PFD report

Alexander Frederick Richard GREEN · Prevention of Future Deaths report

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Issued 1 Apr 2019•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
3

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 raised3

  1. Failure of handovers to support effective communication and challenge
    Part of recurring concern: Unreliable clinical handover processes
  2. Failure to apply the NICE head injury guideline before attributing depressed consciousness to intoxication
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries
  3. Failure to recognise and mitigate bias when assessing possible intoxication
    Part of recurring concern: Failure to investigate concerning presentations beyond initial appearance and self-report
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.11

  1. Action

    Pilot further standardised paediatric handover improvements, including the validated ISOBAR tool.

    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 9 June 2019.
  2. Action

    Launch an education and awareness campaign supporting SBAR as the core element of patient-level handovers.

    Stated by Royal United Hospitals Bath NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 June 2019.
  3. Action

    Develop a tool guiding staff to exclude brain injury safely in intoxicated patients, including examination findings and a step-by-step head examination.

    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 9 June 2019.

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 handovers to support effective communication and challenge

Wider context from the report

“1. The handover at around 8am resulted in a failure to challenge and communicate effectively. Handovers need to be considered across the whole of the trust not just the emergency department to ensure they are appropriate and effective. The reason I include this as a trust wide matter of concern is that I have recently dealt with another case where there were failures in the handover on another ward at the Royal United Hospital. I have been advised that other hospitals use the SBAR tool at handovers to assist in communication. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes.

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 apply the NICE head injury guideline before attributing depressed consciousness to intoxication

Wider context from the report

“2. The NICE guideline for head injury was not considered appropriate for use in this case when it is clearly designed for exactly this case – you ascribe depressed conscious levels to intoxication only after a significant brain injury has been excluded. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries.

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 recognise and mitigate bias when assessing possible intoxication

Wider context from the report

“3. There was an assumption by everyone managing Alex that he was intoxicated when in fact he had a significant head injury; SWAST I am told have developed training in relation to bias (and intoxication is included in that). ”

Is this part of a recurring concern?

Yes — Failure to investigate concerning presentations beyond initial appearance and self-report.

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

Pilot further standardised paediatric handover improvements, including the validated ISOBAR tool.

Verbatim wording from the response

“There has been a review of improvements already made in general medicine handovers to see how good practice can be built upon and spread throughout the hospital. A draft standard operating procedure that forms the core of all handovers has been approved. Paediatrics have made significant changes to standardise handovers and are piloting further improvements including use of a validated extended SBAR tool called ISOBAR. It is agreed that SBAR will be the core element for all patient level handovers across the hospital and an education and awareness campaign is about to be launched.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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

Launch an education and awareness campaign supporting SBAR as the core element of patient-level handovers.

Verbatim wording from the response

“There has been a review of improvements already made in general medicine handovers to see how good practice can be built upon and spread throughout the hospital. A draft standard operating procedure that forms the core of all handovers has been approved. Paediatrics have made significant changes to standardise handovers and are piloting further improvements including use of a validated extended SBAR tool called ISOBAR. It is agreed that SBAR will be the core element for all patient level handovers across the hospital and an education and awareness campaign is about to be launched.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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 a tool guiding staff to exclude brain injury safely in intoxicated patients, including examination findings and a step-by-step head examination.

Verbatim wording from the response

“We are developing a tool that will assist and guide staff in safely excluding a brain injury in those patients who are believed to be intoxicated, that will strike the right balance between CT scanning those patients who need a scan and avoiding scanning those patients where a CT scan is only likely to cause potentially avoidable harm through exposure to radiation. It is envisaged that this tool will set out specific findings on an examination that might indicate a brain injury as opposed to intoxication, including a detailed step by step guide on how to carry out a thorough physical examination of a patient’s head.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019

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

Use the confirmation-bias training tool in every ED junior doctor teaching programme and reiterate it in department handovers.

Verbatim wording from the response

“Working with the South West Ambulance Service, a training tool has been created which includes “Confirmation Bias” and the need to challenge the working diagnosis in any patient who fails to follow the anticipated clinical course. This will be utilised in every ED junior doctor teaching programme and reiterated in department handovers.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019

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

Incorporate SBAR into paediatric, nursing, and Observation Unit handover documentation and processes.

Verbatim wording from the response

“b) An SBAR tool has been added to the Paediatric proforma used to facilitate safe handover between clinicians, specifically focusing on outstanding concerns and actions to be taken.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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

Operate a working group to standardise handovers through education and training, reporting to the Deteriorating Patient Steering Group.

Verbatim wording from the response

“The Medical Director has commissioned a working group with the Trust Medical Safety Lead to improve handovers through standardisation, education and training. This group reports into the Deteriorating Patient Steering Group, chaired by the Medical Director, with a focus on reducing avoidable harm. This is a Trust breakthrough Objective for 2019/20.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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 existing general medicine handover improvements to identify good practice for wider hospital adoption.

Verbatim wording from the response

“There has been a review of improvements already made in general medicine handovers to see how good practice can be built upon and spread throughout the hospital. A draft standard operating procedure that forms the core of all handovers has been approved. Paediatrics have made significant changes to standardise handovers and are piloting further improvements including use of a validated extended SBAR tool called ISOBAR. It is agreed that SBAR will be the core element for all patient level handovers across the hospital and an education and awareness campaign is about to be launched.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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

Establish a pathway for senior review and further investigation when intoxicated patients do not recover within the expected timeframe after significant head injury is excluded.

Verbatim wording from the response

“For those patients in whom a significant head injury has been excluded and are diagnosed as being intoxicated, the Trust has developed a pathway to ensure that patients who fail to recover within the anticipated timeframe are reviewed by a senior doctor. This is to consider the possibility of an alternative diagnosis such as injury or illness not detected on initial assessment and to allow appropriate further investigations to be completed.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019

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

Approve a draft standard operating procedure as the core standard for Trust handovers.

Verbatim wording from the response

“There has been a review of improvements already made in general medicine handovers to see how good practice can be built upon and spread throughout the hospital. A draft standard operating procedure that forms the core of all handovers has been approved. Paediatrics have made significant changes to standardise handovers and are piloting further improvements including use of a validated extended SBAR tool called ISOBAR. It is agreed that SBAR will be the core element for all patient level handovers across the hospital and an education and awareness campaign is about to be launched.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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

Create a training tool addressing confirmation bias and challenging diagnoses when patients fail to follow the expected clinical course.

Verbatim wording from the response

“Working with the South West Ambulance Service, a training tool has been created which includes “Confirmation Bias” and the need to challenge the working diagnosis in any patient who fails to follow the anticipated clinical course. This will be utilised in every ED junior doctor teaching programme and reiterated in department handovers.”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 2 · response
Published 9 June 2019

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

Allocate non-referred patients to an ED clinician expected to remain present throughout their ED stay, barring unforeseen circumstances.

Verbatim wording from the response

“The Emergency Department have taken the following steps:”

Source location

2019-0117-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
Page 1 · response
Published 9 June 2019

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