PFD report

Michael Nestor WYSOCKYJY · Prevention of Future Deaths report

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Issued 24 May 2022•Norfolk

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised2

  1. Lack of escalation arrangements for outstanding x-ray requests
    Part of recurring concern: Failure to ensure scheduled investigations are followed upPart of recurring concern: Unreliable X-ray request and progression processes
  2. Inability to offload ambulances promptly, delaying access to x-ray
    Part of recurring concern: Delays in ambulance-to-hospital patient handoverPart of recurring concern: Failure to maintain safe hospital patient flow
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.1

  1. Action

    Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Physical constraints prevent X-rays on ambulances; no alternative exists beyond careful clinical assessment during busy periods.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 escalation arrangements for outstanding x-ray requests

Wider context from the report

“2. The need for an x-ray remains with the nurse, nurse in charge and/or doctor. If an x-ray is not carried out, the request remains with the nurse, nurse in charge and/or doctor and it was not clear from the evidence there is anything in place to ensure this is escalated and the x-ray takes place. This is something that can be missed in a busy department. ”

Is this part of a recurring concern?

Yes — Failure to ensure scheduled investigations are followed up; Unreliable X-ray request and progression processes.

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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

Inability to offload ambulances promptly, delaying access to x-ray

Wider context from the report

“1. The ED was busy at the time and unable to offload ambulances. An x-ray cannot be carried out on an ambulance and must wait until the patient is in ED. If the patient remains on the ambulance for several hours this can delay the x-ray taking place. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover; Failure to maintain safe hospital patient flow.

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

Upgrade the Emergency Department two-hourly-round checklist to prompt escalation of outstanding investigations, including imaging and blood tests.

Verbatim wording from the response

“Response: The Emergency Department does operate a system whereby two hourly rounds are conducted for patients in the department. This is carried out by the Band 7 nurse in charge and involves a checklist of clinical and other criteria to ensure that if clinically indicated, appropriate escalation takes place. The intention is that amongst all the other parameters if an investigation such as imaging or blood tests is awaited, this should also be escalated if there is a need to do so. However, it is correct to say that at the time of the inquest the check list contained no specific reference to investigations. The checklist has therefore been upgraded to include this (new version attached with the amendment highlighted).”

Source location

Response from NHS Queen Elizabeth Hospital Kings's Lynn
Page 2 · response
Published 24 May 2022

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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

Physical constraints prevent X-rays on ambulances; no alternative exists beyond careful clinical assessment during busy periods.

Verbatim wording from the response

“Response: It is correct to say that an X-ray cannot be undertaken on an ambulance because the radiology equipment that generates ionising radiation is insufficiently mobile and too large to be used in this setting. If it is thought by the assessing clinician who goes on to the ambulance that a patient’s need for an X-ray is urgent or an emergency, that patient will be prioritised to be removed from the vehicle as soon as possible. Although conditions for patients are not ideal whilst waiting to enter the Emergency Department, in this way their clinical needs in terms of urgent imaging remain the same as if the patient had already been transferred into the department.”

Source location

Response from NHS Queen Elizabeth Hospital Kings's Lynn
Page 1 · response
Published 24 May 2022

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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