PFD report

Roger Albert Saxby · Prevention of Future Deaths report

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Issued 8 Dec 2017•Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Insufficient discussion with patients about their care
    Part of recurring concern: Failure to discuss patient care options and decisions
  2. Unstructured discussions about patients’ subsequent care
  3. Failure to consider patients’ best interests before repeat hub-to-hub transfers
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Use learning from this case to inform future decisions about similar hub-to-hub transfers.

    Stated by St George'S University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  2. Action

    Accept patients from another hub in similar circumstances, while limiting transfer back to a hub hospital to exceptional cases after due consideration.

    Stated by St George'S University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Care plans and team communication were clear, although lost clinical notes prevented demonstrating that structure.

    Stated by St George'S University Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient discussion with patients about their care

Wider context from the report

“There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

Is this part of a recurring concern?

Yes — Failure to discuss patient care options and decisions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unstructured discussions about patients’ subsequent care

Wider context from the report

“There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to consider patients’ best interests before repeat hub-to-hub transfers

Wider context from the report

“There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in decisions to transfer patients between vascular hubs

Wider context from the report

“There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in starting thrombolysis after arrival at a receiving vascular hub

Wider context from the report

“There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

Is this part of a recurring concern?

Yes — Unsafe coordination of thrombolysis 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide urgent clinical decision-making and care

Wider context from the report

“There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of a vascular hub to maintain required staffing and resources

Wider context from the report

“There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

Is this part of a recurring concern?

Yes — Insufficient safe staffing and senior cover out of hours.

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

Use learning from this case to inform future decisions about similar hub-to-hub transfers.

Verbatim wording from the response

“Thank you for raising these concerns which has given us the opportunity to deliberate carefully about future hub to hub transfers. The vascular and interventional radiology”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 3 · response
Published 11 February 2018

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

Accept patients from another hub in similar circumstances, while limiting transfer back to a hub hospital to exceptional cases after due consideration.

Verbatim wording from the response

“Going forward, having discussed and reflected on this case, it is the clinicians’ and the trust’s view that to refuse to accept patients from another hub in similar circumstances as that of Mr Saxby will not be in any patient’s best interests, and in fact is more likely to cause patient harm and death. However, once a patient is accepted, a transfer back to a hub hospital will only take place in exceptional circumstances and after due consideration.”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 3 · response
Published 11 February 2018

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

Care plans and team communication were clear, although lost clinical notes prevented demonstrating that structure.

Verbatim wording from the response

“The clinicians involved in Mr Saxby’s care have reiterated that they were clear about the actions and plans. There was good communication within the team and they had conveyed the plan to Mr Saxby at each stage. Most regrettably, as you were made aware at the inquest, the clinical notes made by the vascular team were lost and this lamentable situation has meant that they have been unable to demonstrate that there was clarity and structure in the care plan.”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 2 · response
Published 11 February 2018

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

Thrombolysis was commenced as promptly as reasonably possible after arrival, without compromising patient safety.

Verbatim wording from the response

“Mr Saxby arrived at St George’s at 16:45 hours on Friday 28 July 2017 and underwent thrombolysis at 19:00 hours. Colleagues from both the vascular and interventional radiology (IR) teams have reviewed Mr. Saxby’s pathway and they are absolutely confident that thrombolysis in this case was commenced as soon as it was safe and practical to do so. Mr. Saxby had to be assessed and clerked, and prepared for theatre including being consented for the procedure. Having reviewed the theatre list for 28 July 2017, the IR service has confirmed that the IR suite was not available to take a patient at around 17:00 hours in any event as they had an on-going case at the time. As soon as the case was completed and the IR suite was cleaned and prepared for the next case, the IR on call team sent for Mr. Saxby. Mr Saxby arrived in the IR suite at 18:30 hours.”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 1 · response
Published 11 February 2018

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

Transfer back to the referring hospital was considered in the patient’s best interests to support rehabilitation and care closer to home.

Verbatim wording from the response

“I believe the Brighton trust has provided an explanation for why Mr Saxby needed to be transferred to St.Georges. I will address here the issue of the transfer back to Royal Surrey County Hospital (RSCH). As per the evidence heard at the inquest, the transfer back was discussed with the referring team at RSCH and it was agreed that it would be in Mr. Saxby’s best interests to have the amputation closer to home to prevent a prolonged period in a London hospital. The vascular service has confirmed that the repatriation of patients following amputation is extremely difficult and can take many weeks, and this hinders the commencement of any planning for proper rehabilitation and social care that Mr Saxby would have needed at home.”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 3 · response
Published 11 February 2018

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 decision not to amputate at the weekend was reasonable given the clinical presentation and rehabilitation planning needs.

Verbatim wording from the response

“████████ has reflected deeply on the care provided to Mr. Saxby and discussed this with his peers, including the clinical lead for Vascular Surgery, ████████ accepts that in retrospect, it may appear that there was no sense of urgency at the time, however, in dealing with the reality of what was before him, he did not feel it appropriate at the time to undertake the amputation over the weekend. His peers, including ████████ who has independently reviewed the decision not to amputate at the weekend, agree that this was a reasonable decision taking into consideration Mr. Saxby’s clinical presentation and the plans that had to be made for his on-going rehabilitation needs.”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 2 · response
Published 11 February 2018

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

Hub-to-hub transfers should not be categorically prohibited because accepting patients may prevent harm; transfers back should occur only exceptionally.

Verbatim wording from the response

“A hub to hub transfer is, as you have heard, an uncommon event. In this case, Mr. Saxby’s transfer was accepted by St. George’s because interventional radiology cover was not available at the Royal Surrey County Hospital at the weekend and so transfer was accepted by St. George’s to give Mr.Saxby the best chance of salvaging his leg. However, despite best efforts by the interventional radiology team, it was recognised that he was going to need an amputation and, for the reasons explained above, the decision was made, in conjunction with Mr. Saxby’s cell agreement, for the transfer back to RSCH. The subsequent catastrophic turn of events for Mr. Saxby has been a source of the deepest regret for the clinicians and trust.”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 3 · response
Published 11 February 2018

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

There were repeated discussions with the patient about amputation, despite lost records preventing corroboration.

Verbatim wording from the response

“Prof Loftus has indicated that he saw Mr. Saxby on five occasions over the 48-hour period and Mr. Ben Patterson saw the patient more often than that. ████████ has”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 2 · response
Published 11 February 2018

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Continue staged rollout of fully electronic records to reduce the risk of lost paper notes.

    Stated by St George'S University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.

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

Continue staged rollout of fully electronic records to reduce the risk of lost paper notes.

Verbatim wording from the response

“As I have alluded to in the initial PFD response letter, the trust has been moving towards fully electronic records in stages. When this is fully rolled out, such incidences of loss of paper notes will be greatly reduced.”

Source location

2017-0365-Response-by-St-Georges-Universty-Hospital
Page 2 · response
Published 11 February 2018

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026