PFD report

Olive DAYNES · Prevention of Future Deaths report

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Issued 28 Mar 2017•South Lincolnshire

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 raised1

  1. Failure to communicate hospital advice, medication changes and increased INR levels to the GP in time
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable communication of critical medication information to GPs
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.5

  1. Action

    Issue and recirculate standards for communicating test results between secondary and primary care.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2017.
  2. Action

    Develop electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2017.
  3. Action

    Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2017.

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

  1. Position

    Electronic A&E-to-GP communication cannot yet be implemented because competing Trust-wide electronic systems and IT upgrades constrain progress.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 communicate hospital advice, medication changes and increased INR levels to the GP in time

Wider context from the report

“1. On 28/12/2015 Mrs. Daynes was admitted to Accident and Emergency at the Pilgrim Hospital, Fishtoft, and Boston following painful / sore legs/ulcers. 2. Her INR was recorded at 3.6, her medication changed and the matter was referred back to the GP. 3. A doctor from the GP's surgery saw Mrs Daynes the next day on 29th December 2015 but was unaware of the advice provided by the hospital, change in medication or increased IRN levels. 4. The hospital wrote to the surgery and the letter arrived on 4/2/2016 (date stamp verified by the Coroner). 5. In the intervening period the patients INR increased to over 9 and she passed away on 5/1/2016. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable communication of critical medication information to GPs.

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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

Issue and recirculate standards for communicating test results between secondary and primary care.

Verbatim wording from the response

“7. In 2016 the Trust and the Lincolnshire Local Medical Committee issued a document setting the standards and principles by which test results should be communicated by secondary and primary care. I enclose a copy of this document which was sent to all clinicians within ULHT. This has been circulated again to remind colleagues of their responsibilities.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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

Develop electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.

Verbatim wording from the response

“9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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

Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.

Verbatim wording from the response

“5. In order to prevent similar deaths in the future, the discharge letter is sent by electronic means to the appropriate GP email address of the appropriate GP surgery.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 1 · response
Published 5 April 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

Write to the lead clinicians of all three Accident and Emergency departments about the concerns and required timely communication.

Verbatim wording from the response

“8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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

Circulate an organisation-wide patient safety bulletin on antibiotic-related anticoagulation interactions and timely communication.

Verbatim wording from the response

“8. With reference to the prescription of antibiotics which led to the abnormal anticoagulation for Mrs Daynes, a Patient Safety Bulletin highlighting this interaction and the need for effective and timely communication has been circulated across the organisation. I attach a copy of this. I have written to the Lead Clinicians of our 3 Accident and Emergency Departments highlighting the concerns you have raised as well as the need to ensure appropriate and timely communication.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 2017

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

Electronic A&E-to-GP communication cannot yet be implemented because competing Trust-wide electronic systems and IT upgrades constrain progress.

Verbatim wording from the response

“9. At present electronic communication between the A & E Department and Primary Care is not available to the Trust. However, we are aware of an impending requirement to move to this. We are therefore in the process of developing electronic documentation in the A & E Department which will also enable direct electronic communication of clinical information to the patients GP. Our ability to progress this is influenced by a range of other actions currently being rolled out including:”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 2017

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.6

  1. 1

    Put the electronic hospital-death communication template into operation.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 April 2017.
  2. 2

    Roll out the new electronic maternity system and upgrade the Trust’s information technology software.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2017.
  3. 3

    Develop the electronic communication template for hospital deaths.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2017.
  4. 4

    Introduce electronic prescribing.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 April 2017.
  5. 5

    Introduce electronic patient records.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 April 2017.
  6. 6

    Roll out trust-wide electronic observation and charting across approximately 60 wards.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 April 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

Put the electronic hospital-death communication template into operation.

Verbatim wording from the response

“6. Electronic communication to GPs following the discharge of inpatients is already in place and has been for some time. The expectation is that electronic discharge letters are sent to the patients GP within 24 hours of discharge on 95% of occasions. Our compliance with this has improved from 74% (April 2016) to 83% (March 2017). This is under constant review by a Task and Finish Group which is Chaired by myself. We have also developed a template for the electronic communication of deaths in hospital. The aim of this is in order to facilitate time and communication for the benefit of the relatives, carers and GPs. I anticipate this to be up and running in the next 6 months.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 1 · response
Published 5 April 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

Roll out the new electronic maternity system and upgrade the Trust’s information technology software.

Verbatim wording from the response

“10. Electronic Observation and Charting Trust Wide (approx. 60 Wards), a new electronic maternity system as well as upgrading our IT software. We are also aiming to introduce electronic patient records as well as an electronic prescribing; both of which will improve patient safety. For the immediate future we will remain restricted to conventional correspondence.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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 the electronic communication template for hospital deaths.

Verbatim wording from the response

“6. Electronic communication to GPs following the discharge of inpatients is already in place and has been for some time. The expectation is that electronic discharge letters are sent to the patients GP within 24 hours of discharge on 95% of occasions. Our compliance with this has improved from 74% (April 2016) to 83% (March 2017). This is under constant review by a Task and Finish Group which is Chaired by myself. We have also developed a template for the electronic communication of deaths in hospital. The aim of this is in order to facilitate time and communication for the benefit of the relatives, carers and GPs. I anticipate this to be up and running in the next 6 months.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 1 · response
Published 5 April 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

Introduce electronic prescribing.

Verbatim wording from the response

“10. Electronic Observation and Charting Trust Wide (approx. 60 Wards), a new electronic maternity system as well as upgrading our IT software. We are also aiming to introduce electronic patient records as well as an electronic prescribing; both of which will improve patient safety. For the immediate future we will remain restricted to conventional correspondence.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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

Introduce electronic patient records.

Verbatim wording from the response

“10. Electronic Observation and Charting Trust Wide (approx. 60 Wards), a new electronic maternity system as well as upgrading our IT software. We are also aiming to introduce electronic patient records as well as an electronic prescribing; both of which will improve patient safety. For the immediate future we will remain restricted to conventional correspondence.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 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

Roll out trust-wide electronic observation and charting across approximately 60 wards.

Verbatim wording from the response

“10. Electronic Observation and Charting Trust Wide (approx. 60 Wards), a new electronic maternity system as well as upgrading our IT software. We are also aiming to introduce electronic patient records as well as an electronic prescribing; both of which will improve patient safety. For the immediate future we will remain restricted to conventional correspondence.”

Source location

Regulation-28-response-from-United-Lincolnshire-Hospitals-NHS-Trust-12052017
Page 2 · response
Published 5 April 2017

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