PFD report

Mrs Frances Jean Gibb · Prevention of Future Deaths report

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Issued 10 Dec 2019•Brighton and Hove

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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. Failure to identify mesenteric thrombi in overnight radiology practice
    Part of recurring concern: Unreliable interpretation of diagnostic imagingPart of recurring concern: Unreliable out-of-hours radiological reporting
  2. Failure to use NEWS appropriately
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.8

  1. Action

    Remind radiologists and trainees to specifically assess the superior mesenteric artery when investigating suspected ischaemic bowel.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
  2. Action

    Enable discretionary next-morning Consultant review of scans reported overnight by post-FRCR Part 2b trainees.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
  3. Action

    Extend electronic patient observations to the Maternity Department and Emergency Department.

    Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The missed embolus was difficult to diagnose, perception errors can occur, and no particular reporting pressure, interruption or distraction was identified.

    Stated by University Hospitals Sussex 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 identify mesenteric thrombi in overnight radiology practice

Wider context from the report

“(2) There was a failure to identify a mesenteric thrombus (see Record of Inquest) This appears to have occurred when the junior radiologist was working overnight and under pressures. What lessons have been learned from this? ”

Is this part of a recurring concern?

Yes — Unreliable interpretation of diagnostic imaging; Unreliable out-of-hours radiological reporting.

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 use NEWS appropriately

Wider context from the report

“(1) Once again I must write concerning the serious failings in the use of NEWS. Please see the Record of Inquest for details. When you respond to this Regulation 28 report will you please explain why it is that I regularly send you reports on the misuse of NEWS. Am I to assume that no lessons are being learnt? ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Remind radiologists and trainees to specifically assess the superior mesenteric artery when investigating suspected ischaemic bowel.

Verbatim wording from the response

“1. All Radiologists including trainees have been reminded to look specifically at the SMA when the request is for a queried ischemic bowel.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 3 · response
Published 30 December 2019

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

Enable discretionary next-morning Consultant review of scans reported overnight by post-FRCR Part 2b trainees.

Verbatim wording from the response

“4. Any scans reported by post FRCR Part 2b trainees can be reviewed the following morning by a Consultant at the trainee's discretion.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 3 · response
Published 30 December 2019

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

Extend electronic patient observations to the Maternity Department and Emergency Department.

Verbatim wording from the response

“We cannot agree that lessons have not been learnt in relation to NEWS within the Trust. During his evidence at the inquest, ████████ described how electronic patient observations (Patientrack) are now embedded in the Trust and are working very well. The roll out of electronic patient observations began in July 2019 and to date, all Adult and Paediatric inpatient areas now have the system in place. Later this month the system will be put into the Maternity Department and then to the Emergency Department in May (following other digital changes we are making).”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 1 · response
Published 30 December 2019

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

Embed electronic patient observations with automated NEWS calculation, escalation prompts, and clinical visibility across adult and paediatric inpatient areas.

Verbatim wording from the response

“We cannot agree that lessons have not been learnt in relation to NEWS within the Trust. During his evidence at the inquest, ████████ described how electronic patient observations (Patientrack) are now embedded in the Trust and are working very well. The roll out of electronic patient observations began in July 2019 and to date, all Adult and Paediatric inpatient areas now have the system in place. Later this month the system will be put into the Maternity Department and then to the Emergency Department in May (following other digital changes we are making).”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 1 · response
Published 30 December 2019

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

Re-present the case through the REAL radiology learning and case-review meeting.

Verbatim wording from the response

“5. Mrs Gibb’s case has been re-presented in our REAL (Radiology Events and Learning through case review) meeting.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 3 · response
Published 30 December 2019

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

Provide training for new ward staff on NEWS and escalation of care.

Verbatim wording from the response

“10. All new staff to the ward have received training on both NEWS and the importance of escalation of care.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 2 · response
Published 30 December 2019

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

Change radiology protocols to use thinner two-plane reconstructions for improved regional visualisation.

Verbatim wording from the response

“2. The Protocol has changed so the reconstructions are thinner in two planes to enable better visualisation of the region.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 3 · response
Published 30 December 2019

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

Require next-morning Consultant review of overnight scans reported by pre-FRCR Part 2b trainees.

Verbatim wording from the response

“3. All overnight scans are reviewed by a Consultant the following morning for those reported by pre Fellowship of the Royal College of Radiologists (FRCR) Part 2b trainees overnight.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 3 · response
Published 30 December 2019

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 missed embolus was difficult to diagnose, perception errors can occur, and no particular reporting pressure, interruption or distraction was identified.

Verbatim wording from the response

“Radiology As confirmed in ████████ statement for the inquest, the initial CT report missed an embolus lodged in the superior mesenteric artery which was not causing radiological bowel changes at the time. ████████ confirmed that this was not an easy diagnosis to make and, having shown the scans to some of his Consultant Radiological colleagues, not all of them identified the embolus on the imaging. As acknowledged by ████████ in his statement for the inquest, perception errors such as these unfortunately do occur in the field of radiology and any misses are discussed by the team in regular discrepancy meetings. ████████ did not state that he was under any particular pressure when he reported Mrs Gibb’s scan, and he could not recall any particular interruption or distraction that night.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 2 · response
Published 30 December 2019

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 disputes that lessons were not learned about NEWS, citing effective implementation of electronic observations and escalation prompts.

Verbatim wording from the response

“We cannot agree that lessons have not been learnt in relation to NEWS within the Trust. During his evidence at the inquest, ████████ described how electronic patient observations (Patientrack) are now embedded in the Trust and are working very well. The roll out of electronic patient observations began in July 2019 and to date, all Adult and Paediatric inpatient areas now have the system in place. Later this month the system will be put into the Maternity Department and then to the Emergency Department in May (following other digital changes we are making).”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 1 · response
Published 30 December 2019

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

    Increase Level 9A night-shift Band 6 nursing provision from one nurse to two.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
  2. 2

    Provide a 24-hour Critical Care Outreach service with remote access to Patientrack and acute-deterioration education.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
  3. 3

    Share deterioration learning through Matron-led teaching sessions for Level 9A staff.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
  4. 4

    Conduct After Action Reviews following all MET calls and use a Surgical Division governance process to identify, resolve, and share learning.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.

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

Increase Level 9A night-shift Band 6 nursing provision from one nurse to two.

Verbatim wording from the response

“11. We have increased the number of Band 6 Nurses on night shifts on Level 9A ward from 1 to 2 so the junior staff have more support with clinically deteriorating patients.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 2 · response
Published 30 December 2019

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

Provide a 24-hour Critical Care Outreach service with remote access to Patientrack and acute-deterioration education.

Verbatim wording from the response

“12. The Trust now has a Critical Care Outreach service 24 hours a day (this began on 22 July 2019) and Patientrack can also be viewed remotely by the Critical Outreach team.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 2 · response
Published 30 December 2019

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

Share deterioration learning through Matron-led teaching sessions for Level 9A staff.

Verbatim wording from the response

“8. The case has been discussed (anonymously) at Matron led teaching sessions for all the staff on Level 9A ward to ensure the important learning points have been shared widely.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 2 · response
Published 30 December 2019

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

Conduct After Action Reviews following all MET calls and use a Surgical Division governance process to identify, resolve, and share learning.

Verbatim wording from the response

“9. We also now hold an AAR after all MET calls to ensure any learning is identified and shared, and that any issues are resolved. A robust governance process has been put in place in the Surgical Division to ensure shared learning.”

Source location

2019-0422-Response-from-Brighton-and-Sussex-NHS-Trust-Redacted
Page 2 · response
Published 30 December 2019

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