PFD report

Mary Bertha Johnson · Prevention of Future Deaths report

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Issued 1 Feb 2019•Herefordshire

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised3

  1. Failure to adhere to Consultant instructions on medication provision prior to operation
    Part of recurring concern: Failure to provide required medication promptly when clinically neededPart of recurring concern: Failure to reliably implement consultant clinical instructions
  2. Failure to ensure feeding of patients prior to operation
  3. Insufficient porter availability limiting theatre operations
    Part of recurring concern: Unreliable hospital porter services
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

    Relaunch and clarify thromboprophylaxis guidance for relevant staff, including when prophylaxis should be withheld before surgery.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 February 2019.
  2. Action

    Review all specialty-specific thromboprophylaxis guidelines.

    Stated by Wye Valley NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 February 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 patient was fed appropriately and food and fluids were appropriately restricted before the planned operation.

    Stated by Wye Valley NHS 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 adhere to Consultant instructions on medication provision prior to operation

Wider context from the report

“(1) A lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant’s instructions regarding the provision of medication prior to operation ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed; Failure to reliably implement consultant clinical instructions.

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 ensure feeding of patients prior to operation

Wider context from the report

“(1) A lack of communication between staff highlighted issues concerning: (a) the feeding of patients prior to operation (b) adherence to the Consultant’s instructions regarding the provision of medication prior to operation ”

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

Insufficient porter availability limiting theatre operations

Wider context from the report

“(2) It was suggested that the availability of porters determined the ability of the hospital theatres to carry out operations ”

Is this part of a recurring concern?

Yes — Unreliable hospital porter services.

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

Relaunch and clarify thromboprophylaxis guidance for relevant staff, including when prophylaxis should be withheld before surgery.

Verbatim wording from the response

“Although not actually the root cause for this patient’s death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis prior to surgery, particularly the time period before which it should be withheld. In addition to this, and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and I would be happy to update you on the progress of this at a later date.”

Source location

2019-0458-Response-by-Wye-Valley-NHS-Trust
Page 2 · response
Published 1 February 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

Review all specialty-specific thromboprophylaxis guidelines.

Verbatim wording from the response

“Although not actually the root cause for this patient’s death, we have also taken the opportunity to relaunch and clarify to all pertinent staff, the use of thromboprophylaxis prior to surgery, particularly the time period before which it should be withheld. In addition to this, and this is an ongoing piece of work, all speciality specific thromboprophylaxis guidelines are being reviewed and I would be happy to update you on the progress of this at a later date.”

Source location

2019-0458-Response-by-Wye-Valley-NHS-Trust
Page 2 · response
Published 1 February 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 patient was fed appropriately and food and fluids were appropriately restricted before the planned operation.

Verbatim wording from the response

“Following our investigations, I can confirm that the patient was fed appropriately throughout her stay on the ward and placed nil by mouth, i.e. food and fluids restricted appropriately, prior to the planned operation on Tues 24th July 2018. The investigation has established that the consultants’ instructions were not adequately adhered to over the weekend in question. The plan, quite clearly placed in the notes by the consultant team, for Mrs Johnson to be operated on Monday 23rd July. Fortunately, this instruction appears not to have been read by the nurse caring for the patient over the weekend in question. This nurse appeared to have been under the impression that this patient was to be operated on over the weekend and hence withheld the prescribed thrombo prophylaxis.”

Source location

2019-0458-Response-by-Wye-Valley-NHS-Trust
Page 1 · response
Published 1 February 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

Porter availability had no material effect on the patient's outcome.

Verbatim wording from the response

“The investigation has established that the availability of porters had no material effect on this patient’s outcome.”

Source location

2019-0458-Response-by-Wye-Valley-NHS-Trust
Page 1 · response
Published 1 February 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