PFD report

ROSALIND ANN ADSHEAD · Prevention of Future Deaths report

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Issued 9 Sep 2014•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
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

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

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Concerns raised2

  1. Insufficient ambulance availability during normal working hours
  2. Failure to avoid transferring severely ill patients in the early hours of the morning
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 ambulance availability during normal working hours

Wider context from the report

“During the course of her treatment at Stepping Hill Hospital it was considered that she needed to be moved to Manchester Royal Infirmary for her further care. She had developed an anastomotic leak from the site of the operation and needed to have a covered oesophageal stent to block the leak. She was a very severely ill lady at this stage, yet the move between hospitals took place in the very early hours of the 21st March 2014. The consultant surgeon into whose care she was transferred told me in evidence that “it is not safe to transfer such a patient in the early hours of the morning”, that the transfer at this time “did add to the anxiety and distress in the middle of the night” and that “the shortage of ambulances in the normal working day is not a valid excuse”. ”

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 avoid transferring severely ill patients in the early hours of the morning

Wider context from the report

“During the course of her treatment at Stepping Hill Hospital it was considered that she needed to be moved to Manchester Royal Infirmary for her further care. She had developed an anastomotic leak from the site of the operation and needed to have a covered oesophageal stent to block the leak. She was a very severely ill lady at this stage, yet the move between hospitals took place in the very early hours of the 21st March 2014. The consultant surgeon into whose care she was transferred told me in evidence that “it is not safe to transfer such a patient in the early hours of the morning”, that the transfer at this time “did add to the anxiety and distress in the middle of the night” and that “the shortage of ambulances in the normal working day is not a valid excuse”. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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