PFD report

Gemma Louise Helen RALPH · Prevention of Future Deaths report

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Issued 8 Nov 2024•Staffordshire and Stoke-on-Trent

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

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 robustly monitor bottles of sevoflurane
  2. Failure to confirm or refute the provenance of bottles of sevoflurane
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.6

  1. Action

    Continue exploring and supporting improvements to controlled, authorised and auditable access to medicines.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
  2. Action

    Consider the hospital’s response and any resulting actions concerning Sevoflurane storage and monitoring.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 11 November 2024.
  3. Action

    Develop and submit a business case for automated bulk medicines cabinets and auditable drug-cupboard locks.

    Stated by the Royal Wolverhampton NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    The hospital is responsible for Sevoflurane storage and monitoring, while NHS England will consider its response and any resulting actions.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 robustly monitor bottles of sevoflurane

Wider context from the report

“Notwithstanding an assurance that “the processes in place for safe supply, storage and use of Sevoflurane in the trust is in line with relevant sources of national guidance and best practice” the following remains a source of concern: That bottles of sevoflurane, whether unopened or partially used after theatre, does not appear to be robustly monitored to the degree that it was possible for a bottle of sevoflurane to be removed from Cannock Chase Hospital without this being flagged by the auditing system. That the trust was unable to confirm or refute that the bottle found at the deceased’s home address originated from Cannock Chase Hospital. ”

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

Failure to confirm or refute the provenance of bottles of sevoflurane

Wider context from the report

“Notwithstanding an assurance that “the processes in place for safe supply, storage and use of Sevoflurane in the trust is in line with relevant sources of national guidance and best practice” the following remains a source of concern: That bottles of sevoflurane, whether unopened or partially used after theatre, does not appear to be robustly monitored to the degree that it was possible for a bottle of sevoflurane to be removed from Cannock Chase Hospital without this being flagged by the auditing system. That the trust was unable to confirm or refute that the bottle found at the deceased’s home address originated from Cannock Chase Hospital. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Continue exploring and supporting improvements to controlled, authorised and auditable access to medicines.

Verbatim wording from the response

“NHS England will continue to explore and support improvements in the controlled, authorised and auditable access to medicines.”

Source location

Response from NHS England
Page 2 · response
Published 11 November 2024

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

Consider the hospital’s response and any resulting actions concerning Sevoflurane storage and monitoring.

Verbatim wording from the response

“With regard to your specific concerns about how Sevoflurane is stored and monitored at Cannock Chase Hospital, I note that you have also addressed your Report to the hospital and refer you to their response on these issues. NHS England will also consider the hospital’s response and any actions arising from this in due course.”

Source location

Response from NHS England
Page 2 · response
Published 11 November 2024

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

Develop and submit a business case for automated bulk medicines cabinets and auditable drug-cupboard locks.

Verbatim wording from the response

“To submit a business case to the Trust Board and Black Country ICB for capital monies to purchase and install automated medicines storage cabinets for bulk storage of drugs and auditable locks for drug cupboards. | ████████ | Q1 2025/26 | • Collaborative work has commenced within the Black Country Provider Collaborative Pharmacy Network to write a systemwide business case to purchase and install automated medicines storage cabinets at RWT, DGFT and WHT, with agreement within the network that theatres will be a priority area. There is significant variation within the Black Country ICS as SWB have fully implemented automated medicines storage cabinets across the new MMUH, and therefore if approved, the business case will bring all Black Country Trusts to a similar standard of inventory control.”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 4 · response
Published 11 November 2024

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

Assess whether existing automated storage cabinets can be repurposed for medicines storage as an interim security measure.

Verbatim wording from the response

“• There is a significant risk that a business case will not be approved due to lack of capital monies within the Trust and Black Country ICS, therefore as an interim measure RWT have commenced discussions with the provider of existing automated storage cabinets used for storage of dressings and medical devices in theatres, as to whether it is possible to repurpose these for medicine storage. Early conversations indicate they may not be suitable for medicines storage, thus requiring new cabinets to be purchased.”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 4 · response
Published 11 November 2024

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

Restrict sevoflurane to two supervised bottles, lock storage after theatre sessions, limit bulk access to authorised registered staff, and monitor compliance through pharmacy audits.

Verbatim wording from the response

“Action | Lead | Timescale | Comments Sevoflurane bottles to be in a locked drug cupboard unless under the direct supervision of the anaesthetist. | ████████ | Complete | • The amount of sevoflurane stored in each theatre has been reduced to 2 bottles; the in-use bottle and 1 spare bottle. Both bottles are under the direct supervision of the anaesthetist and are locked away at the end of the theatre session.”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 4 · response
Published 11 November 2024

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 risk-reduction strategies, including improved automation and strengthened medicines storage, recording and audit processes.

Verbatim wording from the response

“We have discussed the Regulation 28 notice with the Regional Chief Pharmacist, and he is in agreement with the above. We will however look at risk reduction strategies e.g. improved use of automation, ensuring our storage, recording and audit processes are robust.”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 4 · response
Published 11 November 2024

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 hospital is responsible for Sevoflurane storage and monitoring, while NHS England will consider its response and any resulting actions.

Verbatim wording from the response

“With regard to your specific concerns about how Sevoflurane is stored and monitored at Cannock Chase Hospital, I note that you have also addressed your Report to the hospital and refer you to their response on these issues. NHS England will also consider the hospital’s response and any actions arising from this in due course.”

Source location

Response from NHS England
Page 2 · response
Published 11 November 2024

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

Managing sevoflurane as a controlled drug may be impractical because of staffing, measurement and storage-capacity requirements.

Verbatim wording from the response

“• Making sevoflurane a controlled drug and/or implementing Scan4Safety are the only ways the Trust may have been able to identify, with a degree of certainty, that a single bottle of sevoflurane was unaccounted for. The Trust could consider managing sevoflurane as a controlled drug (we do this for Oromorph for example) but the practicalities of this are likely to outweigh the current risk of diversion. Theose considerations are:”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 3 · response
Published 11 November 2024

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 government must decide whether sevoflurane should be classified as a controlled drug.

Verbatim wording from the response

“Actions that require national consideration / are outside of the control of the Trust”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 3 · response
Published 11 November 2024

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

Local monitoring and access controls would have limited risk-reduction impact unless implemented as a national requirement.

Verbatim wording from the response

“Actions that the Trust could consider to improve audit and / or restrict access to sevoflurane to authorised registered staff only are listed below. These measures would improve on what we already have but would not necessarily identify if someone was diverting small volumes of sevoflurane and therefore deliver limited effect on risk reduction.”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 3 · response
Published 11 November 2024

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

Automated medicines cabinets may not be implemented because required capital funding might not be approved.

Verbatim wording from the response

“To submit a business case to the Trust Board and Black Country ICB for capital monies to purchase and install automated medicines storage cabinets for bulk storage of drugs and auditable locks for drug cupboards. | ████████ | Q1 2025/26 | • Collaborative work has commenced within the Black Country Provider Collaborative Pharmacy Network to write a systemwide business case to purchase and install automated medicines storage cabinets at RWT, DGFT and WHT, with agreement within the network that theatres will be a priority area. There is significant variation within the Black Country ICS as SWB have fully implemented automated medicines storage cabinets across the new MMUH, and therefore if approved, the business case will bring all Black Country Trusts to a similar standard of inventory control.”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 4 · response
Published 11 November 2024

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

    Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Comprehensive monitoring of all potentially harmful medicines would be disproportionate, operationally impractical and unaffordable.

    Stated by the Royal Wolverhampton NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    The Royal College of Anaesthetists must consider whether theatre medicine-cupboard access arrangements require further exceptions or review.

    Stated by the Royal Wolverhampton NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Gemma, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 11 November 2024

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

Comprehensive monitoring of all potentially harmful medicines would be disproportionate, operationally impractical and unaffordable.

Verbatim wording from the response

“The context of this is explained in the narrative above, this risk contextually applies to any drug of any type that does not fall under the controlled drugs legislation. If the trust were to take some form of action in relation to sevoflurane specifically it would not close the risk of any person taking a fatal dose of any other drug that they have legitimate access to as part of their role. To take action to address this risk in all drugs would be disproportionate to the risk, would create different risks and most likely be operationally impractical and unaffordable.”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 2 · response
Published 11 November 2024

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 Royal College of Anaesthetists must consider whether theatre medicine-cupboard access arrangements require further exceptions or review.

Verbatim wording from the response

“Actions that require national consideration / are outside of the control of the Trust”

Source location

Response from The Royal Wolverhampton NHS Trust
Page 3 · response
Published 11 November 2024

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