court until February 2024, more than a year after Mrs Seddon’s death.
3. My concerns relate to –
a) the very significant delay in addressing whether the missed abdominal pathology was the result of a reporting error ;
b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of the error;
c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner;
d) the absence of evidence that all relevant learning arising from the above has occurred and any actions arising from
such learning have been completed;
e) the potential risk of death to others in the event of a recurrence of any of the above.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of proper assessment of harm caused by reporting errors
Wider context from the report “1. The Trust became aware on the 7th of February 2023 that abdominal pathology requiring urgent assessment had been missed when Mrs Seddon’s CT scan was initially reported on the 30th of January 2023. I found at inquest that there had been significant progression of Mrs Seddon’s bowel obstruction in the period between the initial report and the subsequent review, and that the delay in identifying her condition more than minimally contributed to her death.
2. The Trust referred Mrs Seddon’s death to the Coroner on the basis that her family was concerned about possible omissions in primary care. Despite the Trust becoming aware of the missed pathology on the 7th of February 2023, it does not appear to have set in motion any process of investigation of the case until approximately September 2023. I was advised that a radiology case could be concluded in October 2023 that there had been a reporting error and that a reasonable body of radiologists would have identified the concerning pathology on the CT scan. This finding was referred to the clinical care group responsible for Mrs Seddon’s care for them to assess whether the error had caused harm to Mrs Seddon, but no such definitive assessment took place and the Trust closed the investigation. As a result, no disclosure was made to Mrs Seddon’s family of the error in accordance with the Trust’s statutory Duty of Candour. The report of the closed investigation, indicating that an error had occurred in the reporting of the scan but no assessment of harm had been made, was not received by the court until February 2024, more than a year after Mrs Seddon’s death.
3. My concerns relate to –
a) the very significant delay in addressing whether the missed abdominal pathology was the result of a reporting error;
b) the absence of any proper assessment of harm caused to Mrs Seddon as a result of the error ;
c) the delay in clear disclosure of the error to Mrs Seddon’s family and to the Coroner;
d) the absence of evidence that all relevant learning arising from the above has occurred and any actions arising from
such learning have been completed;
e) the potential risk of death to others in the event of a recurrence of any of the above.
” 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 Establish daily incident review and weekly escalation to Care Group governance leadership.
Verbatim wording from the response “The governance structure within the Care Group, to review incidents, has significantly changed with a daily review of all incidents and weekly escalation process to Care Group Governance Lead (Consultant Anaesthetist) and Associate Chief Nurse.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation 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 Discuss anonymised radiology cases through REALM and monitor reporter participation through annual appraisal.
Verbatim wording from the response “This case was discussed at the Radiology Events and Learning Meeting (REALM) in November 2023. Minutes are not kept as per Royal College of Radiologists guidance and all cases are anonymised, to encourage open discussion. Attendance at REALM is high within the Trust and participation is monitored and discussed at individual reporter’s annual appraisal.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation 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 Revise the Radiology Duty of Candour SOP with assessment procedures and response timeframes for discrepancy and harm-feedback cases.
Verbatim wording from the response “The Trust Radiology Duty of Candour Standard Operating Procedure (SOP) (available should you wish to have sight of this) describes how discrepancies are assessed to establish if radiological errors have occurred and how these are then disclosed to clinicians to evaluate degree of harm and inform duty of candour conversations if required. This SOP is in line with, and applies, national Royal College guidance to our processes. It was last revised in July 2024, before this inquest, and that update included specifying the one-week turnaround timeframe for reporters responding to a candour panel, improving efficiency from the Radiology side of the process, and a two-week response timeframe for treating clinicians to respond to Radiology letters disclosing confirmed radiological errors and requesting feedback on the degree of harm.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation 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 Add weekly Senior Leadership Team review and escalation of discrepancy cases lacking feedback on the level of harm.
Verbatim wording from the response “A governance structure for reporting and escalation was added for discrepancy cases which involves the review of incidents at the weekly Senior Leadership Team (Assistant Chief Nurse, Assistant Chief Operating Officer, Care Group Director and the governance team) meetings, where the lack of feedback on the level of harm can be escalated.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation 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 the incident-response policy requiring a hot debrief or another incident response after relevant incidents.
Verbatim wording from the response “It is to be noted that at the time of the incident the Trust followed its previous policy on incident management. The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged that this incident should have had, under the old policy, a 72-hour report, and this was not undertaken. This has been reviewed within the Surgery Care Group and the new policy requiring either hot debrief or other form of incident response is now in place and is being used to proper effect.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation 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 Update the Incident Management Policy and Compassionate Engagement and Duty of Candour Policy.
Verbatim wording from the response “Following the introduction of the new PSIRF framework the Trust updated the Incident Management Policy and Procedures (March 2024) and its Duty of Candour Policy, now called Compassionate Engagement and Duty of Candour Policy (June 2024) which are available should you wish to have sight of them.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation 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 Submit further Radiology SOP updates for Radiology Directorate review and Care Group Board approval.
Verbatim wording from the response “Further updates to the SOP have been developed to clarify that the receiving treating clinician’s Care Group governance team should be copied into the initial correspondence to the clinician, and if required escalation for feedback on level of harm will take place with the Cancer, Specialist and Support Services (CSCS) Care Group Director contacting the Director of the respective Care Group. This will ensure a more timely outcome regarding level of harm and in turn a duty of candour conversation with patient and/or family with the treating clinician, supported by a radiologist. These updates will be submitted to the next Radiology Directorate Meeting and on approval to CSCS Care Group Board for virtual agreement on 12/12/24.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation 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 PSIRF-based systems to record, monitor, review and learn from incidents across the Trust.
Verbatim wording from the response “It is to be noted that at the time of the incident the Trust followed its previous policy on incident management. The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged that this incident should have had, under the old policy, a 72-hour report, and this was not undertaken. This has been reviewed within the Surgery Care Group and the new policy requiring either hot debrief or other form of incident response is now in place and is being used to proper effect.” Source location Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
Open published response
14 Oct 2024 Stephen Frederick DULLING · Prevention of Future Deaths report North Yorkshire and York
View report summary
Concerns raised 10 Failure to assess and escalate refusal of intravenous fluids View source Failure to establish whether an assessed risk of harm had increased and required emergency intervention View source Failure to explain anticipated police assistance View source Failure to provide practical emergency-care advice to carers View source Failure to ensure the recorded and implemented diet reflects identified nutritional needs View source Delays in undertaking and completing patient safety investigation reviews View source Delayed nursing response to information about choking View source Failure to implement and maintain food charts after malnutrition risk assessment View source Failure to make direct nutritional-needs inquiries of the primary carer View source Failure to debrief choking-incident staff within 72 hours View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Frederick DULLING · 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
Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.
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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and escalate refusal of intravenous fluids
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids ;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish whether an assessed risk of harm had increased and required emergency intervention
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered , nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to explain anticipated police assistance
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance, nor explain what assistance it was considered or anticipated could be provided by the police .
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide practical emergency-care advice to carers
Wider context from the report “1. I heard evidence that on 29 August 2023, the day after Mr Dulling had been assessed at home by two members of the Crisis Team, his wife contacted the All Age Crisis Line number she had been given. She spoke to a clinician from the Crisis Team and reported that she and her husband were outside their home address, he was angry and distressed and she needed help. The advice given to Mrs Dulling was to call the police if she was concerned for her safety. Mrs Dulling ended the call frustrated at the lack of practical advice and assistance.
2. Mr Dulling had been deemed to present a risk of harm to himself and others when assessed by Crisis Team members on 28 August 2023. My concern is that the call did not establish whether this risk had increased, such that Mental Health Act detention or other emergency intervention should be considered, nor offer practical advice to Mrs Dulling about taking her husband to an acute hospital or calling an ambulance , nor explain what assistance it was considered or anticipated could be provided by the police.
3. My concern is that a repetition of such a limited response could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure the recorded and implemented diet reflects identified nutritional needs
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above ;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in undertaking and completing patient safety investigation reviews
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review , resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delayed nursing response to information about choking
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking ;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and maintain food charts after malnutrition risk assessment
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment ;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make direct nutritional-needs inquiries of the primary carer
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs , despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to debrief choking-incident staff within 72 hours
Wider context from the report “4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings –
a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity;
b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above;
c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment;
d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids;
e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking;
f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event . This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest.
5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others.
” 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 Carry out quality-improvement work addressing poor compliance with nutritional assessment and food-chart requirements.
Verbatim wording from the response “not optimal and are in the process of bringing these assessments together into one section of Nucleus (electronic digital nursing record) and this is due to go live in January 2025. We are confident that this will significantly reduce the risk of essential information being overlooked. The Trust recognises the previous poor compliance in this area, as identified in Mr Dulling’s case, and this is a focus of current quality improvement project work. The Trust has completed a Patient Safety Incident Investigation (PSII) cluster review of Speech and Language Therapy (SLT) and swallow related incidents. This was presented to the Trust’s Serious Incident Group in December 2024 with an associated action plan.” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 Implement and use a policy requiring a hot debrief or other incident response after relevant events.
Verbatim wording from the response “It is to be noted that at the time of the incident the Trust followed its previous policy on incident management. The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged the investigation undertaken following this incident was not timely nor optimal. This has been reviewed with the Medicine Care Group and the new policy requiring either hot” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 Introduce a Nucleus fluid assessment for all patients that prompts hydration monitoring according to clinical need.
Verbatim wording from the response “Since this incident occurred there is a new fluid assessment, as part of the Nucleus digital patient record, which is completed for all patients. This then prompts appropriate hydration monitoring dependant on the level of clinical need. The Food, Nutrition and Hydration Policy clearly states that when a patient lacks capacity a best interest’s decision should be made about ongoing fluid management, in consultation with family or carers.” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 Consolidate eating, drinking and nutrition assessments into one Nucleus section.
Verbatim wording from the response “It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not detailed enough and that a food chart was not instigated/completed when it should have been.
The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in November 2024. There are currently several assessments, relating to eating and drinking and nutrition, that nursing staff undertake when a patient is admitted. These assessments are not all located in the same place and not as intuitive as they could be. We recognise that this is” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 Update the Food, Nutrition and Hydration Policy to require best-interest decisions on fluid management for patients lacking capacity, in consultation with family or carers.
Verbatim wording from the response “It is accepted that the assessment of Mr Dulling’s nutritional needs on admission was not detailed enough and that a food chart was not instigated/completed when it should have been.
The Trust’s Food, Nutrition and Hydration Policy (available if required) was updated in November 2024. There are currently several assessments, relating to eating and drinking and nutrition, that nursing staff undertake when a patient is admitted. These assessments are not all located in the same place and not as intuitive as they could be. We recognise that this is” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 Maintain a dedicated Medicine Care Group Clinical Governance Team to review reported patient-safety events daily, request learning responses and escalate severe or moderate harm events.
Verbatim wording from the response “debrief or other form of incident response is now in place and is being used to proper effect. The Medicine Care Group has a dedicated Clinical Governance Team who review all reported patient safety events on a daily basis, appropriate learning responses identified and requested, and any severe or moderate harm patient safety events escalated to the Care Group quadrature.” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 Complete and present a cluster review of speech-and-language-therapy and swallow-related incidents with an associated action plan.
Verbatim wording from the response “not optimal and are in the process of bringing these assessments together into one section of Nucleus (electronic digital nursing record) and this is due to go live in January 2025. We are confident that this will significantly reduce the risk of essential information being overlooked. The Trust recognises the previous poor compliance in this area, as identified in Mr Dulling’s case, and this is a focus of current quality improvement project work. The Trust has completed a Patient Safety Incident Investigation (PSII) cluster review of Speech and Language Therapy (SLT) and swallow related incidents. This was presented to the Trust’s Serious Incident Group in December 2024 with an associated action plan.” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 revised incident-management systems and processes for recording, monitoring, reviewing and learning from patient-safety incidents.
Verbatim wording from the response “It is to be noted that at the time of the incident the Trust followed its previous policy on incident management. The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged the investigation undertaken following this incident was not timely nor optimal. This has been reviewed with the Medicine Care Group and the new policy requiring either hot” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation 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 nurse’s response to the choking was only briefly delayed because they were administering medication to another patient.
Verbatim wording from the response “e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking” Source location Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
Open published response
26 Jul 2017 KENNETH JOHN SWIFT · Prevention of Future Deaths report York City
View report summary
Concerns raised 1 Unavailability of falls sensors for patients assessed at risk of falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
KENNETH JOHN SWIFT · 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 John Swift was admitted to York Hospital with community acquired pneumonia and, while assessed as being at risk of falls, fell unaccompanied on 21 April 2017 and fractured his neck of femur. He died in hospital on 28 April 2017. The principal concern was that no falls sensor was immediately available despite his assessed risk and attempts to mobilise without supervision, raising concerns about the potential for similar fall-related harm to other patients.
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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of falls sensors for patients assessed at risk of falls
Wider context from the report “(1) Although assessed as being at risk of falls and despite being positioned in a bay that was close to the Nurses’ Station in the Ward for better observation, Mr Swift was also recommended to have a falls sensor as he was observed by occupational therapist and physiotherapist trying to mobilise without supervision despite advice not to do so.
(2) It was said in evidence that:
No falls sensor was immediately available- Mr Swift was put on a ‘waiting list’ of 34 existing patients needing such equipment.
The cost of a chair sensor was said to be £60; of a bed sensor £90. The Hospital was said to be in a tendering process to acquire such equipment.
In the relevant Ward (AMU/AMB) 95% of the usual 30 patients (when full) at any one time would have been assessed at risk of falls.
Four sensors have been acquired since Mr Swift’s death for use at the present time in that Ward.
(3) Such a mechanism may have made staff aware that Mr Swift, an elderly man known to be capable of confusion and already suffering from infection that could be aggravated by immobility if injured, was mobilising unsupervised.
(4) That in this Ward at least there is the potential for future deaths resulting from, or the aggravation of, conditions by the consequences of falls in other patients.
” Open source report
20 Apr 2016 Angus Jonathan Labofski WEST · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1 Failure to retain the placenta and all its appendages for pathological examination when a newborn is deteriorating and may die View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Angus Jonathan Labofski WEST · 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
Angus Jonathan Labofski WEST was born on 24 January 2015 and became unwell shortly afterward, developing severe hypoxic-ischaemic encephalopathy. His death was confirmed at Martin House Children’s Hospice on 20 February 2015. The principal concern was that the placenta was not retained, limiting possible pathological examination into factors that might have contributed to his death.
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 York and Scarborough Teaching Hospitals NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to retain the placenta and all its appendages for pathological examination when a newborn is deteriorating and may die
Wider context from the report “(1) After the baby was born the placenta was not retained . Within a short time after his birth he became unwell and despite all efforts his death was confirmed. It was likely that a post mortem examination would be needed to determine the cause of death. It would have been of assistance to the Pathologist to be able to examine the placenta to show the possibility of a toxoplasmosis infection; to establish if relevant the possibility of placental abruption and to establish if the umbilical cord was kinked, trapped or in any way damaged which could have caused or contributed to the death. I therefore recommend and request that when it is foreseeable that at birth or shortly thereafter, the baby’s condition is poor and is deteriorating which may lead to death, then the placenta and all its appendages should be retained and be made available to the Pathologist for further examination .
” 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 Retain placentas for poor-condition, extremely preterm or deteriorating babies locally for 30 days, then send them to Leeds for histopathology if the baby dies, subject to consent.
Verbatim wording from the response “As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.” Source location 2016-0158-Response-by-York-Teaching-Hospital
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 24-hour retention of live-birth placentas through bagging, labelling, dating and refrigerated or labour-ward storage, followed by permitted disposal when conditions are satisfactory.
Verbatim wording from the response “As a consequence of the tragic outcome in this case and the inquest findings we undertake to institute the following standard operating procedure in respect to retention of placenta following childbirth. Points a) and b) are current standard practice and the remaining points are to be instituted by September 1st 2016.” Source location 2016-0158-Response-by-York-Teaching-Hospital
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 The Trust considers that its undertakings constitute all reasonable steps needed to prevent a similar occurrence.
Verbatim wording from the response “I hope that this undertaking alleviates the concerns raised during the recent inquest and reassures you that all reasonable steps have been taken to prevent a similar occurrence in the future. I would be happy to write to you again after the proposed implementation date to confirm that the Trust has complied with these undertakings.” Source location 2016-0158-Response-by-York-Teaching-Hospital
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations