23 Dec 2025 Colin Richard BROWN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 3 Failure to routinely check for patients' choking risks during handovers View source Delays in making electronic patient information accessible to receiving hospital staff View source Failure to transport patients' care plans with them to hospital 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
Colin Richard BROWN · 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
Colin Richard Brown attended York Hospital Emergency Department on 28 March 2025 and choked on food provided by the hospital, leading to a cardiac arrest and transfer to intensive care. He died on 31 March 2025. The concerns were that his care plan was not transported to hospital and that information about his choking risk might not be reliably communicated or checked during the handover period.
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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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check for patients' choking risks during handovers
Wider context from the report “During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital. There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown. Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers . It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves , as was the case here.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in making electronic patient information accessible to receiving hospital staff
Wider context from the report “During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital. There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown . Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers. It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves, as was the case here.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to transport patients' care plans with them to hospital
Wider context from the report “During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital . There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown. Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers. It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves, as was the case here.
” Open source report
19 Jul 2023 Carole MCQUINN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 10 Failure to record post-discharge infection concerns View source Failure to record clinical observations during hospital attendance View source Failure to record inter-hospital clinical communications View source Failure to arrange follow-up appointments at discharge View source Failure to escalate suspected infection concerns to the treating team View source Failure to provide discharge medications View source Lack of discharge notes View source Failure to ensure swab results are reviewed View source Failure to seek specialist input from the Leeds treating team View source Safety hazard associated with evening hospital discharges View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Carole MCQUINN · 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
Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.
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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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record post-discharge infection concerns
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same . Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical observations during hospital attendance
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22 . The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record inter-hospital clinical communications
Wider context from the report “3. The deceased had an emergency admission to York Hospital on 4/5/22 with suspected intra-abdominal sepsis. A York doctor was verbally tasked with communicating with the surgical team at Leeds to report back on a comparison of CT scans from both hospitals. No record of this contact - which was verbally reported in positive terms - was made by either hospital and no evidence could be provided as to who had spoken to whom and in what terms . Further, despite the lengthy and complex treatment the deceased had undergone in Leeds, and her attendance there the day prior to admission to York, no contact was made by the treating team at York with the treating team at Leeds, to allow for additional specialist input into the deceased's management and consideration of possible transfer of care.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange follow-up appointments at discharge
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place . Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate suspected infection concerns to the treating team
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide discharge medications
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of discharge notes
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note , medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure swab results are reviewed
Wider context from the report “2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed . No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22 . These omissions led to missed opportunities for earlier assessment and treatment of the deceased.
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to seek specialist input from the Leeds treating team
Wider context from the report “3. The deceased had an emergency admission to York Hospital on 4/5/22 with suspected intra-abdominal sepsis. A York doctor was verbally tasked with communicating with the surgical team at Leeds to report back on a comparison of CT scans from both hospitals. No record of this contact - which was verbally reported in positive terms - was made by either hospital and no evidence could be provided as to who had spoken to whom and in what terms. Further, despite the lengthy and complex treatment the deceased had undergone in Leeds, and her attendance there the day prior to admission to York, no contact was made by the treating team at York with the treating team at Leeds , to allow for additional specialist input into the deceased's management and consideration of possible transfer of care .
” 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 Hospital; that does not assign responsibility.
PFD Monitor interpretation Safety hazard associated with evening hospital discharges
Wider context from the report “1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself , and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations