PFD report

Adrienne Caroline STUDHOLME · Prevention of Future Deaths report

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Issued 10 Oct 2025•Lancashire and Blackburn with Darwen

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
4

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 raised4

  1. Inaccurate fluid balance charting failing to account for all sources of fluid provision
    Part of recurring concern: Unreliable recording of fluid balance information
  2. Lack of a procedure requiring contact with the original treating department on readmission after recent surgery
    Part of recurring concern: Unreliable communication with original treating teams after post-procedure readmission
  3. Failure to take unwitnessed seizure activity into account in Emergency Department assessment
    Part of recurring concern: Unreliable seizure care and management
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.4

  1. Action

    Monitor implementation of revised professional standards through internal assurance processes, escalating issues to the Quality Committee until embedded in business as usual.

    Stated by East Lancashire Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2025.
  2. Action

    Develop revised internal professional standards for response to support prompt surgical-team responses.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
  3. Action

    Remind Emergency Department and surgical clinicians to urgently contact the surgical team when clinical judgement indicates a possible surgical complication.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.

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

  1. Position

    Routine contact with the original surgical department after readmission is not considered necessary where the presenting problem appears unrelated to previous surgery.

    Stated by East Lancashire Hospitals NHS TrustNo action considered necessaryThe respondent said that 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

Inaccurate fluid balance charting failing to account for all sources of fluid provision

Wider context from the report

“(1) The fluid balance chart was found to be inaccurate. The evidence suggested that the accuracy of the chart relied on staff collecting and refilling empty water jugs and took no account of steps families may take to provide fluid ”

Is this part of a recurring concern?

Yes — Unreliable recording of fluid balance information.

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

Lack of a procedure requiring contact with the original treating department on readmission after recent surgery

Wider context from the report

“(3) Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department. In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department. ”

Is this part of a recurring concern?

Yes — Unreliable communication with original treating teams after post-procedure readmission.

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 take unwitnessed seizure activity into account in Emergency Department assessment

Wider context from the report

“(2) Evidence was heard that seizure activity would not be taken into account in assessing a patient in the Emergency Department unless it was witnessed by a member of staff ”

Is this part of a recurring concern?

Yes — Unreliable seizure care and management.

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

Lack of standard operating practice and training to ensure recent surgery is considered in Emergency Department triage

Wider context from the report

“(3) Evidence was heard that on readmission via the Emergency Department following recent surgery, there is no procedure requiring contact with the original treating department. In addition, there is no standard operating practice and no training ensuring that recent surgery is taken into account in a triage in the Emergency department. ”

Is this part of a recurring concern?

Yes — Unreliable emergency-department triage.

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

Monitor implementation of revised professional standards through internal assurance processes, escalating issues to the Quality Committee until embedded in business as usual.

Verbatim wording from the response

“It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.”

Source location

Response from East Lancashire NHS Trust
Page 2 · response
Published 14 October 2025

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 revised internal professional standards for response to support prompt surgical-team responses.

Verbatim wording from the response

“It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.”

Source location

Response from East Lancashire NHS Trust
Page 2 · response
Published 14 October 2025

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

Remind Emergency Department and surgical clinicians to urgently contact the surgical team when clinical judgement indicates a possible surgical complication.

Verbatim wording from the response

“It is accepted, however, that where clinical judgement indicates the possibility that a direct surgical complication may have arisen, then urgent contact with the surgical team is essential. Clinicians from the ED have been reminded of the importance of this, and clinicians from the surgical teams of the importance of prompt response. Indeed, a revised version of our internal professional standards for response has been developed, and the Trust commits to monitor these once implemented.”

Source location

Response from East Lancashire NHS Trust
Page 2 · response
Published 14 October 2025

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

Test and develop risk-based fluid monitoring, including patient and family recording of fluid intake for inclusion in fluid balance charts.

Verbatim wording from the response

“The Trust acknowledges that fluid monitoring is a recognised national challenge across the NHS. We are committed to addressing this issue locally and have implemented, and continue to develop, measures aimed at improving the accuracy and consistency of fluid balance monitoring within our services.”

Source location

Response from East Lancashire NHS Trust
Page 2 · response
Published 14 October 2025

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

Routine contact with the original surgical department after readmission is not considered necessary where the presenting problem appears unrelated to previous surgery.

Verbatim wording from the response

“The third area of concern is that there is currently no process for patient’s who present to the Emergency Department following recent surgery to be seen by the original treating department. This is not amenable to a simple procedure – a referral in the context of a problem unrelated to the surgery, where the surgical team may not have expertise related to that condition, would be both futile and add complexity. In this case the initial presentation did not indicate any link with the previous procedure during triage.”

Source location

Response from East Lancashire NHS Trust
Page 2 · response
Published 14 October 2025

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 concern that unwitnessed seizure activity is not considered in Emergency Department assessment does not reflect current or historic practice.

Verbatim wording from the response

“With respect to point 2, this concern appears to have arisen from a miscommunication of the evidence provided and reflects neither current nor historic practice within the Emergency Department. Having contacted the consultant who was giving evidence, the point they were trying to convey was that a history of seizures would not warrant immediate escalation to a doctor (either from triage or subsequently). An actively seizing patient would represent a potential medical emergency, or - were it to occur in the department - a potential deterioration in a patient’s condition and that this therefore would be immediately escalated when reported from any source.”

Source location

Response from East Lancashire NHS Trust
Page 2 · response
Published 14 October 2025

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