PFD report

Mr James Mc Manus · Prevention of Future Deaths report

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Issued 13 Mar 2015•Manchester North

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
7

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 staff knowledge, application and implementation of guidelines for managing bleeding associated with thrombolytic therapy
    Part of recurring concern: Unsafe management of significant bleeding
  2. Lack of staff knowledge, application and implementation of protocols for managing massive blood loss
    Part of recurring concern: Unsafe management of significant bleeding
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

    Deliver mandatory training on thrombolysis policies and associated bleeding risks to medical staff.

    Stated by Pennine Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 March 2015.
  2. Action

    Deliver thrombolysis and bleeding-risk training to Critical Care staff.

    Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 March 2015.
  3. Action

    Circulate and maintain the new thrombolysis policy on the Trust intranet.

    Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 March 2015.

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 knowledge, application and implementation of guidelines for managing bleeding associated with thrombolytic therapy

Wider context from the report

“1. I am concerned about the lack of knowledge, application and implementation of key protocols by Trust staff – in particular, guidelines for the management of bleeding associated with thrombolytic therapy and the management of massive blood loss. ”

Is this part of a recurring concern?

Yes — Unsafe management of significant bleeding.

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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

Lack of staff knowledge, application and implementation of protocols for managing massive blood loss

Wider context from the report

“1. I am concerned about the lack of knowledge, application and implementation of key protocols by Trust staff – in particular, guidelines for the management of bleeding associated with thrombolytic therapy and the management of massive blood loss. ”

Is this part of a recurring concern?

Yes — Unsafe management of significant bleeding.

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

Deliver mandatory training on thrombolysis policies and associated bleeding risks to medical staff.

Verbatim wording from the response

“• Development of a training presentation incorporating the policies and guidelines regarding Thrombolysis and management of associated bleeding risks. This presentation will take place on 22nd May 2015, during the Clinical Governance Audit session, attendance is mandatory for all levels of medical staff. ████████, Vascular Surgeon and ████████ Clinical Lead for Anaesthetics will lead on this presentation. Prior to the audit day the Directorate Manager for Vascular Surgery will ensure that all levels of Vascular medical staff receive copies of the policies to be discussed.”

Source location

2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Page 1 · response
Published 13 March 2015

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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

Deliver thrombolysis and bleeding-risk training to Critical Care staff.

Verbatim wording from the response

“• New Thrombolysis Policy drafted November 2014 prior to inquest (please see attached in appendix 1). The new Thrombolysis policy was circulated and is now available on the Trust Intranet. All Critical Care staff have had a series of Training sessions in the care of the thrombolysed patient which was provided by the Vascular and Radiology Consultants. The session dates were held on the following dates, 14th and 27th October 2014 and on 10th and 24th November 2014.”

Source location

2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Page 1 · response
Published 13 March 2015

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

Circulate and maintain the new thrombolysis policy on the Trust intranet.

Verbatim wording from the response

“• New Thrombolysis Policy drafted November 2014 prior to inquest (please see attached in appendix 1). The new Thrombolysis policy was circulated and is now available on the Trust Intranet. All Critical Care staff have had a series of Training sessions in the care of the thrombolysed patient which was provided by the Vascular and Radiology Consultants. The session dates were held on the following dates, 14th and 27th October 2014 and on 10th and 24th November 2014.”

Source location

2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Page 1 · response
Published 13 March 2015

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Oversee completion of the actions through assigned dates and conduct health-record quality spot checks with the clinical audit team.

    Stated by Pennine Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 March 2015.
  2. 2

    Deliver Clinical Record Keeping training requiring documentation of discussions, meetings and patient-management decisions.

    Stated by Pennine Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 March 2015.
  3. 3

    Deliver training to improve communication pathways between clinicians and specialties.

    Stated by Pennine Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 March 2015.
  4. 4

    Review the Adult Critical Care Operational Policy to establish senior consultant liaison when the consultant surgeon is unavailable.

    Stated by Pennine Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 March 2015.

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

Oversee completion of the actions through assigned dates and conduct health-record quality spot checks with the clinical audit team.

Verbatim wording from the response

“In order to confirm that all actions are implemented the Senior Directorate Manager will have overall responsibility for ensuring the completion of the actions within the assigned dates. This will include spot checks on the quality of health records with support from the clinical audit team.”

Source location

2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Page 2 · response
Published 13 March 2015

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

Deliver Clinical Record Keeping training requiring documentation of discussions, meetings and patient-management decisions.

Verbatim wording from the response

“• Development of a training presentation incorporating Clinical Record Keeping. Presentations will be delivered on the Clinical Governance Audit sessions. The Directorate Manager for Vascular Surgery is arranging this as a matter of priority, with an expected completion date of September 2015. Staff will be advised that all discussions, multidisciplinary meetings that are held and decisions made regarding patient management plans are to be clearly documented as a permanent record in the patient’s case notes.”

Source location

2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Page 2 · response
Published 13 March 2015

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

Deliver training to improve communication pathways between clinicians and specialties.

Verbatim wording from the response

“• Development of training regarding the improvement of communication pathways between clinicians and specialties.”

Source location

2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Page 2 · response
Published 13 March 2015

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 the Adult Critical Care Operational Policy to establish senior consultant liaison when the consultant surgeon is unavailable.

Verbatim wording from the response

“• Review of Adult Critical Care Operational Policy - this will incorporate a mechanism that enables a senior member of a referring Consultants Team, to liaise with the consultant Intensivist when the consultant surgeon is unavailable (i.e. if they are scrubbed in theatre.) This will include Vascular and Anaesthetic consultants and representatives from the Divisions of Surgery, Medicine and Women and Children’s. The Directorate Manager is arranging this meeting with me and the intention is that this will be completed by July 2015.”

Source location

2015-0097-Response-by-Pennine-Acute-Hospitals-NHS-Trust
Page 2 · response
Published 13 March 2015

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