PFD report

John Michael Matthews · Prevention of Future Deaths report

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Issued 29 Jan 2015•Manchester South

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
5

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 raised5

  1. Failure to provide the doctor with access to the complete computerised system
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable access to relevant clinical records for safe care
  2. Failure to make the PRF available to the doctor providing emergency care
    Part of recurring concern: Unreliable access to relevant clinical records for safe carePart of recurring concern: Unreliable ambulance-to-emergency-department patient-information handover
  3. Failure to institute neurological observations
    Part of recurring concern: Failure to carry out required neurological observations
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

    Disseminate learning about vital information handover and neurological observations through meetings, safety huddles and the ED Quality Newsletter.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2015.
  2. Action

    Institute ED checklists preventing patients from leaving before requested investigations and treatments are completed.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2015.

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

  1. Position

    The ambulance information system worked: the PRF was scanned before the doctor assessed the patient.

    Stated by Stockport 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 provide the doctor with access to the complete computerised system

Wider context from the report

“2. The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable access to relevant clinical records for safe 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 make the PRF available to the doctor providing emergency care

Wider context from the report

“2. The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care; Unreliable ambulance-to-emergency-department patient-information handover.

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 institute neurological observations

Wider context from the report

“3. It was agreed by the ED consultant giving evidence that neurological observations ought to have been instituted, but they were not. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations.

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 make the ambulance Patient Report Form available to the triage nurse before triage

Wider context from the report

“1. Whilst in the Emergency Department at Stepping Hill Hospital, he was triaged without the triage nurse having seen the ambulance Patient Report Form. ”

Is this part of a recurring concern?

Yes — Unreliable ambulance-to-emergency-department patient-information handover.

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 sending patients for a head CT scan

Wider context from the report

“4. There was an unnecessary and to some extent unexplained delay in sending him for a CT scan of his head. ”

Is this part of a recurring concern?

Yes — Failure to provide timely access to clinically indicated CT scanning; Unreliable timeliness of radiology imaging and reporting.

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

Disseminate learning about vital information handover and neurological observations through meetings, safety huddles and the ED Quality Newsletter.

Verbatim wording from the response

“The ED Matron has re-iterated to all nursing staff that vital information must be passed on to the doctors. This has formally been discussed in the sisters’ meeting and at safety huddles. Safety Huddles are times when nurses and doctors meet for handover at the beginning or end of each shift. At these times information is shared about current patients along with any specific department information or to highlight any learning identified following investigations into incidents or complaints. Neurological observation needs have been discussed during these safety huddles, at Sisters’ meetings and shared within the ED Quality Newsletter which is sent to all ED staff.”

Source location

2015-0034-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 29 January 2015

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

Institute ED checklists preventing patients from leaving before requested investigations and treatments are completed.

Verbatim wording from the response

“For the future, to avoid a reoccurrence of this incident, we have instituted a system of checklists whereby a patient cannot leave the ED without all the investigations and treatments being completed. The investigations requested are clearly shown on Advantis ED therefore the nurse caring for the patient and the shift co-ordinator will be aware of investigations requested.”

Source location

2015-0034-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 29 January 2015

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 ambulance information system worked: the PRF was scanned before the doctor assessed the patient.

Verbatim wording from the response

“In his statement to you, ████████ states that “Paramedic notes were not available to me.” What is clear on review of the events is that the triage nurse received a verbal handover as per usual practice. A review of the electronic system has been undertaken which shows that the ambulance document (PRF) was scanned and was added to the system within 13 minutes of arrival and ten minutes prior to the doctor seeing the patient so it is apparent that the system in place to link the paper document with the electronic document worked. I am unable to explain why the locum doctor did not review this information but am assured he was given the training to enable him to do so.”

Source location

2015-0034-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 29 January 2015

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.2

  1. 1

    Review and amend the induction training pack and written information provided to staff.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 January 2015.
  2. 2

    Work with locum agencies to provide induction information before locum shifts.

    Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2015.

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 and amend the induction training pack and written information provided to staff.

Verbatim wording from the response

“To prevent a future occurrence of a similar situation, we have reviewed the induction training pack and amended the written information given to staff; this was launched in November 2014. We also”

Source location

2015-0034-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 29 January 2015

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

Work with locum agencies to provide induction information before locum shifts.

Verbatim wording from the response

“work closely with locum agencies to get this information to the locum doctor as quickly as possible prior to their shifts so they have time to review and digest it before commencing their shift.”

Source location

2015-0034-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 29 January 2015

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