PFD report

Anne Taylor · Prevention of Future Deaths report

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Issued 8 Nov 2024•Manchester West

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

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 to assess capacity to decide to leave hospital
    Part of recurring concern: Failure to recognise impaired decision-making capacity in care decisionsPart of recurring concern: Unreliable assessment and recording of patients’ mental capacityPart of recurring concern: Unreliable safeguards when patients leave before clinical assessment
  2. Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment
    Part of recurring concern: Unreliable safeguards when patients leave before clinical assessment
  3. Failure to consider secondary investigations during clinical waiting times
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.8

  1. Action

    Publish and implement the two-year delivery plan for recovering urgent and emergency care services.

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

    Support regions and providers to eliminate longer-term crowding in emergency departments and improve patient flow.

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

    Use operational planning guidance to direct health systems toward improved patient flow and clinical outcomes.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete 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.1

  1. Position

    Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.

    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 assess capacity to decide to leave hospital

Wider context from the report

“3. No evidence was provided that the deceased’s capacity to decide to leave the hospital was assessed given the history of suspected head injury. ”

Is this part of a recurring concern?

Yes — Failure to recognise impaired decision-making capacity in care decisions; Unreliable assessment and recording of patients’ mental capacity; Unreliable safeguards when patients leave before clinical assessment.

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 clarity in the standard operating procedure for patients leaving hospital before clinical assessment

Wider context from the report

“4. Reference was made to a new standard operating procedure being developed relating to patients leaving the hospital before a clinical assessment occurs, but it was unclear what this will include. ”

Is this part of a recurring concern?

Yes — Unreliable safeguards when patients leave before clinical assessment.

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 consider secondary investigations during clinical waiting times

Wider context from the report

“2. There was no consideration of whether secondary investigations could be undertaken during the waiting time for example CT scan which would likely be required by a clinician in order to make a diagnosis. ”

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

Delays in clinical assessment resulting in patients leaving hospital before assessment

Wider context from the report

“1. During evidence, it was heard that the deceased had elected to leave the Hospital on Friday 19 July because of waiting times, before being clinically assessed. ”

Is this part of a recurring concern?

Yes — Failure to conduct timely, appropriate clinical assessments; Unreliable safeguards when patients leave before clinical assessment.

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

Publish and implement the two-year delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response

“NHS England recognises the significant pressures on all NHS services and, in January 2023, published a two-year Delivery plan for recovering urgent and emergency care (UEC) services. The plan prioritised improvements to four hour performance in Emergency Departments and outlined key actions to recover and improve urgent and emergency care services. Despite significant challenges, including higher than anticipated demand, there has been a marked improvement in the headline ambition, with over 2.5 million more people completing their Accident & Emergency treatment within four hours in 2023/24 compared to 2022/23.”

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

Support regions and providers to eliminate longer-term crowding in emergency departments and improve patient flow.

Verbatim wording from the response

“NHS England is working to support its regions to support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance where health systems were asked to focus on areas to deliver improved patient flow and this has included increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

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

Use operational planning guidance to direct health systems toward improved patient flow and clinical outcomes.

Verbatim wording from the response

“NHS England is working to support its regions to support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance where health systems were asked to focus on areas to deliver improved patient flow and this has included increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

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

Disseminate the approved Standard Operating Procedure across urgent and emergency care areas.

Verbatim wording from the response

“A Standard Operating Procedure (SOP) for patients who leave the emergency department whilst waiting to be seen has now been drafted and is going through NCA approval processes, with an estimated approval date of 6th February 2025. We append the working draft for your information. This guideline sets out the responsibilities of clinical and nursing staff when an adult leaves an emergency care setting prior to being assessed or receiving treatment, so that the patient is safeguarded appropriately with the aim of:”

Source location

Response from Northern Care Alliance
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

Implement the NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.

Verbatim wording from the response

“In addition to the above, as of 25th November 2024, Salford Royal Hospital has become an early adopter of the NHSE Acuity Tool, an initial assessment model which aims to standardize the measurement of acuity in Emergency Departments and Urgent Treatment Centres. Patients who attend the ED at Salford Royal now receive an initial, primary assessment to identify patients with an acuity 1, 2 or 5 which will allow them to either be directed immediately to a receiving location or be directed to an alternative provider such as primary care. Acuity 1 patients are those with immediate life/limb threatening illness/injury, acuity 2 are those with imminent life/limb threatening illness/injury and acuity 5 denotes no threat to life or limb, no ED specific resource necessary. Patients who do not meet an acuity 1, 2 or 5 will then go on to receive a secondary assessment.”

Source location

Response from Northern Care Alliance
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 obtain approval for a Standard Operating Procedure governing patients leaving the emergency department before assessment or treatment.

Verbatim wording from the response

“Additionally, it was highlighted that at the time of Mrs Taylor’s attendance there was no formalized Standard Operating Procedure within Salford Royal’s Emergency Department defining the actions to take when a patient leaves before clinical assessment. Salford site has an electronic self-discharge checklist designed for ward-based use, but no guidance or policy to describe the appropriate completion of this, or relevant steps to take, in the emergency department setting.”

Source location

Response from Northern Care Alliance
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

Continue work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.

Verbatim wording from the response

“The target time for secondary assessment is 15 minutes, Salford Care Organisation are on track to achieve this. Progress of the early adopter programme is being shared with NHSE at regular intervals. Patients receiving a secondary assessment can be identified for early clinical intervention and front loading of essential investigations such as, CT scan. Work is ongoing to meet the NHSE secondary assessment target to provide the significant benefits it offers of reducing the risk of patients with serious conditions sitting in the waiting room for a long time undiagnosed. In addition, the new acuity tool, has a specific question regarding mental capacity assessment relating to a patient’s decision to leave the department.”

Source location

Response from Northern Care Alliance
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 and frontload secondary investigations, including CT scanning, for head-injury patients meeting NICE criteria while they await clinical review.

Verbatim wording from the response

“The review determined that going forwards secondary investigations (such as a CT scan) should be considered and frontloaded for patients who are identified as meeting NICE guidelines criteria for CT scan in head injury, whilst they await clinical review. The new NHSE Acuity tool process described below will support this.”

Source location

Response from Northern Care Alliance
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

Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.

Verbatim wording from the response

“I note that your Report has also been sent to Salford Royal Hospital Foundation Trust, who are the appropriate organisation to respond to the concerns raised. NHS England has asked to be sighted on the Trust’s response to the Coroner and will review this once received.”

Source location

Response from NHS England
Page 1 · 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.4

  1. 1

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning nationally and regionally.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
  2. 2

    Undertake an After-Action Review under PSIRF to identify learning and opportunities to improve emergency department systems.

    Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
  3. 3

    Circulate learning from the incident and draft Standard Operating Procedure through safety messages and directorate governance meetings.

    Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2024.
  4. 4

    Share regular progress updates on the NHSE Acuity Tool early-adopter programme with NHS England.

    Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning nationally and regionally.

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 Anne, 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 action was interpreted

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

PFD Monitor interpretation

Undertake an After-Action Review under PSIRF to identify learning and opportunities to improve emergency department systems.

Verbatim wording from the response

“I understand that following Mrs Taylor re-attending hospital on 20th July 2024, and the diagnosis of acute subdural haematoma being made, a clinical incident was immediately reported by a nurse in the Emergency Department regarding the ED attendance the previous evening. This incident was triaged via our usual governance systems, and it was felt that although an earlier diagnosis would sadly not have changed the outcome for Mrs Taylor, there was an opportunity for learning and improving our systems and so an After-Action Review was undertaken under the Patient Safety Incident Response Framework (PSIRF).”

Source location

Response from Northern Care Alliance
Page 1 · 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

Circulate learning from the incident and draft Standard Operating Procedure through safety messages and directorate governance meetings.

Verbatim wording from the response

“Once approved the SOP will be shared with all urgent and emergency care areas for dissemination. In the interim, learning from the incident and draft SOP will be circulated through safety messages and in the directorate governance meeting.”

Source location

Response from Northern Care Alliance
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

Share regular progress updates on the NHSE Acuity Tool early-adopter programme with NHS England.

Verbatim wording from the response

“The target time for secondary assessment is 15 minutes, Salford Care Organisation are on track to achieve this. Progress of the early adopter programme is being shared with NHSE at regular intervals. Patients receiving a secondary assessment can be identified for early clinical intervention and front loading of essential investigations such as, CT scan. Work is ongoing to meet the NHSE secondary assessment target to provide the significant benefits it offers of reducing the risk of patients with serious conditions sitting in the waiting room for a long time undiagnosed. In addition, the new acuity tool, has a specific question regarding mental capacity assessment relating to a patient’s decision to leave the department.”

Source location

Response from Northern Care Alliance
Page 2 · 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