PFD report

Elsie Mallalie u · Prevention of Future Deaths report

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Issued 17 Nov 2014•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.

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Concerns
8

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 raised8

  1. Failure to activate intravenous antibiotic infusions
    Part of recurring concern: Unsafe medication administration
  2. Failure to make appropriate resuscitation and critical-care escalation decisions
  3. Insufficient qualified ward staffing capacity for patient workload and complexity
    Part of recurring concern: Insufficient clinical workload capacity for completing important patient-care tasksPart of recurring concern: Insufficient qualified healthcare staffing capacity
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

    Develop and pilot integrated health records across specialties to improve information sharing and prevent loss of vital information.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 November 2014.
  2. Action

    Reduce agency-staff use, address substantive vacancies and maintain registered nursing levels.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2014.
  3. Action

    Replace PARS with NEWS, train Trust staff in NEWS scoring, provide an escalation guide and maintain refresher training as needed.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2014.

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

  1. Position

    The patient was not written off; the DNAR decision was appropriate and escalation to ventilation remained reasonable under responsible medical opinion.

    Stated by Tameside and Glossop Integrated Care 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 activate intravenous antibiotic infusions

Wider context from the report

“5. A Consultant agreed with my conclusion that this patient was “written off” and that a DNAR should not have been placed and that she could have been escalated to ITU/HDU where the infection which in fact led to her death, might have been treatable. Whilst on ward 41 she was administered antibiotics for this condition but the nursing staff had failed to “turn on “the drip delivering the drug. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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 appropriate resuscitation and critical-care escalation decisions

Wider context from the report

“5. A Consultant agreed with my conclusion that this patient was “written off” and that a DNAR should not have been placed and that she could have been escalated to ITU/HDU where the infection which in fact led to her death, might have been treatable. Whilst on ward 41 she was administered antibiotics for this condition but the nursing staff had failed to “turn on “the drip delivering the drug. ”

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

Insufficient qualified ward staffing capacity for patient workload and complexity

Wider context from the report

“4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10) ”

Is this part of a recurring concern?

Yes — Insufficient clinical workload capacity for completing important patient-care tasks; Insufficient qualified healthcare staffing capacity.

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 conduct timely and continuous patient observations

Wider context from the report

“4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10) ”

Is this part of a recurring concern?

Yes — Failure to maintain required continuous patient observation.

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

Placement of patients in inappropriate wards

Wider context from the report

“1. During the course of her relatively short stay in the hospital she was moved to Ward 41 which, as agreed in evidence by senior medical staff, was an inappropriate ward for her. ”

Is this part of a recurring concern?

Yes — Failure to ensure people are placed in care settings suitable for their needs.

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 accurately calculate and use patient observation scores

Wider context from the report

“4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10) ”

Is this part of a recurring concern?

Yes — Unreliable clinical Early Warning Score systems for deterioration; Unreliable patient observation arrangements.

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 staff training to use high flow oxygen equipment

Wider context from the report

“2. She was entirely dependent on high flow oxygen, but none of the staff on ward 41 was trained to use this equipment. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence to administer oxygen therapy.

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 adequately record essential patient care in medical and nursing notes

Wider context from the report

“3. The medical and nursing notes on ward 41 were woefully inadequate, and failed to record some of the most basic care which was, or ought to have been, given. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Develop and pilot integrated health records across specialties to improve information sharing and prevent loss of vital information.

Verbatim wording from the response

“There is also a proposal for integrated health records and for a pilot project to take place for each specialty within the Trust. A task and finish group is currently exploring this but to date ITU, Outreach and AMU began trialling integrated notes in November 2014. Integrated health records are now standard across most Trusts and should safeguard against vital information being lost as well as having a more universal and systematic approach to sharing information. Overall, it will provide a more transparent and robust approach throughout the Trust.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 17 November 2014

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

Reduce agency-staff use, address substantive vacancies and maintain registered nursing levels.

Verbatim wording from the response

“Response The staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs Mallalieu was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014

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

Replace PARS with NEWS, train Trust staff in NEWS scoring, provide an escalation guide and maintain refresher training as needed.

Verbatim wording from the response

“With regards the failure to take observations during the night shift; this occurred because a member of the nursing staff unfortunately miscalculated the PARS score, which meant that Mrs Mallalieu did not have her observations taken as she would have done if scoring had been correct. Since Mrs Mallalieu’s treatment the PARS scoring system has been replaced by a different system called NEWS and Trust staff have been trained in the use of it. A quick reference NEWS escalation and response guide has also been made available to all staff. The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014

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

Train orthopaedic doctors, including during junior-doctor induction, on senior approval, documentation and appropriate ward transfers.

Verbatim wording from the response

“Response Following detailed investigations, action has been taken to minimise the risk of inappropriate transfer occurring in the future. Training has been provided to doctors in the Orthopaedic Department to make them aware of the following:”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 1 · response
Published 17 November 2014

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

Communicate requirements to consider staffing levels and skills before transfers between specialties or ward areas.

Verbatim wording from the response

“We have taken action to address this by communicating to all staff that where possible, staffing levels and skills must be considered prior to transfer between specialties and / or ward areas, to ensure that patients continue to receive the appropriate level of care. Additionally, a schedule of training has been put in place for the staff on Ward 41 regarding high-flow oxygen, although it is rarely used by staff on Ward 41. Training by the Trust’s equipment trainer has progressed and sessions will be on the wards where all staff would be able to attend as appropriate. In the meantime, the physiotherapists are also providing staff with training on the wards when there is a patient requiring high flow oxygen. Following feedback, we know that the physiotherapists are being very supportive in this interim role.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 17 November 2014

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

Review current record-keeping training to reinforce clarity and completeness.

Verbatim wording from the response

“Response The Trust’s internal investigation identified deficiencies in the record keeping in this case and is undertaking a review of its current training on record keeping standards. Such training will reinforce the need for clarity and completeness.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 17 November 2014

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

Provide high-flow oxygen training for Ward 41 staff through scheduled equipment-trainer sessions and interim physiotherapist support.

Verbatim wording from the response

“We have taken action to address this by communicating to all staff that where possible, staffing levels and skills must be considered prior to transfer between specialties and / or ward areas, to ensure that patients continue to receive the appropriate level of care. Additionally, a schedule of training has been put in place for the staff on Ward 41 regarding high-flow oxygen, although it is rarely used by staff on Ward 41. Training by the Trust’s equipment trainer has progressed and sessions will be on the wards where all staff would be able to attend as appropriate. In the meantime, the physiotherapists are also providing staff with training on the wards when there is a patient requiring high flow oxygen. Following feedback, we know that the physiotherapists are being very supportive in this interim role.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 17 November 2014

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

Assess staffing through ward-based accreditation and unannounced walk rounds.

Verbatim wording from the response

“Staffing is also being assessed as part of ward based accreditation and unannounced walk rounds.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014

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

Monitor staffing levels and skill mix through daily reporting, assurance processes, escalation arrangements and senior nursing support.

Verbatim wording from the response

“Nurse staffing levels are being monitored through multiple assurance sources including the Trust Board Hard Truths paper. Additionally, the Trust’s Board is actively monitoring staff levels and the skill mix across the Trust. This involves staff levels being considered daily alongside daily staffing level reports and bed management, which involves the Deputy Director of Nursing. There is also a focus on reporting low staffing levels following which there is an escalation process involving the individual nurse in-charge, the senior nurse, the Divisional Head of Nursing and the Director of Nursing. This will also enable senior nurse intervention and support where required.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014

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 patient was not written off; the DNAR decision was appropriate and escalation to ventilation remained reasonable under responsible medical opinion.

Verbatim wording from the response

“Response Although, as addressed above, Mrs Mallalieu should not have been transferred to Ward 41 from the Trauma Unit it is certainly not the case that she was “written off”. Nevertheless, admittedly she was a very ill patient with a poor prognosis and this was supported by the Trust’s commissioned independent expert report of ████████ Consultant Geriatrician which was sent to your offices prior to the inquest.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 4 · response
Published 17 November 2014

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

Ward 41 staffing levels met national guidelines, although the ward was busy and further action addressed agency use and substantive vacancies.

Verbatim wording from the response

“Response The staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs Mallalieu was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained.”

Source location

2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014

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