PFD report

David Michael little · Prevention of Future Deaths report

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Issued 28 Jun 2016•Manchester 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
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised7

  1. Failure to train staff to recognise blocked-bowel symptoms and their seriousness
    Part of recurring concern: Unsafe recognition and escalation of bowel obstruction
  2. Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable healthcare patient transfer processesPart of recurring concern: Unreliable recording of service-user movements
  3. Failure to assess differential diagnoses from the most serious potential condition
    Part of recurring concern: Failure to consider or reconsider serious alternative diagnoses
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

    Establish and ratify a small bowel obstruction surgical pathway covering diagnostic priorities and monitoring for this patient group.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2016.
  2. Action

    Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2016.
  3. Action

    Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2016.

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

  1. Position

    The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 train staff to recognise blocked-bowel symptoms and their seriousness

Wider context from the report

“2. The hospital had no clear diagnostic pathway or monitoring plan on admission, the staff appeared not to be trained to recognise the symptoms of a blocked bowel nor the potential seriousness thereof nor to be aware of the dire consequences of failure to diagnose and treat appropriately. ”

Is this part of a recurring concern?

Yes — Unsafe recognition and escalation of bowel obstruction.

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 keep clear records of inpatient radiology transfers, purposes, procedures and ward returns

Wider context from the report

“1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable healthcare patient transfer processes; Unreliable recording of service-user movements.

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 assess differential diagnoses from the most serious potential condition

Wider context from the report

“3. Where there is a differential diagnosis of two or more potential conditions, the staff simply treated the least serious and assumed that was the correct diagnosis rather than taking the most serious and working backwards from that standpoint. ”

Is this part of a recurring concern?

Yes — Failure to consider or reconsider serious alternative diagnoses.

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 verify inpatient identity before transfer to radiology

Wider context from the report

“1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day. ”

Is this part of a recurring concern?

Yes — Unreliable patient identification during healthcare contacts.

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

Lack of a clear diagnostic pathway and monitoring plan on admission

Wider context from the report

“2. The hospital had no clear diagnostic pathway or monitoring plan on admission, the staff appeared not to be trained to recognise the symptoms of a blocked bowel nor the potential seriousness thereof nor to be aware of the dire consequences of failure to diagnose and treat appropriately. ”

Is this part of a recurring concern?

Yes — Unreliable admission assessment of patients.

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 communicate adequately with families

Wider context from the report

“4. The communication between and among staff generally was poor but especially between the radiology department and the clinicians and nurses. There was little or no good communication with the family which led to additional distress for them at a time of great sorrow. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Poor communication between radiology staff and clinicians and nurses

Wider context from the report

“4. The communication between and among staff generally was poor but especially between the radiology department and the clinicians and nurses. There was little or no good communication with the family which led to additional distress for them at a time of great sorrow. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff; Unreliable coordination of radiology services between healthcare teams.

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

Establish and ratify a small bowel obstruction surgical pathway covering diagnostic priorities and monitoring for this patient group.

Verbatim wording from the response

“The Trust has devised a small bowel obstruction surgical pathway (Document 3 attached) which now describes the pathway and monitoring plan for this patient group. Learning undertaken following Mr Little’s death has been incorporated into this pathway. It has been agreed by the surgical, nursing and clinical teams and will be ratified as described in the document, through the governance forums in General Surgery, Radiology, Urgent Care & Critical Care before being signed off at Trust level by the end of September.”

Source location

2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 28 June 2016

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 Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.

Verbatim wording from the response

“Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.”

Source location

2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 28 June 2016

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 and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.

Verbatim wording from the response

“In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.”

Source location

2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 28 June 2016

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 patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.

Verbatim wording from the response

“1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.”

Source location

2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 1 · response
Published 28 June 2016

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