PFD report

Sari Marlene KEEN · Prevention of Future Deaths report

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Issued 16 Apr 2014•Bedfordshire and Luton

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
15

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. Lack of sufficient staffing for patient caseloads
    Part of recurring concern: Insufficient qualified healthcare staffing capacityPart of recurring concern: Insufficient safe staffing and senior cover out of hours
  2. Failure of staff to recognise an un-recordable blood pressure as a medical emergency requiring a crash call
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Unreliable activation of emergency medical response teamsPart of recurring concern: Unsafe recognition and response to significantly abnormal blood pressure
  3. Failure to escalate care when overwhelmed
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.10

  1. Action

    Emphasise Medical Emergency Team availability during mandatory basic life support training for all staff groups.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2014.
  2. Action

    Pilot a revised observation and escalation process, with registered nurses observing patients requiring observations more frequently than every four hours.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2014.
  3. Action

    Increase the number of nurses allocated to ward 22 at night following the staffing establishment review.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing cardiac-arrest protocols, medical-emergency procedures and mandatory training are considered sufficient arrangements for activating the appropriate response.

    Stated by The 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

Lack of sufficient staffing for patient caseloads

Wider context from the report

“(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual. They felt overwhelmed and yet unable to escalate the care. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity; Insufficient safe staffing and senior cover out of hours.

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 staff to recognise an un-recordable blood pressure as a medical emergency requiring a crash call

Wider context from the report

“(2) It was apparent that many Senior and Junior Members of Staff were not aware that an ‘un-recordable blood pressure’ was a ‘medical emergency’ and should have resulted in a crash call going out for immediate resuscitation. Perhaps the Protocols for the Crash Team need to be reviewed. ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it; Unreliable activation of emergency medical response teams; Unsafe recognition and response to significantly abnormal blood pressure.

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 escalate care when overwhelmed

Wider context from the report

“(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual. They felt overwhelmed and yet unable to escalate the care. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Emphasise Medical Emergency Team availability during mandatory basic life support training for all staff groups.

Verbatim wording from the response

“In addition, we have a separate “Medical Emergency Team” policy, designed to be activated in situations where a patient is deteriorating but is not yet in cardiac arrest. This involves activation of the bleeps of the medical registrar and the ITU registrar by switchboard with a message asking the medical emergency team to go to ward X immediately. For patients deteriorating between 8am and 10pm, we have the third option of summoning the ITU Outreach team to review the patient. This can be initiated by either medical or nursing staff, and results in a review by a nurse trained in assessment of critically ill patients who can then escalate to either the medical team or the ITU team as appropriate.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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

Pilot a revised observation and escalation process, with registered nurses observing patients requiring observations more frequently than every four hours.

Verbatim wording from the response

“• A revised observation and escalation process is currently being piloted on 4 wards. A key change is the introduction of registered nurses to undertake the observations of all patients who require observations more than 4 hourly. Health Care Assistants also undertake observations but it was noted that the registered nurse has a greater ability and opportunity to identify other factors that might indicate deterioration where a Health Care Assistant would not be skilled enough to identify the patient during the actual observation process. Early indications are that there is a more timely escalation from nurses at the earlier signs of deterioration.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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

Increase the number of nurses allocated to ward 22 at night following the staffing establishment review.

Verbatim wording from the response

“Nursing Staff establishments are reviewed every six months using a number of different approaches. This includes using the expert opinions of the Chief Nurse, dedicated specialty matron and ward manager who have greater insight into the local clinical need and context of each ward setting. The establishments are also reviewed in the context of the wider quality performance of the ward which includes key nursing quality indicators, patient experience scores and workforce indicators such as sickness and turnover rates. In fact following our most recent establishment review the actual numbers of nurses on ward 22 at night has been increased.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 16 April 2014

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

Adopt a policy enabling HDU nursing staff to escalate deteriorating patients directly to the consultant when timely action is not taken.

Verbatim wording from the response

“In addition in HDU, we have adopted a policy a few months ago that empowers nursing staff to escalate concerns regarding a deteriorating patient directly to the consultant if they feel that appropriate action is not being taken quickly enough, and we will look at the feasibility of extending this to all ward areas. This has worked well.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 16 April 2014

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

Develop a revised hospital-at-night model to provide a robust 24/7 service.

Verbatim wording from the response

“• The Trust has also undertaken a review of the clinical support available at night across the Trust. Further work is underway to develop a revised ‘hospital at night’ model to meet the national strategy requirement of a robust 24/7 service.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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

Reinforce junior doctors’ escalation responsibilities through the medical education training programme.

Verbatim wording from the response

“• The requirement to escalate is also reinforced by the Director for Medical Education as part of the junior doctor’s training programme.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 16 April 2014

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

Continue dialogue with junior doctors and reinforce consultants’ expectations to support escalation about deteriorating patients.

Verbatim wording from the response

“For doctors, in cases where a deteriorating patient requires specialist input, escalation is by the surgical on-call team to the Medical registrar, the ITU registrar, ITU outreach (during their hours of operation 08.00 – 22.00) or the link anaesthetist. If they foresee that they will be unable to respond within an appropriate timescale, it is their duty to inform the referring doctor of this at the time, to allow additional assistance to be sought.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 16 April 2014

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

Evaluate current nurse and doctor training on identifying deteriorating patients and develop an improvement proposal informed by cardiac-arrest learning.

Verbatim wording from the response

“• Evaluation of the current training for nurses and doctors on the identification of the deteriorating patient is in progress with a proposal to improve the content as reflected in the learning from Root Cause Analysis of cardiac arrests.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 4 · response
Published 16 April 2014

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

Raise insufficient staffing and early escalation with ward staff through daily safety brief discussions.

Verbatim wording from the response

“The following actions have been undertaken to minimise the risk of this happening again:”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 16 April 2014

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

Review clinical support available at night across the Trust.

Verbatim wording from the response

“• The Trust has also undertaken a review of the clinical support available at night across the Trust. Further work is underway to develop a revised ‘hospital at night’ model to meet the national strategy requirement of a robust 24/7 service.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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

Existing cardiac-arrest protocols, medical-emergency procedures and mandatory training are considered sufficient arrangements for activating the appropriate response.

Verbatim wording from the response

“We have very clear and specific protocols for activation of the cardiac arrest process, which every member of staff is expected to be conversant with. It is taught through basic life support, which is an element of mandatory training for all clinical staff.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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

Existing staffing reviews, risk assessments and on-call arrangements are considered sufficient to ensure adequate medical and nursing staffing.

Verbatim wording from the response

“Nursing Staff establishments are reviewed every six months using a number of different approaches. This includes using the expert opinions of the Chief Nurse, dedicated specialty matron and ward manager who have greater insight into the local clinical need and context of each ward setting. The establishments are also reviewed in the context of the wider quality performance of the ward which includes key nursing quality indicators, patient experience scores and workforce indicators such as sickness and turnover rates. In fact following our most recent establishment review the actual numbers of nurses on ward 22 at night has been increased.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 16 April 2014

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.5

  1. 1

    Establish a dedicated steering group to identify barriers to effective management of deteriorating patients.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2014.
  2. 2

    Present the case at the Grand Round, Trust Patient Safety Meetings and Senior Nurse meetings to share learning.

    Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 16 April 2014.
  3. 3

    Introduce an up-to-date high-risk patient list for the senior clinical sister on night duty to prioritise patient reviews.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2014.
  4. 4

    Relaunch SBAR communication across the Trust to standardise deterioration-related communication.

    Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2014.
  5. 5

    Introduce a revised consultant-led Root Cause Analysis process for investigating all cardiac arrests.

    Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 16 April 2014.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish a dedicated steering group to identify barriers to effective management of deteriorating patients.

Verbatim wording from the response

“Further actions include:”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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

Present the case at the Grand Round, Trust Patient Safety Meetings and Senior Nurse meetings to share learning.

Verbatim wording from the response

“• This case will be presented at the Grand Round, Trust Patient Safety Meetings and Senior Nurse meetings so that learning can be shared.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 4 · response
Published 16 April 2014

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

Introduce an up-to-date high-risk patient list for the senior clinical sister on night duty to prioritise patient reviews.

Verbatim wording from the response

“The following actions have been undertaken to minimise the risk of this happening again:”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 16 April 2014

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

Relaunch SBAR communication across the Trust to standardise deterioration-related communication.

Verbatim wording from the response

“• Re-launch of the standard communication tool - SBAR (Situation, Background, Assessment, Recommendations). Analysis of the RCAs for cardiac arrests has identified the importance of communicating in a clear and concise way. The drive to standardise the communication is being led by the Critical Care Outreach Team and this should provide clearer details regarding the deterioration of the patient. This in turn will promote a more timely medical response and enable the medical staff to prioritise their workload more effectively.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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

Introduce a revised consultant-led Root Cause Analysis process for investigating all cardiac arrests.

Verbatim wording from the response

“• A revised Root Cause Analysis (RCA) process for investigating all cardiac arrests has been introduced which is now being led by the Consultant responsible for the patient rather than the former process which was led by the resuscitation officer.”

Source location

2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014

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