PFD report

Ms Susan Joan Elliott (Sue) · Prevention of Future Deaths report

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Issued 6 Aug 2018•Sunderland

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
4

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

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to obtain definitive diagnostic imaging before discharge
    Part of recurring concern: Unreliable clinical decisions about when CT scanning is needed
  2. Failure to act on reported x-ray findings
    Part of recurring concern: Unreliable radiology processes for communicating findings and initiating required follow-up
  3. Potentially delayed surgical treatment
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.2

  1. Action

    Include the Emergency Department Injured Elderly NWB Guideline in junior doctor induction and stress discussion of referrals at trauma x-ray meetings.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2018.
  2. Action

    Review and relaunch the injured elderly non-weight-bearing pathway across the Trust to raise clinicians’ awareness.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 October 2018.

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

  1. Position

    The radiograph and report were viewed by three medical staff and were therefore not reported and ignored.

    Stated by South Tyneside and Sunderland 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 obtain definitive diagnostic imaging before discharge

Wider context from the report

“No CT scan was undertaken prior to discharge on 9th August 2017, so there was no definitive diagnosis and decisions were based on clinical impression. ”

Is this part of a recurring concern?

Yes — Unreliable clinical decisions about when CT scanning is needed.

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 act on reported x-ray findings

Wider context from the report

“The orthopaedic surgeon in his evidence confirmed that the x-ray of 4th August 2017 was “reported on and ignored” ”

Is this part of a recurring concern?

Yes — Unreliable radiology processes for communicating findings and initiating required follow-up.

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

Potentially delayed surgical treatment

Wider context from the report

“In all likelihood surgery was an earlier possibility for Sue. ”

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

Lack of documented protocols for treatment and 24/7 CT scanning and reporting

Wider context from the report

“Reference was made to new protocols about the treatment of patients presenting with similar conditions such as Sue (particularly for 24/7 CT scanning/reporting), but no documents were produced. ”

Is this part of a recurring concern?

Yes — Inadequate safety guidance for CT scanning and reporting.

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

Include the Emergency Department Injured Elderly NWB Guideline in junior doctor induction and stress discussion of referrals at trauma x-ray meetings.

Verbatim wording from the response

“At the inquest, the same witness also made reference to new protocols about the treatment of patients presenting with similar conditions such as Ms Elliott, but did not produce any documents. I would like to assure you that we do have an “Emergency Department Injured Elderly Non-Wight Bearing (NWGB) Guideline” which was developed in 2015. This guideline provides clear recommendations for cross sectional (CT) imaging and reporting, where pain or dysfunction suggests an occult fracture. I have provided a copy of this guideline.”

Source location

2018-0275-Response-by-City-Hospital-Sunderland-NHS-Trust
Page 2 · response
Published 30 October 2018

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 and relaunch the injured elderly non-weight-bearing pathway across the Trust to raise clinicians’ awareness.

Verbatim wording from the response

“The guideline is now included in the T&O junior doctor induction programme and the importance of all referrals being discussed at the trauma x-ray meeting is also stressed within this training. Our internal investigation has acknowledged that we need to review and relaunch this pathway across the Trust in order to raise clinicians’ awareness and this has been addressed within the action plan.”

Source location

2018-0275-Response-by-City-Hospital-Sunderland-NHS-Trust
Page 2 · response
Published 30 October 2018

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 radiograph and report were viewed by three medical staff and were therefore not reported and ignored.

Verbatim wording from the response

“You will recall that one of the witnesses in his evidence at Ms Elliott’s inquest, suggested that Ms Elliott’s radiograph of 4th August 2017 was “reported and ignored”. I would like to reassure you that following a thorough internal investigation, I can confirm that both the radiograph and the associated radiology report were viewed on our electronic system (Meditech) between 4th and 5th August 2017 by three different members of medical staff who considered the report alongside Ms Elliott’s clinical presentation and status.”

Source location

2018-0275-Response-by-City-Hospital-Sunderland-NHS-Trust
Page 1 · response
Published 30 October 2018

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.1

  1. 1

    Oversee action-plan progress through the Executive Director of Nursing, Midwifery and Allied Health Professionals, with briefing and reporting to the Clinical Governance Steering Group.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 October 2018.

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 action-plan progress through the Executive Director of Nursing, Midwifery and Allied Health Professionals, with briefing and reporting to the Clinical Governance Steering Group.

Verbatim wording from the response

“As you will note from the enclosed action plan, the Trust is addressing the shortfalls highlighted during our investigation and the inquest, in order to prevent future deaths in similar circumstances. Progress of the actions detailed within the action plan will be overseen by ████████ Executive Director of Nursing, Midwifery and Allied Health Professionals, who will keep me briefed and report to the Trust’s Clinical Governance Steering Group.”

Source location

2018-0275-Response-by-City-Hospital-Sunderland-NHS-Trust
Page 2 · response
Published 30 October 2018

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