PFD report

William Henry BERGMAN · Prevention of Future Deaths report

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Issued 31 Oct 2017•Inner North London

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
7

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised7

  1. Failure to obtain medical review after head injury
    Part of recurring concern: Failure to assess and respond promptly to significant signs of injuryPart of recurring concern: Failure to seek medical attention when a person's condition warrants it
  2. Failure to obtain detailed symptom information after head injury
    Part of recurring concern: Failure to reliably assess and diagnose injuriesPart of recurring concern: Incomplete clinical history-taking
  3. Failure to revise management when new signs emerge after head injury
    Part of recurring concern: Failure to assess and respond promptly to significant signs of injury
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

    Introduce a formal trust-wide policy for managing head injury in patients and staff.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
  2. Action

    Extend the post-head-injury guidance and training rollout to other inpatient areas.

    Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
  3. Action

    Roll out new post-head-injury guidance and training across Royal London Hospital Older Peoples Service wards.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 2018.

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 medical review after head injury

Wider context from the report

“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

Is this part of a recurring concern?

Yes — Failure to assess and respond promptly to significant signs of injury; Failure to seek medical attention when a person's condition warrants it.

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 obtain detailed symptom information after head injury

Wider context from the report

“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

Is this part of a recurring concern?

Yes — Failure to reliably assess and diagnose injuries; Incomplete clinical history-taking.

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 revise management when new signs emerge after head injury

Wider context from the report

“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

Is this part of a recurring concern?

Yes — Failure to assess and respond promptly to significant signs of injury.

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 obtain and repeat immediate general observations after head injury

Wider context from the report

“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

Is this part of a recurring concern?

Yes — Failure to assess and respond promptly to significant signs of injury.

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

Delays in completing incident reports

Wider context from the report

“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

Is this part of a recurring concern?

Yes — Unreliable reporting of patient-safety incidents.

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 consider the potential for serious consequences from head injury in vulnerable older people

Wider context from the report

“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

Is this part of a recurring concern?

Yes — Failure to reliably assess and diagnose injuries.

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 obtain and repeat immediate neurological observations after head injury

Wider context from the report

“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations.

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

Introduce a formal trust-wide policy for managing head injury in patients and staff.

Verbatim wording from the response

“Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).”

Source location

2017-0343-Barts-NHS-Trust
Page 1 · response
Published 4 February 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

Extend the post-head-injury guidance and training rollout to other inpatient areas.

Verbatim wording from the response

“Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).”

Source location

2017-0343-Barts-NHS-Trust
Page 1 · response
Published 4 February 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

Roll out new post-head-injury guidance and training across Royal London Hospital Older Peoples Service wards.

Verbatim wording from the response

“Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).”

Source location

2017-0343-Barts-NHS-Trust
Page 1 · response
Published 4 February 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

    Distribute a trust safety notice warning hospital-group wards about risks in post-head-injury management.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 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

Distribute a trust safety notice warning hospital-group wards about risks in post-head-injury management.

Verbatim wording from the response

“A trust safety notice was also distributed site wide warning other wards in our hospital group of the risks associated with post head injury management.”

Source location

2017-0343-Barts-NHS-Trust
Page 1 · response
Published 4 February 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