PFD report

Nicholas Rousseau · Prevention of Future Deaths report

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Issued 28 Mar 2021•Milton Keynes

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised2

  1. Failure to follow NICE sepsis risk stratification guidance for lactate levels above 2
    Part of recurring concern: Failure to reliably recognise and respond promptly to sepsisPart of recurring concern: Unreliable escalation of assessed safety risk levels
  2. Lack of consistent senior staff practice for assessing and repeating elevated lactate levels
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

    Update the MKUH sepsis policy at its scheduled November 2021 review.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.

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

  1. Position

    The patient was not suspected of sepsis and lacked high-risk criteria, so guidelines did not mandate repeat lactate measurement or imply likely clinical benefit.

    Stated by Milton Keynes University Hospital 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

Failure to follow NICE sepsis risk stratification guidance for lactate levels above 2

Wider context from the report

“(1) In the course of oral evidence Dr ████████ and ████████ ████████, both Consultants in Accident and Emergency Medicine at the hospital gave conflicting accounts of how much importance they would ascribe to the lactate level which was nearly twice the upper limit of normal and whether they would repeat it before discharge. ████████ told me he would not repeat it because he saw lots of patients with elevated lactate and with the resources he had available he would be spending a disproportionate amount of time checking lactate levels in patients who ultimately would be fine. We spent some time on the point and with reference to the NICE Sepsis Risk Stratification Tools. The Guideline is clear that if a lactate is above 2 then the patient should be escalated to high risk. ████████ was challenged several times on his position that irrespective of the guidelines he would not routinely repeat the lactate level dismissing it as an unnecessary burden. He maintained that position. Dr ███ took a flatly contrary view and said that she would repeat it irrespective of the burden of work it may generate. These contrasting opinions indicate a degree of confusion amongst the senior staff at Milton Keynes University Hospital Accident and Emergency Department which in my view poses a threat to patients with sepsis and with elevated lactate levels. The disregarding of the NICE Guidelines simply because it is inconvenient is disturbing. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond promptly to sepsis; Unreliable escalation of assessed safety risk levels.

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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

Lack of consistent senior staff practice for assessing and repeating elevated lactate levels

Wider context from the report

“(1) In the course of oral evidence Dr ████████ and ████████ ████████, both Consultants in Accident and Emergency Medicine at the hospital gave conflicting accounts of how much importance they would ascribe to the lactate level which was nearly twice the upper limit of normal and whether they would repeat it before discharge. ████████ told me he would not repeat it because he saw lots of patients with elevated lactate and with the resources he had available he would be spending a disproportionate amount of time checking lactate levels in patients who ultimately would be fine. We spent some time on the point and with reference to the NICE Sepsis Risk Stratification Tools. The Guideline is clear that if a lactate is above 2 then the patient should be escalated to high risk. ████████ was challenged several times on his position that irrespective of the guidelines he would not routinely repeat the lactate level dismissing it as an unnecessary burden. He maintained that position. Dr ███ took a flatly contrary view and said that she would repeat it irrespective of the burden of work it may generate. These contrasting opinions indicate a degree of confusion amongst the senior staff at Milton Keynes University Hospital Accident and Emergency Department which in my view poses a threat to patients with sepsis and with elevated lactate levels. The disregarding of the NICE Guidelines simply because it is inconvenient is disturbing. ”

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

Update the MKUH sepsis policy at its scheduled November 2021 review.

Verbatim wording from the response

“• Maintains a local MKUH policy that is consistent with national guidance (including NG51). The current policy is due for scheduled review in November 2021.”

Source location

2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
Page 3 · response
Published 30 March 2021

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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 patient was not suspected of sepsis and lacked high-risk criteria, so guidelines did not mandate repeat lactate measurement or imply likely clinical benefit.

Verbatim wording from the response

“Before coming to the substantive matter of blood lactate levels, I would like to take this opportunity to extend my condolences and sympathies to Mr Rousseau’s family. I am conscious that any sense of divergence in view, at Inquest, between HM Coroner and attending physicians will have added to the family’s distress. I am not clear from the Regulation 28 report whether you consider that an alternative course of action regarding the measurement of blood lactate might have afforded an opportunity to alter the subsequent clinical course and Mr Rousseau’s ultimately death. For avoidance of doubt, we do not consider this likely.”

Source location

2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
Page 1 · response
Published 30 March 2021

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.3

  1. 1

    Consider designating a departmental sepsis lead with responsibilities for maintaining the profile of sepsis.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
  2. 2

    Discuss the report, response and case summary at an appropriate departmental forum to disseminate the issues and reinforce challenges diagnosing bowel ischaemia.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.
  3. 3

    Repeat a local audit of suspected-sepsis management against the eight RCEM standards.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 March 2021.

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

Consider designating a departmental sepsis lead with responsibilities for maintaining the profile of sepsis.

Verbatim wording from the response

“The profile of sepsis is also high across the wider Trust.”

Source location

2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
Page 4 · response
Published 30 March 2021

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 the report, response and case summary at an appropriate departmental forum to disseminate the issues and reinforce challenges diagnosing bowel ischaemia.

Verbatim wording from the response

“We shall also ensure that the Regulation 28 report, this response and a summary of Mr Rousseau’s case are discussed at an appropriate departmental forum in order to ensure that there is a wide understanding of the issues raised and that clinicians are reminded of the particular challenges in making a positive diagnosis of bowel ischaemia.”

Source location

2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
Page 4 · response
Published 30 March 2021

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

Repeat a local audit of suspected-sepsis management against the eight RCEM standards.

Verbatim wording from the response

“• Participates in Royal College of Emergency Medicine (RCEM) national audits, including the audit on sepsis in 2016-17. This audit examined performance in relation to 8 standards and the Trust performed at / above the peer median.”

Source location

2021-0087-Response-from-Milton-Keynes-University-Hospital-Redacted
Page 4 · response
Published 30 March 2021

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