PFD report

Elsie May Treece · Prevention of Future Deaths report

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Issued 16 Dec 2013•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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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.

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Concerns and recipient responses

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Concerns raised1

  1. Failure to report inappropriate patient-handling incidents
    Part of recurring concern: Unreliable reporting of patient-safety incidents
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

    Link with the University to raise student nurses’ awareness of incident reporting and feedback mechanisms.

    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 16 December 2013.
  2. Action

    Provide additional incident-reporting training and support for Ward 6.

    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 16 December 2013.
  3. Action

    Implement paper-based documentation and incident reporting, with subsequent manual entry into the electronic system during HISS downtime.

    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 16 December 2013.

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 report inappropriate patient-handling incidents

Wider context from the report

“(1) I received information from the family that on the afternoon of the 26 July 2013, following difficulties in moving Mrs Treece, for a while hospital staff left one of Mrs Treece’s daughters (aged 70) supporting her mother. One of them then returned with a blue lifting bag with handles but she was not properly supported and fell back heavily on the bed with some force. Investigation has been carried out by ████████ the Ward 6 manager and I received a report which indicates there is no record of any such incident either in paper records, electronic records or from speaking to staff on duty. I did not investigate this incident fully because on balance it is unlikely to have been significant so far as the death is concerned. However the view I took on the evidence I did hear was that there had been an incident which should have been reported and may well not have been. I therefore write to you to enquire if staff need to be reminded or may need further training regarding the requirement to report inappropriate incidents even if no major harm seems to come to the patient involved. (2) While writing to you perhaps you could also find out for me the reasons why Mrs Treece did not have a CT scan of her head following the attendance on the 18 July 2013. This is not strictly a matter for this formal report but an answer would be appreciated. ”

Is this part of a recurring concern?

Yes — Unreliable reporting of patient-safety incidents.

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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

Link with the University to raise student nurses’ awareness of incident reporting and feedback mechanisms.

Verbatim wording from the response

“More recently, we have linked in with the University to raise awareness with student nurses surrounding the importance of incident reporting and the feedback mechanisms which occur.”

Source location

2013-0376-Response-by-Burton-Hospitals-NHS
Page 1 · response
Published 16 December 2013

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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

Provide additional incident-reporting training and support for Ward 6.

Verbatim wording from the response

“Currently training is provided at Trust induction days, mandatory update training days, online training and ad hoc sessions in ward and department areas and provided for medical staff in different forum. Ad hoc training is provided as requested, and in light of this request for information from HM Coroner, we have arranged to provide additional training and support for Ward 6.”

Source location

2013-0376-Response-by-Burton-Hospitals-NHS
Page 1 · response
Published 16 December 2013

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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

Implement paper-based documentation and incident reporting, with subsequent manual entry into the electronic system during HISS downtime.

Verbatim wording from the response

“Whilst it has been acknowledged that there was a period of downtime for the HISS computer system which occurred during the time of Mrs Treece’s admission, contingency plans were put in place which instigated the use of paper based documentation, and including paper based incident forms. Those paper incident forms received during and following the downtime were manually entered into the electronic system.”

Source location

2013-0376-Response-by-Burton-Hospitals-NHS
Page 1 · response
Published 16 December 2013

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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

    The patient’s symptoms and signs did not indicate a significant head injury or require CT imaging under NICE guidance.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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’s symptoms and signs did not indicate a significant head injury or require CT imaging under NICE guidance.

Verbatim wording from the response

“Her symptoms and signs were not consistent with a significant head injury and therefore we would not have proceeded to do a CT scan as per NICE head injury guidance. There was no indication to carry out a CT scan at the time.”

Source location

2013-0376-Response-by-Burton-Hospitals-NHS
Page 2 · response
Published 16 December 2013

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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