PFD report

Doris Mary Ridgwell · Prevention of Future Deaths report

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Issued 15 May 2018•Surrey

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
2

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 raised3

  1. Delays in authorising abnormal results onto the Clinical Manager system
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
  2. Omission of blood test results from discharge summaries
    Part of recurring concern: Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPsPart of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
  3. Insufficiently clear procedures for telephoning abnormal coagulation results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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.1

  1. Action

    Revise the coagulation-results procedure to require escalation, prompt Clinical Manager release, documented communication, and shift handover when urgent abnormal results cannot be promptly telephoned.

    Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 July 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Including hospital blood results in discharge summaries is not considered necessary because GPs can access those results through Telepath.

    Stated by Epsom and St Helier University Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 authorising abnormal results onto the Clinical Manager system

Wider context from the report

“Abnormal results are not authorised onto the Clinical Manager system to be viewed by Healthcare professionals by Laboratory staff until they have telephoned the results through to the ward, which can potentially cause a delay in these being available on the system; ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Omission of blood test results from discharge summaries

Wider context from the report

“The Discharge summaries provided to GPs following discharge from Hospital do not include blood tests results, meaning a potential safeguard to check these results is missed; ”

Is this part of a recurring concern?

Yes — Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs; Failure to communicate clinically important information reliably between care services; Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficiently clear procedures for telephoning abnormal coagulation results

Wider context from the report

“The Trust’s Standard Operating Procedure for Telephoning of Coagulation Results is not sufficiently clear regarding what action should be taken by staff in the Blood Sciences Department to ensure abnormal coagulation results are made known to the treating Healthcare professionals; - A new Standard Operating Procedure has been prepared, but having had sight of this, I do not believe this clearly outlines for Laboratory staff the steps to be taken in telephoning through abnormal Coagulation Results; ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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

Revise the coagulation-results procedure to require escalation, prompt Clinical Manager release, documented communication, and shift handover when urgent abnormal results cannot be promptly telephoned.

Verbatim wording from the response

“The Root Cause Analysis investigation carried out following this incident identified the fact that the Trust’s Standard Operating Procedure for the telephoning of clinically urgent abnormal coagulation results was not robust enough and that the procedure required strengthening. As a result of the investigation the Standard Operating Procedure was revised to make it clear that where it is not possible to get hold of a clinician who has requested a blood result which has been deemed clinically urgent, this needs to be handed over to those working the next shift in the Blood Sciences Department so that continues attempts to contact this clinician can be made. This strengthened the process but following the concerns raised at the inquest hearing we have strengthened the process even further.”

Source location

2018-0151-Response-by-Epsom-St-Helier-University-Hospital
Page 3 · response
Published 8 July 2018

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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

Including hospital blood results in discharge summaries is not considered necessary because GPs can access those results through Telepath.

Verbatim wording from the response

“The possibility of including blood results from hospitals within hospital discharge summaries was discussed with a GP representative from the local area at the Clinical Quality Review Group on 24 May 2018. They did not feel they would be able to review blood results within patient’s discharge summaries. Moreover, it is not felt that it would be appropriate to rely on GP’s to act as a potential safeguard for abnormal results. Blood results taken in hospital can be accessed by GP’s via a computerised patient management system, Telepath.”

Source location

2018-0151-Response-by-Epsom-St-Helier-University-Hospital
Page 5 · response
Published 8 July 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

    Issue guidance requiring clinical staff to communicate clinically urgent abnormal results to patients and ensure appropriate action, including when patients have left hospital.

    Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 July 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

Issue guidance requiring clinical staff to communicate clinically urgent abnormal results to patients and ensure appropriate action, including when patients have left hospital.

Verbatim wording from the response

“We have issued new guidance for all staff to make it clear that if they are made aware of a patient’s clinically urgent abnormal result from the Blood Sciences Department and that patient has left the hospital, it is the responsibility of that individual to ensure that appropriate action is taken. Appropriate action will be dependent on the significance of the abnormal result and will range from calling the patient back to hospital for urgent review to contacting the patient and their GP to make them aware of the abnormal result and asking them to arrange an appropriate outpatient appointment.”

Source location

2018-0151-Response-by-Epsom-St-Helier-University-Hospital
Page 5 · response
Published 8 July 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