PFD report

Claire Joan Elizabeth MEDHURST · Prevention of Future Deaths report

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Issued 10 Aug 2017•Mid Kent and Medway

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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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

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Concerns raised2

  1. Failure to provide cautionary advice about further use of paracetamol or ibuprofen as analgesics at discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure of haematology laboratory alerting for abnormal ALT and toxic paracetamol results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable clinical safety-alert systemsPart of recurring concern: Unreliable laboratory notification of safety-critical problems and resultsPart of recurring concern: Unreliable monitoring and follow-up of clinically required laboratory tests
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.9

  1. Action

    Discuss overdose medication safety advice in Emergency Department daily safety huddles.

    Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
  2. Action

    Require staff to document discharge advice given to overdose patients in medical notes.

    Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
  3. Action

    Ratify, print and distribute the overdose information leaflet through Emergency Department discharge planning, with documented explanation and subsequent audit.

    Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 November 2017.

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 cautionary advice about further use of paracetamol or ibuprofen as analgesics at discharge

Wider context from the report

“(1) The discharge process on 25th January 2017 did not include any cautionary advice as to the further use of medications such as paracetamol or ibuprofen as an analgesic particularly when Claire Medhurst had been experiencing headaches shortly before discharge and had been prescribed ibuprofen ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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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

Failure of haematology laboratory alerting for abnormal ALT and toxic paracetamol results

Wider context from the report

“(2) The treating clinicians did not receive an alert from the haematology laboratory for the abnormal results for ALT and toxic levels of paracetamol ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable clinical safety-alert systems; Unreliable laboratory notification of safety-critical problems and results; Unreliable monitoring and follow-up of clinically required laboratory tests.

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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 overdose medication safety advice in Emergency Department daily safety huddles.

Verbatim wording from the response

“2. The importance of providing essential information about paracetamol overdose and precaution around the use of other drugs that contains paracetamol upon discharge has been discussed in the Emergency Department daily safety huddles to ensure that all members of staff are aware of the importance of providing such information.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017

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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

Require staff to document discharge advice given to overdose patients in medical notes.

Verbatim wording from the response

“3. Staff are required to record the advice given to patients in the patients’ medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practice can be evidenced. The results from the first of these audit results is attached as appendix 1. The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017

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

Ratify, print and distribute the overdose information leaflet through Emergency Department discharge planning, with documented explanation and subsequent audit.

Verbatim wording from the response

“4. An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6th October 2017. Once ratified, leaflets will be printed and available in the ED on 23rd October 2017. Patients will receive this information as part of their medical management and discharge plan. Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme. The patient paracetamol overdose leaflet is attached as appendix 2.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 2 · response
Published 25 November 2017

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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

Brief Emergency Department and acute assessment staff on paracetamol and ibuprofen safety advice for overdose patients.

Verbatim wording from the response

“1. All key relevant staff will receive feedback via the appropriate staff meeting. These meetings are already scheduled and all clinicians within the Emergency Department and the acute assessment areas will receive the information through the staff briefings. All staff will be given an overview of the case and the importance of providing essential information to patients and their families on the use of drugs containing paracetamol and ibuprofen will be detailed.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017

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

Conduct monthly audits of documented overdose medication advice until practice is assured to be embedded and sustained.

Verbatim wording from the response

“3. Staff are required to record the advice given to patients in the patients’ medical notes. A spot check audit will be undertaken and this will take place regularly in order to ensure a consistent change in practice can be evidenced. The results from the first of these audit results is attached as appendix 1. The audit will occur monthly until the Directorate Governance Committee is assured that this practice is fully embedded and sustained.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 1 · response
Published 25 November 2017

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 an information leaflet explaining paracetamol overdose and medication precautions.

Verbatim wording from the response

“4. An information leaflet has been developed and will be ratified via the Directorate Governance Board on 6th October 2017. Once ratified, leaflets will be printed and available in the ED on 23rd October 2017. Patients will receive this information as part of their medical management and discharge plan. Staff will include in their documentation that a leaflet has been given and fully explained to the patient. Once implemented, this will be included in the monthly audit programme. The patient paracetamol overdose leaflet is attached as appendix 2.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 2 · response
Published 25 November 2017

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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

Audit compliance with SBAR reporting and associated critical-result protocols.

Verbatim wording from the response

“3. An audit will be conducted in October 2017 to measure compliance with SBAR and the associated protocols, and ensure Trust procedures are being adhered to.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 3 · response
Published 25 November 2017

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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

Require nurse-in-charge review of every overdose patient before transfer or discharge, incorporating the requirement into the revised operating framework.

Verbatim wording from the response

“5. All patients with an overdose must be reviewed by the nurse in charge of the department/acute assessment wards prior to their transfer or discharge. This will ensure that the patients’ medical management and discharge plan has been fully implemented. In the case of paracetamol overdose this has been included in the revised standard operating framework (appendix 3). The Trust adhere to national poisons guidance and access to this is available to all staff working in the ED/acute assessment areas.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 2 · response
Published 25 November 2017

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

Implement an automated paracetamol phone-trigger and ALT alert prompting laboratory staff to telephone critical results to requesting clinicians.

Verbatim wording from the response

“2. As a result of this incident an algorithm has been written to add a ‘paracetamol to phone’ trigger test. Furthermore, on the first occurrence of an ALT level outside of the safe range (>825), the system flags a reminder to the laboratory staff to telephone it through to the requesting clinician. This flagging system was implemented on 5th September 2017 and applies to all tests were the levels are outside of the safe range and require immediate actions by a clinician. The Biochemistry Department “when to telephone a result” document is attached as appendix 5.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 3 · response
Published 25 November 2017

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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

    Share the laboratory investigation outcome with staff involved and support reflective learning.

    Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.

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

Share the laboratory investigation outcome with staff involved and support reflective learning.

Verbatim wording from the response

“1. On 4th September 2017, the outcome of the investigation was shared with the staff involved in the incident. The member of staff was able to conclude a reflective practice and has demonstrated learning from this incident and that their usual standard of work is in line with Trust policy.”

Source location

2017-0270-Response-by-Medway-NSH-Trust
Page 3 · response
Published 25 November 2017

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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