PFD report

Nancy ROGERS · Prevention of Future Deaths report

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Issued 9 Jul 2024•Cumbria

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
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 raised1

  1. Failure to undertake learning or teaching following comparable deaths
    Part of recurring concern: Failure to identify and address recurring safety issues through organisational learningPart of recurring concern: Failure to learn from deaths through systematic review
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.4

  1. Action

    Write an action plan addressing the causes and prevention of missed aortic dissection diagnoses.

    Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
  2. Action

    Display an aortic dissection poster with a linked educational video in emergency department clinical and triage areas.

    Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
  3. Action

    Include aortic dissection in the August induction programme for new doctors.

    Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.

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 undertake learning or teaching following comparable deaths

Wider context from the report

“(1) At the inquest into Shirley Potter's death the hospital report indicated no learning was required as her presentation was not typical. The circumstances in both these cases are remarkably similar in that both ladies attended the emergency department at Furness General and were allowed home only to die within a day of the same cause and as far as the attending clinician at today's hearing knew no learning or teaching has taken place since Nancy's death. ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning; Failure to learn from deaths through systematic review.

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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

Write an action plan addressing the causes and prevention of missed aortic dissection diagnoses.

Verbatim wording from the response

“A meeting was held between the Clinical Lead - Emergency Medicine (FGH), the Clinical Lead - Emergency Medicine (RLI), the Clinical Lead - Urgent Treatment Centre WGH and the Deputy Medical Director (Education, Research, Workforce and Innovation) to discuss the causes of Shirley Potter and Nancy Rogers and another case that we had noted in the jurisdiction of the Senior Coroner Lancashire and Blackburn with Darwen. The discussion at the meeting centred on the best way to disseminate information regarding aortic dissection, in order to reduce the risk of this diagnosis being missed in the future. An action plan was written and since the meeting, the following actions have been put in place:”

Source location

Response from Morecambe Bay NHSFT
Page 1 · response
Published 30 July 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

Display an aortic dissection poster with a linked educational video in emergency department clinical and triage areas.

Verbatim wording from the response

“• An A4 poster has been created (copy attached) and is displayed in the Emergency Department (ED) clinical areas and triage, for quick reference. The QR code links to a video on the Aortic Dissection Charitable Trust's website.”

Source location

Response from Morecambe Bay NHSFT
Page 1 · response
Published 30 July 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

Include aortic dissection in the August induction programme for new doctors.

Verbatim wording from the response

“• Aortic dissection is now included in the new doctor induction in August.”

Source location

Response from Morecambe Bay NHSFT
Page 2 · response
Published 30 July 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

Disseminate the aortic dissection video to medical and nursing staff across emergency, urgent treatment, same-day emergency care and acute medical units, tracking viewings and adding new starters.

Verbatim wording from the response

“• The video on the Aortic Dissection Charitable Trust website is being drawn to the attention of senior and junior medical staff at ED meetings at both of the Trust’s main hospitals, between July and the end of September. A list of the”

Source location

Response from Morecambe Bay NHSFT
Page 1 · response
Published 30 July 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.3

  1. 1

    Create and upload a unified Trust standard operating procedure for managing aortic dissection.

    Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
  2. 2

    Include an audit of the aortic dissection standard operating procedure in the Audit Calendar.

    Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
  3. 3

    Obtain permission from the Aortic Dissection Charitable Trust to use its data and logos in educational materials and discussions.

    Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 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

Create and upload a unified Trust standard operating procedure for managing aortic dissection.

Verbatim wording from the response

“• A Standard Operating Procedure (SOP) for the management of Aortic Dissection is being created, to ensure a consistent approach to the management of aortic dissection throughout the Trust. This will be uploaded to Trust Procedural Documents library, which can be accessed from any Trust computer. There is currently a SOP in the medical guidelines and there are also regional guidelines. These are being combined for clarity and it is anticipated that this will be completed within the next 4-6 weeks.”

Source location

Response from Morecambe Bay NHSFT
Page 2 · response
Published 30 July 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

Include an audit of the aortic dissection standard operating procedure in the Audit Calendar.

Verbatim wording from the response

“• An audit of the SOP has been included in the Audit Calendar.”

Source location

Response from Morecambe Bay NHSFT
Page 2 · response
Published 30 July 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

Obtain permission from the Aortic Dissection Charitable Trust to use its data and logos in educational materials and discussions.

Verbatim wording from the response

“• Contact has been made with the Aortic Dissection Charitable Trust and consent has been obtained to use their data and logos in any materials, teaching or discussions.”

Source location

Response from Morecambe Bay NHSFT
Page 1 · response
Published 30 July 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