PFD report

Valerie Hampson · Prevention of Future Deaths report

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Issued 18 Jun 2025•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
2

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 raised2

  1. Failure to undertake serious incident investigations for learning
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management processes
  2. Failure to provide recommended fracture clinic follow-up after orthopaedic review
    Part of recurring concern: Unreliable care and follow-up for identified fractures
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    No fracture clinic appointment was made because the Emergency Department X-ray identified no fracture.

    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 undertake serious incident investigations for learning

Wider context from the report

“I am concerned that the Trust has not undertaken any serious incident investigation with a view to identifying if any learning could usefully be identified in the light of the progression of Mrs Hampson’s left leg wound whilst under the care of the District Nurses. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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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 provide recommended fracture clinic follow-up after orthopaedic review

Wider context from the report

“It is a further matter of concern that the court heard evidence that an Orthopaedic review undertaken in the Emergency Department on Mrs Hampson’s initial attendance resulted in a recommendation that Mrs Hampson should be followed up in fracture clinic. For reasons which did not become clear during the inquest, the evidence of the consultant orthopaedic surgeon was that no such follow up appears to have taken place. ”

Is this part of a recurring concern?

Yes — Unreliable care and follow-up for identified fractures.

Open source report

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

No fracture clinic appointment was made because the Emergency Department X-ray identified no fracture.

Verbatim wording from the response

“On a further review of the Mrs Hampson’s records, there is no appointment that has been arranged for the out-patient fracture clinic. The discharge documentation states no mention of fracture clinic appointments. The follow up was that once discharged, care would continue under the District Nursing Service. Following Mrs Hampson’s attendance on 30th October 2024 she was admitted and referred to Wythenshawe and she was managed as an in-patient in Tameside Hospital until she could be transferred to Wythenshawe on 1st November 2024. I am sorry that this information was not made clear to you during the inquest. I can confirm that there was no follow up appointment made in the fracture clinic for Mrs Hampson as no fracture was identified.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 3 July 2025

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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

A formal investigation was not considered necessary because the circumstances did not meet the Trust’s investigation criteria.

Verbatim wording from the response

“Since the inquest we have revisit the care and treatment provided to Mrs Hampson. At the point the wound was noted to be deteriorating, Mrs Hampson was referred promptly back to the Emergency Department. The circumstances surrounding how the wound occurred and how it came to deteriorate did not fit the criteria for investigation in that:”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 3 July 2025

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

    Conduct monthly themed masterclasses for staff to share learning from incidents, safeguarding concerns and coronial feedback.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
  2. 2

    Operate a high-impact board to identify and share complex patients’ needs.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
  3. 3

    Share learning from Mrs Hampson’s care through local learning, weekly team meetings and daily escalation huddles.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
  4. 4

    Participate in monthly Continuous Improvement Meetings to cascade lessons across the Division.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The wound was caused by a fall before District Nursing Service involvement, so it did not arise while District Nurses were providing care.

    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 respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct monthly themed masterclasses for staff to share learning from incidents, safeguarding concerns and coronial feedback.

Verbatim wording from the response

“The learning and outcome for Mrs Hampson in regards to the District Nursing Services has been shared at a local learning level since this inquest and at the weekly team meetings and escalation huddles which are held every day at 1pm. Within the last 12 months, the service has introduced a high impact board where details of complex patients’ needs are identified and shared. The service also participates in monthly Continuous Improvement Meetings (CIM) which enables lessons learnt and sharing to be cascaded across the Division. In addition, the Division also conduct monthly masterclass sessions by the Quality and Development Practitioner for the Intermediate Tier Services at the Trust. The masterclass sessions have a different theme each month based on previous incidents, safeguarding concerns or feedback from the coronial process.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 3 July 2025

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

Operate a high-impact board to identify and share complex patients’ needs.

Verbatim wording from the response

“The learning and outcome for Mrs Hampson in regards to the District Nursing Services has been shared at a local learning level since this inquest and at the weekly team meetings and escalation huddles which are held every day at 1pm. Within the last 12 months, the service has introduced a high impact board where details of complex patients’ needs are identified and shared. The service also participates in monthly Continuous Improvement Meetings (CIM) which enables lessons learnt and sharing to be cascaded across the Division. In addition, the Division also conduct monthly masterclass sessions by the Quality and Development Practitioner for the Intermediate Tier Services at the Trust. The masterclass sessions have a different theme each month based on previous incidents, safeguarding concerns or feedback from the coronial process.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 3 July 2025

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 learning from Mrs Hampson’s care through local learning, weekly team meetings and daily escalation huddles.

Verbatim wording from the response

“The learning and outcome for Mrs Hampson in regards to the District Nursing Services has been shared at a local learning level since this inquest and at the weekly team meetings and escalation huddles which are held every day at 1pm. Within the last 12 months, the service has introduced a high impact board where details of complex patients’ needs are identified and shared. The service also participates in monthly Continuous Improvement Meetings (CIM) which enables lessons learnt and sharing to be cascaded across the Division. In addition, the Division also conduct monthly masterclass sessions by the Quality and Development Practitioner for the Intermediate Tier Services at the Trust. The masterclass sessions have a different theme each month based on previous incidents, safeguarding concerns or feedback from the coronial process.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 3 July 2025

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

Participate in monthly Continuous Improvement Meetings to cascade lessons across the Division.

Verbatim wording from the response

“The learning and outcome for Mrs Hampson in regards to the District Nursing Services has been shared at a local learning level since this inquest and at the weekly team meetings and escalation huddles which are held every day at 1pm. Within the last 12 months, the service has introduced a high impact board where details of complex patients’ needs are identified and shared. The service also participates in monthly Continuous Improvement Meetings (CIM) which enables lessons learnt and sharing to be cascaded across the Division. In addition, the Division also conduct monthly masterclass sessions by the Quality and Development Practitioner for the Intermediate Tier Services at the Trust. The masterclass sessions have a different theme each month based on previous incidents, safeguarding concerns or feedback from the coronial process.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 3 July 2025

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 wound was caused by a fall before District Nursing Service involvement, so it did not arise while District Nurses were providing care.

Verbatim wording from the response

“• The wound was caused because of a traumatic injury following a fall which occurred whilst Mrs Hampson was not under the care of the District Nurses.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 3 July 2025

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