PFD report

Susan Margaret ROBERTS · Prevention of Future Deaths report

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Issued 7 Jun 2021•West Yorkshire (Western)

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
4

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 raised4

  1. Failure of Plastic Surgeons to attend round-table analysis during SI investigations
    Part of recurring concern: Inadequate safety incident investigations
  2. Lack of timely and effective handover between surgical specialties
    Part of recurring concern: Unreliable clinical handover processes
  3. Failure of Plastic Surgeons to attend in theatre when their help is requested
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

    Issue and disseminate a necrotising fasciitis protocol specifying which specialty must be contacted and involved at each treatment stage.

    Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2021.
  2. Action

    Revise the Serious Incident Reporting and Investigating policy to require crucial staff to attend multidisciplinary round-table discussions.

    Stated by Bradford Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2021.
  3. Action

    Revise the referral protocol to require the leading specialty to document the agreed plan with the secondary specialty and identify who agreed it.

    Stated by Bradford Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Plastic surgeons become involved after primary abscess management is complete, with the leading specialty documenting the agreed plan when plastics becomes involved.

    Stated by Bradford Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 of Plastic Surgeons to attend round-table analysis during SI investigations

Wider context from the report

“2. That when asked for help at the time and during the investigation, there seems to have been a lack of engagement from the Plastic Surgeons. They failed to join the Orthopaedic Registrar in theatre at the time of the incident and then failed to attend the round table analysis as part of the SI investigation. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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

Lack of timely and effective handover between surgical specialties

Wider context from the report

“1. There has been lack of timely and effective hand over been the different surgical specialties, with an absence of formal protocol. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes.

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 of Plastic Surgeons to attend in theatre when their help is requested

Wider context from the report

“2. That when asked for help at the time and during the investigation, there seems to have been a lack of engagement from the Plastic Surgeons. They failed to join the Orthopaedic Registrar in theatre at the time of the incident and then failed to attend the round table analysis as part of the SI investigation. ”

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

Absence of a formal handover protocol between surgical specialties

Wider context from the report

“1. There has been lack of timely and effective hand over been the different surgical specialties, with an absence of formal protocol. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes.

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

Issue and disseminate a necrotising fasciitis protocol specifying which specialty must be contacted and involved at each treatment stage.

Verbatim wording from the response

“The Bradford Teaching Hospitals NHS Foundation Trust hosts an Electronic Patient Record (EPR). Routine referrals to specialities and individual consultants are made through this system. For time critical medical conditions it is the Trust’s well established practice for a referral to be made directly to the specialty/consultant via telephone. As part of the recommendations following the investigation into this case a protocol for cases of Necrotising Fasciitis has been issued. The protocol clearly stipulates which speciality needs to be contacted and involved and at what point in the treatment dependant on the area of the body that is affected.”

Source location

2021-0195-Response-from-Bradford-Teaching-Hospitals_Published
Page 1 · response
Published 14 June 2021

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

Revise the Serious Incident Reporting and Investigating policy to require crucial staff to attend multidisciplinary round-table discussions.

Verbatim wording from the response

“It is not acceptable for a team to fail to attend when requested to participate in a formal investigation of a patient safety incident. The Trust has an Incident Reporting and Investigation Policy which makes clear its commitment to patient safety and improving the quality of care that it provides, developing a just culture and encouraging staff to be willing to admit mistakes without fear of punitive measures. Staff are therefore actively encouraged and are supported to be open and honest about events and issues that have or could pose a risk to patient safety. It is the Trust’s expectation that all staff participate in and support the investigation into a patient safety incident that they were either directly involved in or could provide insight into why such an event has occurred.”

Source location

2021-0195-Response-from-Bradford-Teaching-Hospitals_Published
Page 2 · response
Published 14 June 2021

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

Revise the referral protocol to require the leading specialty to document the agreed plan with the secondary specialty and identify who agreed it.

Verbatim wording from the response

“To address the point regarding attendance in theatre, we refer back to the earlier statement that it is standard practice that the plastics team will become involved once primary management of abscesses are complete and reconstruction is required. We intend to revise the referral protocol to make it explicit that the leading specialty is responsible for clearly documenting in the patient record the agreed plan with the secondary speciality at the point in the procedure they become involved and who this was agreed with. It must noted that the orthopaedic specialist registrar and the plastics specialist registrar in this case were in direct telephone consultation regarding the treatment of the surgical debridement and further treatment.”

Source location

2021-0195-Response-from-Bradford-Teaching-Hospitals_Published
Page 2 · response
Published 14 June 2021

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

Plastic surgeons become involved after primary abscess management is complete, with the leading specialty documenting the agreed plan when plastics becomes involved.

Verbatim wording from the response

“To address the point regarding attendance in theatre, we refer back to the earlier statement that it is standard practice that the plastics team will become involved once primary management of abscesses are complete and reconstruction is required. We intend to revise the referral protocol to make it explicit that the leading specialty is responsible for clearly documenting in the patient record the agreed plan with the secondary speciality at the point in the procedure they become involved and who this was agreed with. It must noted that the orthopaedic specialist registrar and the plastics specialist registrar in this case were in direct telephone consultation regarding the treatment of the surgical debridement and further treatment.”

Source location

2021-0195-Response-from-Bradford-Teaching-Hospitals_Published
Page 2 · response
Published 14 June 2021

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