PFD report

Jyoti Rao · Prevention of Future Deaths report

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Issued 25 Sep 2024•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
1

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 raised1

  1. Failure to allocate complex transplant patients a named consultant
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.1

  1. Action

    Provide complex renal transplant patients with dedicated outpatient appointments with a named transplant nephrologist responsible for continuity of care.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2024.

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

  1. Position

    Transplant patients have a named responsible consultant: the surgeon who performed the transplant remains the lead consultant.

    Stated by Manchester University 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 allocate complex transplant patients a named consultant

Wider context from the report

“Whilst the court heard evidence as to the advantages of the ‘Consultant of the Week’ model in terms of team working, it is a matter of concern that complex transplant patients such as Miss Rao are not allocated a named consultant, who not only (in conjunction with others) can seek to ensure continuity of care is provided, but also who can take a longer-term view of the patient’s post-operative course and trajectory when complications arise. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 complex renal transplant patients with dedicated outpatient appointments with a named transplant nephrologist responsible for continuity of care.

Verbatim wording from the response

“In addition to this, complex renal transplant patients now have dedicated appointments to be seen by a named transplant nephrologist responsible for providing continuity of care for them in the outpatient setting.”

Source location

Response from Manchester University Hospitals NHS Foundation Trust
Page 2 · response
Published 25 September 2024

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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

Transplant patients have a named responsible consultant: the surgeon who performed the transplant remains the lead consultant.

Verbatim wording from the response

“For patients undergoing transplantation at MRI the consultant surgeon who performed their transplant is the responsible consultant. During their hospital admission, patients are under the joint care of the surgical and medical (nephrology) teams. Ward based cover is provided by the consultants of the week from both transplant surgery and renal medicine who work together and undertake joint ward rounds. This model works well to provide safe and robust cover for all inpatients without being affected by annual leave or other clinical commitments of individual consultants. Patients are discussed every Wednesday at the Ward Patient Review meeting to ensure input from the wider team; this meeting provides oversight by the primary surgeon who remains the lead consultant.”

Source location

Response from Manchester University Hospitals NHS Foundation Trust
Page 2 · response
Published 25 September 2024

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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

Joint surgical and nephrology consultant-of-the-week cover provides safe and robust inpatient care without requiring individual consultant availability.

Verbatim wording from the response

“For patients undergoing transplantation at MRI the consultant surgeon who performed their transplant is the responsible consultant. During their hospital admission, patients are under the joint care of the surgical and medical (nephrology) teams. Ward based cover is provided by the consultants of the week from both transplant surgery and renal medicine who work together and undertake joint ward rounds. This model works well to provide safe and robust cover for all inpatients without being affected by annual leave or other clinical commitments of individual consultants. Patients are discussed every Wednesday at the Ward Patient Review meeting to ensure input from the wider team; this meeting provides oversight by the primary surgeon who remains the lead consultant.”

Source location

Response from Manchester University Hospitals NHS Foundation Trust
Page 2 · response
Published 25 September 2024

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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.2

  1. 1

    Modify the weekly transplant patient review meeting into a multidisciplinary discussion of complex patients, including outpatient team attendance.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2024.
  2. 2

    Continue organisational discussions to strengthen consultant attribution, care ownership and oversight across clinical teams.

    Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2024.

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

Modify the weekly transplant patient review meeting into a multidisciplinary discussion of complex patients, including outpatient team attendance.

Verbatim wording from the response

“The MRI Transplant team have modified the weekly Wednesday Ward Patient Review meeting, mentioned above, to make it an MDT for discussion of complex patients. This provides a more robust multidisciplinary perspective for discussion making that involves all relevant clinical staff. A significant change is the attendance of the outpatient team to support any issues on discharge.”

Source location

Response from Manchester University Hospitals NHS Foundation Trust
Page 2 · response
Published 25 September 2024

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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

Continue organisational discussions to strengthen consultant attribution, care ownership and oversight across clinical teams.

Verbatim wording from the response

“MFT comprises several adult hospital sites within which Consultant of the Week models are utilised. Organisationally the Trust provides clear guidance to clinical teams via the Role and Responsibilities of the Lead (Responsible) Consultant Policy (attached) and there is an organisational focus on consultant attribution. Whilst the remit of this improvement work is wider than the specialty transplant service subject of your Regulation 28 report; I hope to offer you additional assurance that across the organisation discussions in relation to consultant attribution, ownership and oversight of care are taking place across all clinical teams. I anticipate that this work will continue to strengthen the delivery of care to our patients utilising this model, preventing inconsistencies in practices across the organisation.”

Source location

Response from Manchester University Hospitals NHS Foundation Trust
Page 1 · response
Published 25 September 2024

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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