PFD report

Eleanor Emily SHERMAN · Prevention of Future Deaths report

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Issued 26 Nov 2020•Warwickshire

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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: 3
Recipients: 2
Responses found: 1
Stated actions: 11

Recipients and published responses

Recipient name withheldNo response found Warwick HospitalNo response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 1st September 2020 I commenced an investigation into the death of Eleanor Emily SHERMAN 72 years old The investigation concluded at the end of the inquest on 25 November 2020 The conclusion of the inquest was a Narrative Verdict

Mrs Sherman was a woman of 72 years who died on 20 August 2020 at Warwick Hospital.

Mrs Sherman’s cause of death was determined by a post mortem examination to be 1a Subarachnoid and Intracerebellar Haemorrhage 1b Systemic Hypertension.

On 13 August 2020, Mrs Sherman contacted her GP by telephone. He was concerned about her symptoms and referred her to the Ambulatory Emergency Centre(AEC) at Warwick Hospital. The GP telephoned the hospital and indicated that Mrs Sherman needed a scan to exclude a subarachnoid haemorrhage (SAH). He also emailed a referral letter explicitly stating that Mrs Sherman’s presentation should be considered a SAH until proven otherwise. She was misdiagnosed and discharged without a scan. Neither the notes of the GP’s telephone call nor the GP’s email were seen by the treating staff except for final doctor who saw her immediately prior to discharge.

On 15 August 2020, Mrs Sherman re-attended Warwick Hospital. She was seen by a doctor in Emergency Department. He did not have access to the GP’s letter or notes from the attendance on 13th August 2020. The discharge summary from 13th August 2020 would have been available but medical staff were unaware of this. Mrs Sherman’s symptoms were unchanged from her earlier attendance

On 20th August 2020, Mrs Sherman suddenly collapsed at home and was brought to Warwick Hospital by ambulance. A CT scan performed at 15.41 hours confirmed a SAH. She died later that day.

The clinical errors (two misdiagnoses and failure to read GP referral letter) and systemic errors (GP referral letter and AEC notes not available on 15th August 2020) contributed to her death and constitute neglect notwithstanding her presentation of SAH was atypical.

Concerns and recipient responses

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Concerns raised3

Failure to act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan
Part of recurring concern: Unsafe recognition and management of subarachnoid haemorrhage
Inability of the GP team to access the electronic record
Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionable Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
Delays in scanning clinical notes onto the electronic system
Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionable Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records

Responses linked to these concerns

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

Actions described in response 8

Action
Disseminate the revised Acute Headache Pathway across the Trust through the Patient Safety Newsletter and intranet.
Stated by South Warwickshire University NHS Foundation TrustStated completed
Action
Teach junior doctors about subarachnoid haemorrhage and incorporate this case into teaching materials and the junior doctors’ handbook.
Stated by South Warwickshire University NHS Foundation TrustStated completed
Action
Amend the ACP triage form and redesign the AEC MNP GP-referral form to capture GP concerns.
Stated by South Warwickshire University NHS Foundation TrustStated completed

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 3

1
Share incident learning with AEC and ED staff through team meetings and newsletters.
Stated by South Warwickshire University NHS Foundation TrustStated completed
2
Review and critically reappraise care and decision-making to identify organisational learning and assess existing corrective actions.
Stated by South Warwickshire University NHS Foundation TrustStated completed
3
Raise ED staff awareness that AEC discharge summaries are immediately available in Lorenzo patient records.
Stated by South Warwickshire University NHS Foundation TrustStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised3

Failure to act on written instruction to treat as suspected subarachnoid haemorrhage unless excluded by CT scan

Inability of the GP team to access the electronic record

Delays in scanning clinical notes onto the electronic system

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

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

Actions described in response 8

Recipient-stated actions 3