PFD report

Ronald Sidney Ellwood · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 6 Feb 2014•Staffordshire 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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of fresh air in intensive care units
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.3

  1. Action

    Refurbish hospital air-conditioning systems, reassess environmental conditions and redesign controls for increased heat loads, including in the ITU.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 August 2013.
  2. Action

    Maintain annual maintenance, cleaning, pressure and volume checks of Critical Care ventilation systems.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 August 2013.
  3. Action

    Continue ensuring that Critical Care Unit windows remain closed to protect specialised ventilation performance and patient safety.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 August 2013.

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

  1. Position

    The existing specialised ventilation system is considered safer than opening windows, which would compromise air changes and increase contamination risk.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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

Lack of fresh air in intensive care units

Wider context from the report

“Mr Ellwood died as the result of a chest infection. He had spent several weeks in the intensive care unit (ICU) at Queen’s Hospital and I heard helpful evidence from ████████ Clinical Lead for Critical Care about the number of bugs that those invasive tubes are subject to and the need to treat the bugs that may be causing harm. Mr Ellwood’s widow referred to the heat and a lack of fresh air in the ICY. ████████ indicated that the ICU did have air conditioning but he was sympathetic to the suggestion of more fresh air although this was an estates issue. This may have been considered in the past but I wonder if it may be to the benefit rather than detriment of patients in intensive care to have more fresh air (through opened windows) as opposed to recycled air through air conditioning? ”

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

Refurbish hospital air-conditioning systems, reassess environmental conditions and redesign controls for increased heat loads, including in the ITU.

Verbatim wording from the response

“A refurbishment of the Air Conditioning Systems units within the hospital is currently planned to commence with the next years capital program. At this time the current environmental conditions within the hospital will be re-evaluated and the system designed to control the environment with the additional heat loads within the building, especially within the ITU unit where the advancement in medical equipment has substantially increased the heat loadings within ITU.”

Source location

2013-0222-Response-by-Burton-Hospitals-NHS-Foundation-Trust
Page 3 · response
Published 15 August 2013

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

Maintain annual maintenance, cleaning, pressure and volume checks of Critical Care ventilation systems.

Verbatim wording from the response

“The systems are subjected to annual maintenance by the estates staff and this was last carried out in March 2013. The ventilation work and systems were cleaned and systems pressures and volumes were externally assessed by Total Environmental and Mechanical Services (TEAMS) in July 2010 and there is no requirement for alterations to the system before the next revalidation checks in 2015.”

Source location

2013-0222-Response-by-Burton-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 15 August 2013

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

Continue ensuring that Critical Care Unit windows remain closed to protect specialised ventilation performance and patient safety.

Verbatim wording from the response

“The system is designed to operate with all windows closed so that the temperature can be controlled. In 2001 when the High Dependency Unit was added to the hospital, additional supplementary cooling was added to the critical care unit suite, again with 100% fresh air.”

Source location

2013-0222-Response-by-Burton-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 15 August 2013

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 existing specialised ventilation system is considered safer than opening windows, which would compromise air changes and increase contamination risk.

Verbatim wording from the response

“The Trust can demonstrate that the Critical Care Unit conforms to the applicable guidance and memorandum from specialised ventilation. By opening the windows, it makes this system less efficient and compromise air changes that may lead to increased environmental air contamination. The system is appropriately maintained and checked.”

Source location

2013-0222-Response-by-Burton-Hospitals-NHS-Foundation-Trust
Page 3 · response
Published 15 August 2013

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

No alteration to the ventilation system is required before the next revalidation checks because it is maintained and externally assessed.

Verbatim wording from the response

“The systems are subjected to annual maintenance by the estates staff and this was last carried out in March 2013. The ventilation work and systems were cleaned and systems pressures and volumes were externally assessed by Total Environmental and Mechanical Services (TEAMS) in July 2010 and there is no requirement for alterations to the system before the next revalidation checks in 2015.”

Source location

2013-0222-Response-by-Burton-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 15 August 2013

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Routine microbiological testing is not considered necessary because guidance does not require it and testing occurs when linked cases indicate a risk.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 microbiological testing is not considered necessary because guidance does not require it and testing occurs when linked cases indicate a risk.

Verbatim wording from the response

“The guidance does not indicate that microbiological testing is necessary.”

Source location

2013-0222-Response-by-Burton-Hospitals-NHS-Foundation-Trust
Page 2 · response
Published 15 August 2013

Open published response
Back to top

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