PFD report

Carol Ann Gibson · Prevention of Future Deaths report

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Issued 12 Oct 2013•Cheshire

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

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 raised4

  1. Lack of a robust system for posting patient safety alerts
    Part of recurring concern: Unreliable clinical safety-alert systems
  2. Lack of staff understanding and training to respond appropriately to patient safety alerts
  3. Failure of posted patient safety alerts to correctly and sufficiently identify the problem
    Part of recurring concern: Unreliable clinical safety-alert systems
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 robust system for posting patient safety alerts

Wider context from the report

“1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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 understanding and training to respond appropriately to patient safety alerts

Wider context from the report

“1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”

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

Failure of posted patient safety alerts to correctly and sufficiently identify the problem

Wider context from the report

“1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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 check adverse-reaction alerts before prescribing

Wider context from the report

“1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”

Is this part of a recurring concern?

Yes — Unreliable clinician management of medication side effects; Unsafe medication prescribing.

Open source report
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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