PFD report

Elizabeth Mavis HUTCHINS · Prevention of Future Deaths report

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Issued 19 Apr 2023•Avon

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. Unavailability of an acute cardiac syndrome specialist nurse practitioner role
  2. Lack of a hospital at night team for managing and coordinating night-time clinical calls and tasks
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

    Complete the business case and Standard Operating Procedure for the Hospital at Night approach.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 April 2023.
  2. Action

    Repurpose existing night doctors and Night Sisters as a Hospital at Night Team and introduce the approach using PDSA methodology.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.

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

Unavailability of an acute cardiac syndrome specialist nurse practitioner role

Wider context from the report

“I was told that there have been a number of changes following this death at the RUH. However that there were two areas which remain outstanding: (1) The hospital at night team, to assist with management of the hospital at night, take calls from wards, log and triage the calls, coordinate the night team, send clinicians tasks – this is still to be put into place, funding has not been secured for this. (2) The acute cardiac syndrome (ACS) specialist nurse practitioner role – this is not in existence at this time which I am told would be an excellent compliment for the teams and support staff during the daytime hours. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 hospital at night team for managing and coordinating night-time clinical calls and tasks

Wider context from the report

“I was told that there have been a number of changes following this death at the RUH. However that there were two areas which remain outstanding: (1) The hospital at night team, to assist with management of the hospital at night, take calls from wards, log and triage the calls, coordinate the night team, send clinicians tasks – this is still to be put into place, funding has not been secured for this. (2) The acute cardiac syndrome (ACS) specialist nurse practitioner role – this is not in existence at this time which I am told would be an excellent compliment for the teams and support staff during the daytime hours. ”

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

Complete the business case and Standard Operating Procedure for the Hospital at Night approach.

Verbatim wording from the response

“Weekly meetings are taking place led by the Deputy Medical Director which have secured significant clinical engagement. The Trust has in post 11 doctors at night and 3.6 whole time equivalent band 6 Night Sisters. This resource will be re-purposed to operate as a Hospital at Night Team. A business case for additional resource to support this new approach to night time working has been written, together with a Standard Operating Procedure. This will be introduced, utilising PDSA methodology, from July 2023.”

Source location

Response from Royal United Hosiptals Bath NHS Foundation Trust
Page 1 · response
Published 26 April 2023

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

Repurpose existing night doctors and Night Sisters as a Hospital at Night Team and introduce the approach using PDSA methodology.

Verbatim wording from the response

“Weekly meetings are taking place led by the Deputy Medical Director which have secured significant clinical engagement. The Trust has in post 11 doctors at night and 3.6 whole time equivalent band 6 Night Sisters. This resource will be re-purposed to operate as a Hospital at Night Team. A business case for additional resource to support this new approach to night time working has been written, together with a Standard Operating Procedure. This will be introduced, utilising PDSA methodology, from July 2023.”

Source location

Response from Royal United Hosiptals Bath NHS Foundation Trust
Page 1 · response
Published 26 April 2023

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

    Conduct weekly meetings led by the Deputy Medical Director to secure clinical engagement for the Hospital at Night approach.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2023.
  2. 2

    Deliver bespoke acute cardiac syndrome training to the Outreach Nursing Team and Night Sisters, recording the session and adding completion to formal training records.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 April 2023.

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 weekly meetings led by the Deputy Medical Director to secure clinical engagement for the Hospital at Night approach.

Verbatim wording from the response

“Weekly meetings are taking place led by the Deputy Medical Director which have secured significant clinical engagement. The Trust has in post 11 doctors at night and 3.6 whole time equivalent band 6 Night Sisters. This resource will be re-purposed to operate as a Hospital at Night Team. A business case for additional resource to support this new approach to night time working has been written, together with a Standard Operating Procedure. This will be introduced, utilising PDSA methodology, from July 2023.”

Source location

Response from Royal United Hosiptals Bath NHS Foundation Trust
Page 1 · response
Published 26 April 2023

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

Deliver bespoke acute cardiac syndrome training to the Outreach Nursing Team and Night Sisters, recording the session and adding completion to formal training records.

Verbatim wording from the response

“The Outreach Nursing Team and Night Sisters will receive bespoke ACS training from a Consultant Cardiologist. The Outreach Team are called to assess deteriorating in-patients and work 24/7 so are ideally placed to upskill in this area. The training will commence within eight weeks and the aim is for the whole team to receive this training within six months. The training will initially be delivered as a “live” session and will then be recorded to maximise ease of access. Completion of this training will form part of the Night Sisters’ and Outreach Nursing Team’s formal training record.”

Source location

Response from Royal United Hosiptals Bath NHS Foundation Trust
Page 1 · response
Published 26 April 2023

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