Nancy ROGERS · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 9 Jul 2024•Cumbria

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
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

Full report text

This is the full text from the original published report.

Open published report

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

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. University Hospitals of Morecambe Bay NHS Foundation Trust

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

  2. University Hospitals of Morecambe Bay NHS Foundation Trust

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

  3. University Hospitals of Morecambe Bay NHS Foundation Trust

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

  4. University Hospitals of Morecambe Bay NHS Foundation Trust

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

  5. University Hospitals of Morecambe Bay NHS Foundation Trust

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

  6. University Hospitals of Morecambe Bay NHS Foundation Trust

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

  7. University Hospitals of Morecambe Bay NHS Foundation Trust

    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.

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.

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

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

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

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

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

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

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

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 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

Open published response
Back to top

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