Patricia Norfolk · Prevention of Future Deaths report

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Issued 5 Jul 2017•Manchester North

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
9

Described in responses

Recipients and published responses

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. Lack of daily senior clinician reviews for patients
    Part of recurring concern: Failure to provide effective senior clinical oversight of patient care

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Pennine Acute Hospitals NHS Trust

    Prepare a medical staffing paper to improve seven-day standards for daily senior clinical review.

  2. Pennine Acute Hospitals NHS Trust

    Feed the aspirational daily senior review action back to responsible action-plan leads for reflection on future actions.

  3. Pennine Acute Hospitals NHS Trust

    Train staff to recognise and escalate deteriorating patients.

  4. Pennine Acute Hospitals NHS Trust

    Establish a deteriorating-patient service improvement programme involving entire ward teams.

  5. Pennine Acute Hospitals NHS Trust

    Implement the National Early Warning Score for deteriorating patients.

  6. Pennine Acute Hospitals NHS Trust

    Recruit four substantive consultant posts to increase capacity for seven-day clinical review.

  7. Pennine Acute Hospitals NHS Trust

    Complete a full learning cycle on the deteriorating-patient change package.

  8. Pennine Acute Hospitals NHS Trust

    Select Innovation Wards to adopt the deteriorating-patient change package.

  9. Pennine Acute Hospitals NHS Trust

    Implement improved medical staffing to support seven-day clinical review.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Pennine Acute Hospitals NHS Trust

    The Trust considered the actions within its power to improve daily senior clinical review already taken and communicated, requiring no additional response work.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Pennine Acute Hospitals NHS Trust

    The Trust could not realistically provide daily senior clinical review to all patients because medical staffing constraints were outside its control.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. Pennine Acute Hospitals NHS Trust

    Further action on daily senior clinical review without recruitment should be addressed to the Secretary of State for Health as a national issue.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Lack of daily senior clinician reviews for patients

Wider context from the report

“That patients, such as the deceased, were not being receiving a daily senior clinician review. I have been appraised of the developments that the Trust is aspiring to in relation to senior daily reviews and decision making and recognise the steps the Trust is taking to recruit appropriate staff to undertake such reviews. However, I remain concerned regarding what happens to patients in the interim period pending recruitment and appointment. ”

Is this part of a recurring concern?

Yes — Failure to provide effective senior clinical oversight of patient care.

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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

Prepare a medical staffing paper to improve seven-day standards for daily senior clinical review.

Verbatim wording from the response

“Whilst not considered as contributory to Patricia Norfolk’s death, the necessity for daily senior clinical review did form part of the recommended actions to be taken by the Trust following its Root Cause Analysis (RCA). As outlined in the directive of Professor Makin (dated 15 March 2017), a paper on medical staffing in general and acute medicine within the Trust was prepared with a view to improving seven day standards for daily senior clinical review. This directive was provided to you under cover of a letter dated 15 March 2017.”

Source location

2017-0438
Page 1 · response
Published 5 July 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

Feed the aspirational daily senior review action back to responsible action-plan leads for reflection on future actions.

Verbatim wording from the response

“The Trust acknowledges that the action as per the RCA report for ‘all patients to receive a daily senior clinician review’ was, with hindsight, more aspirational than realistically achievable due to circumstances outside its control, as detailed above. This has been fed back to those responsible for the action plan, for reflection when considering future actions.”

Source location

2017-0438
Page 3 · response
Published 5 July 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

Train staff to recognise and escalate deteriorating patients.

Verbatim wording from the response

“To bridge the gap between the present situation and when medical staffing is optimised, the Trust has put in place a huge service improvement piece, led by Salford Royal, on the care of the deteriorating patient. It has involved entire ward teams & further details can be shared if needed. We have implemented the National Early Warning Score as a result of this and there has been training in recognition and escalation of the deteriorating patient.”

Source location

2017-0438
Page 2 · response
Published 5 July 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

Establish a deteriorating-patient service improvement programme involving entire ward teams.

Verbatim wording from the response

“To bridge the gap between the present situation and when medical staffing is optimised, the Trust has put in place a huge service improvement piece, led by Salford Royal, on the care of the deteriorating patient. It has involved entire ward teams & further details can be shared if needed. We have implemented the National Early Warning Score as a result of this and there has been training in recognition and escalation of the deteriorating patient.”

Source location

2017-0438
Page 2 · response
Published 5 July 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

Implement the National Early Warning Score for deteriorating patients.

Verbatim wording from the response

“To bridge the gap between the present situation and when medical staffing is optimised, the Trust has put in place a huge service improvement piece, led by Salford Royal, on the care of the deteriorating patient. It has involved entire ward teams & further details can be shared if needed. We have implemented the National Early Warning Score as a result of this and there has been training in recognition and escalation of the deteriorating patient.”

Source location

2017-0438
Page 2 · response
Published 5 July 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

Recruit four substantive consultant posts to increase capacity for seven-day clinical review.

Verbatim wording from the response

“Ultimately improved medical staffing will achieve seven day clinical review albeit the numbers required currently will be lessened with improvement in patient flow. Recruitment into posts is on-going and a Diabetologist, a Chest Consultant and a Geriatrician will start this year, with further interviews planned. £10 million of funding for new consultant posts has been agreed by our Salford Group colleagues.”

Source location

2017-0438
Page 2 · response
Published 5 July 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

Complete a full learning cycle on the deteriorating-patient change package.

Verbatim wording from the response

“The deteriorating patient collaborative will ensure that seven day clinical review will be available to those patients medically requiring of it. Mirroring the approach adopted by our Salford Group colleagues during their successful improvement collaborative in 2008, a full cycle of learning as regard to the methodology of the change package will be completed in November 2017 following which a cohort of Innovation Wards will be selected to represent a range of divisions and specialities across the organisation. These Innovation Wards will become the early adopters of the change package and will inform as to its spread and sustainability which will in turn inform the Trust-wide roll out of the successful interventions.”

Source location

2017-0438
Page 2 · response
Published 5 July 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

Select Innovation Wards to adopt the deteriorating-patient change package.

Verbatim wording from the response

“The deteriorating patient collaborative will ensure that seven day clinical review will be available to those patients medically requiring of it. Mirroring the approach adopted by our Salford Group colleagues during their successful improvement collaborative in 2008, a full cycle of learning as regard to the methodology of the change package will be completed in November 2017 following which a cohort of Innovation Wards will be selected to represent a range of divisions and specialities across the organisation. These Innovation Wards will become the early adopters of the change package and will inform as to its spread and sustainability which will in turn inform the Trust-wide roll out of the successful interventions.”

Source location

2017-0438
Page 2 · response
Published 5 July 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

Implement improved medical staffing to support seven-day clinical review.

Verbatim wording from the response

“Having considered the content of the letter and its enclosures, including the directive of Professor Makin, you subsequently highlighted that no corresponding timescale was attached to the stated aspiration of the Trust to deliver daily senior clinical decision making and sought further information. This information was provided within an email dated 26 May which provided you with a timescale for the implementation of improved daily senior clinical decision making, namely following the completion of the recruitment process of two new substantive consultant posts, estimated at that time to be September 2017. The precursor to these posts was Trust Board agreement to the paper prepared by Professor Makin and provision of funding for the two new substantive posts.”

Source location

2017-0438
Page 2 · response
Published 5 July 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

The Trust considered the actions within its power to improve daily senior clinical review already taken and communicated, requiring no additional response work.

Verbatim wording from the response

“The use of your PFD Report has not had any meaningful practical effect on the improvement of public safety given the actions within the Trust’s power to take have already been taken and communicated to you in advance of you issuing your PFD Report. Furthermore, the PFD Report’s practical effect is questionable given the date for the Trust’s response loosely coincides with the date originally envisaged for the implementation of improved medical staffing.”

Source location

2017-0438
Page 3 · response
Published 5 July 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

The Trust could not realistically provide daily senior clinical review to all patients because medical staffing constraints were outside its control.

Verbatim wording from the response

“The Trust acknowledges that the action as per the RCA report for ‘all patients to receive a daily senior clinician review’ was, with hindsight, more aspirational than realistically achievable due to circumstances outside its control, as detailed above. This has been fed back to those responsible for the action plan, for reflection when considering future actions.”

Source location

2017-0438
Page 3 · response
Published 5 July 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

Further action on daily senior clinical review without recruitment should be addressed to the Secretary of State for Health as a national issue.

Verbatim wording from the response

“Whilst the Trust has taken steps to address this within its locality, as previously indicated, this is a national issue and consequently any steps to address your concern as to daily senior clinical review in the absence of recruitment such as that undertaken by the Trust would more appropriately addressed to The Rt Hon Jeremy Hunt MP, Secretary of State for Health.”

Source location

2017-0438
Page 3 · response
Published 5 July 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