Report evidence summary
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
× 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 expedite emergency MRI scanning and document escalation attempts
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan . There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan ;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” Is this part of a recurring concern? Yes — Unreliable access to timely MRI scanning .
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 by treating clinicians to recognise and record activation of the septic shock pathway
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest ;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Independent operation of adverse-incident review and Legal Services departments
Wider context from the report “(3) The Department undertaking reviews of adverse incidents appears to operate independently from the Legal Services Department
” 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 Failure to obtain family views and concerns during the adverse-death review
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest .
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Inappropriate and undocumented prioritisation of urgent MRI scans
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category . There is no documentation as to any rationale for the priority allocation ;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Incomplete investigation of suspected high cervical-spine infection
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG ;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 completing adverse-death review reports
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance ;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Radiology scan prioritisation dependent on personal clinician attendance or discussion rather than clinical need
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need ;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 identify the responsible specialty and document its management in medical records
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 perform the required contrast MRI scan initially
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day .
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death
Wider context from the report “(1) The Trust has an ineffectual system to detect adverse outcomes where the patient is transferred to a tertiary centre for treatment and subsequently dies ;
” 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 expedite scanning or contact tertiary neurosurgical services after specialist input
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services ;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Insufficient senior clinical oversight of review conclusions
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn .
” 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 Factual inaccuracies in adverse-incident review summaries
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading ;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Inappropriate allocation of cases to structured judgement review
Wider context from the report “(2) The Trust's review of this case was seriously deficient in the following instances:
a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest.
b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance;
c. The case was inappropriately allocated to a structured judgement review ;
d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading;
e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that:
i. the EWS score was sufficient to trigger the septic shock pathway;
ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor";
iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust);
iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest;
v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event.
f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan;
g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services;
h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG;
i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation;
j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day.
k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need;
l. There was insufficient senior clinical oversight of the conclusions drawn.
” 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 Insufficient MRI scanner capacity for urgent scans
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity . At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans.
” Is this part of a recurring concern? Yes — Unreliable access to timely MRI scanning .
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 evaluate whether MRI capacity changes improve urgent scan times
Wider context from the report “(4) The delay in obtaining the scan was partly attributed to a lack of MRI scanner capacity. At the inquest the Trust could only provide conjecture as to whether or not alterations to scan capacity had made any difference to the time taken to obtain urgent scans .
” Is this part of a recurring concern? Yes — Unreliable access to timely MRI scanning .
Open source report
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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 Develop and validate a traffic-light system showing radiology diagnostic waits to support escalation of urgent imaging.
Verbatim wording from the response “The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Introduce weekly Executive review of divisional investigations before SIRI Panel submission.
Verbatim wording from the response “A weekly Executive review of Divisional investigations due at SIRI Panel has been introduced from 21 April to monitor the quality of reports prior to submission. This aims to ensure that the quality of the investigation may be identified earlier and at a senior enough level to require any further improvements to be made without delaying the process or submission to your court. A pro forma for Serious Incident investigations, with a front sheet for sign off each stage, has been developed in line with the National Patient Safety Strategy and PSIRF requirements; which prompts investigators to clearly link the problems, learning and recommendations to individual actions that are focused on preventing the same incident reoccurring. I understand a pilot version of this proforma was received favourably by one of your team at an inquest last week.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Operate two new MRI systems at Burnley and progress replacement and upgrading of the oldest Blackburn MRI assets.
Verbatim wording from the response “In October 2020, ELHT commissioned two new Magnetic Resonance Imaging (MRI) systems on the Burnley General Teaching Hospital site. These scanners were replacement assets identified as part of the government initiative which aimed to replace all MRI systems over 10 years old. The initial intention was to replace the Philips MRI system at Burnley and the Trust owned asset at RBH. However, due to” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Develop a funded cohort of investigators and family liaison officers with allocated time, training and administrative support.
Verbatim wording from the response “A full review and update of investigation process has been completed, in line with Patient Safety Incident Response Framework. Funding has been agreed in support of a proposal to develop a cohort of investigators and family liaison officers with allocated time, specific training and administrative resource to enable timely and thorough investigations. This team will report to the Assistant Director of Safety and Risk and work in partnership with the legal team to coordinate investigations and learning on behalf of the trust.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.
Verbatim wording from the response “Radiology in-patient Co-ordinator/Navigator role was established in November 2019. This role has supported improved patient flow and communication between referring clinical teams and the radiology team. Cover is provided 52 weeks of the year by the Radiology Administrative function. A Standard Operating Procedure describing the functions of this role and the actions required by referrers to improve access and efficiency in radiology is being developed to support this function. Communications have been clarified to advise on the most appropriate manner for teams to access the In-patient Navigator. This is the route that teams will use to find out when a scan is planned and also to expedite imaging which has not yet been planned.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Review inpatient radiology priorities at vetting stage and align time-based priorities with NICE guidance where applicable.
Verbatim wording from the response “We are currently also reviewing the In-patient priorities applied at vetting stage by Radiology. It is anticipated that these will be time-based allowing a better understanding of the priority applied at vetting; aligned to NICE guidance for urgent imaging where stated. This will allow pressures within the system to be escalated so that clinical decisions can be made on how best to proceed.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Complete a Trust-wide review and update of the serious-incident investigation process in line with the Patient Safety Incident Response Framework.
Verbatim wording from the response “A full review and update of investigation process has been completed, in line with Patient Safety Incident Response Framework. Funding has been agreed in support of a proposal to develop a cohort of investigators and family liaison officers with allocated time, specific training and administrative resource to enable timely and thorough investigations. This team will report to the Assistant Director of Safety and Risk and work in partnership with the legal team to coordinate investigations and learning on behalf of the trust.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 use a Serious Incident investigation pro forma with staged sign-off and links between problems, learning and preventive actions.
Verbatim wording from the response “A weekly Executive review of Divisional investigations due at SIRI Panel has been introduced from 21 April to monitor the quality of reports prior to submission. This aims to ensure that the quality of the investigation may be identified earlier and at a senior enough level to require any further improvements to be made without delaying the process or submission to your court. A pro forma for Serious Incident investigations, with a front sheet for sign off each stage, has been developed in line with the National Patient Safety Strategy and PSIRF requirements; which prompts investigators to clearly link the problems, learning and recommendations to individual actions that are focused on preventing the same incident reoccurring. I understand a pilot version of this proforma was received favourably by one of your team at an inquest last week.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Roll out the radiology inpatient dashboard to wards and clinical services.
Verbatim wording from the response “The Radiology in patient dashboard has been developed using our business intelligence system and is currently used in key areas of the Trust. Roll out of the dashboard is progressing. The next steps are to demonstrate and share access to the dashboard at the Nursing & Midwifery Forum, Foundation Teaching and Clinical Leadership to accelerate roll out to the wards and clinical services.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Hold twice-weekly clinico-radiological meetings to discuss difficult cases and support imaging decisions without requiring personal attendance.
Verbatim wording from the response “Clinico-radiological meetings were established in November 2020 and now occur twice weekly on Monday and Friday on AMU. It is intended that when possible, a third meeting will be provided on a Wednesday to provide better support through the working week. This development allows a forum in which difficult cases can be discussed and advice and guidance provided on the optimum imaging technique and/or interpretation of unusual report findings and has been a significant success; building improved relationships and communication between clinical teams on AMU and the radiology directorate. This meeting explicitly addresses the human factors highlighted in this case; ensuring that patient management is equitable regardless of the staff on duty and that clinical discussions can be held without personal attendance.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Revise radiology Internal Professional Standards and monitor compliance weekly against imaging requirements.
Verbatim wording from the response “The Internal Professional Standards (IPS) have been revised by the Radiology Directorate to support the requirements for imaging in this cohort of patients. The compliance with the standards are monitored weekly at the Radiology Performance Meeting. Phase two of the Power BI dashboard development is to include the IPS for in-patient turnaround times. We are also working on a traffic light system which will demonstrate, at a glance, the average waits for radiology diagnostics supporting the need to expedite urgent imaging. The first draft of the traffic light system is now "live" on the radiology intranet site and is being validated prior to display in a more prominent area of the Trust intranet.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Introduce a weekly complex-case coordination meeting integrating legal services and complaints, coordinating investigations and early family liaison.
Verbatim wording from the response “A weekly complex case coordination meeting has been introduced to enable early coordination with legal services and complaints team, to agree appropriate routes for investigation and ensure all families concerns are understood. This has enabled a full review of case currently listed for inquest and any potential delays or concerns regarding linked investigation processes. This complex case group coordinates all cases that cross divisions, are listed for an inquest, have an ongoing investigation of any kind (eg complaint/SJR/LeDeR) and ensures families are contacted by an allocated family liaison officer at as early a stage as possible.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Establish a senior core group to oversee action-plan implementation and monitor embedding into Trust processes.
Verbatim wording from the response “A core group has been established to oversee the implementation of this action plan led by the Associate Director of Quality and Safety, the Deputy Medical Director and Director of Nursing to ensure senior oversight of the issues raised. Please be assured that this group will continue to meet until all actions have been embedded as business as usual into Trust processes with clear reporting and monitoring processes in place.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 The Regional Medical Examiner group is to consider establishing a cross-hospital feedback mechanism for detecting deaths after patient transfers.
Verbatim wording from the response “achieving this when asked. Recognising the focus and role of the Medical Examiners, across all Trusts; our Lead Medical Examiner has asked the Regional Team to consider whether these roles could support with this issue. We await a response.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Systematic follow-up of transferred patients who later die is difficult because the Trust depends on timely notification by other organisations.
Verbatim wording from the response “You raised a concern re the lack of systems to follow up patients who once transferred go on to deteriorate in other Trusts. It has proved difficult to achieve this from a systems perspective. Achieving this is heavily reliant on the Trust being informed of a patient having unfortunately died, in a timely manner. Mr Medley’s case has clearly demonstrated the impact of the absence of this system, but no Trust we have spoken to has been able to describe a standardised systematic approach to” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 The MRI scan without contrast was considered appropriate because the clinical question was adequately answered and additional contrast had limited diagnostic utility.
Verbatim wording from the response “The MRI scan in question was vetted on 2nd July 2019 by a senior Consultant Radiologist and CRIS (Radiology Information System) records demonstrate that it was felt that the clinical question posed by the clinical team could be adequately answered by an MRI scan without the administration of contrast media. The referral was re-vetted the next day (3rd July 2019) by a second Consultant Radiologist who also agreed that contrast media was not required.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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 Provide inquest attendance and statement-writing training to relevant staff.
Stated by East Lancashire Hospitals NHS Trust Stated completedThe respondent said that this action was complete when they made their response on 8 March 2021. View source 2 Continue monitoring action-plan implementation through Trust-wide quality governance and Quality Committee reporting until actions are embedded.
Stated by East Lancashire Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source 3 Update the investigation policy and introduce audit measures against investigation standards for Trust-wide governance monitoring.
Stated by East Lancashire Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source 4 Recruit two additional solicitors and an inquest coordinator through advertised posts.
Stated by East Lancashire Hospitals NHS Trust Stated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021. View source
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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 Provide inquest attendance and statement-writing training to relevant staff.
Verbatim wording from the response “The Trust’s Legal team are currently advertising 2 additional solicitor posts and an inquest coordinator. Inquests attendance and statement writing training provided in partnership with Hempsons on 22nd June. Planned dates for a continued programme of training is awaited.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Continue monitoring action-plan implementation through Trust-wide quality governance and Quality Committee reporting until actions are embedded.
Verbatim wording from the response “The action plan implementation will continue to be monitored at Trust Wide Quality Governance meeting and will report to the Quality Committee until all actions have been embedded as business as usual with monitoring processes in place.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Open published response
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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 Update the investigation policy and introduce audit measures against investigation standards for Trust-wide governance monitoring.
Verbatim wording from the response “A full policy update is underway in line with the above mentioned proposal including new audit measures against investigation standards which will be monitored at Trust-wide Governance meeting.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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 Recruit two additional solicitors and an inquest coordinator through advertised posts.
Verbatim wording from the response “The Trust’s Legal team are currently advertising 2 additional solicitor posts and an inquest coordinator. Inquests attendance and statement writing training provided in partnership with Hempsons on 22nd June. Planned dates for a continued programme of training is awaited.” Source location 2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
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