PFD report

Alfred Grimshaw · Prevention of Future Deaths report

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Issued 28 Oct 2016•Blackburn, Hyndburn and Ribble Valley

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to report a visible hip fracture on an x-ray report
    Part of recurring concern: Failure to reliably assess and diagnose injuries
  2. Failure to carry out requested physiotherapy or occupational therapy review before discharge
  3. Failure to sign and date handwritten clinical notes
    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 An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Put specific measures in place to reduce the risk of further radiology reporting errors.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 October 2016.

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 report a visible hip fracture on an x-ray report

Wider context from the report

“1. On being assessed in the emergency department on the 26th May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise so x-ray was carried out in order to rule out the possibility of a fracture to his hip. 2. On the 27th May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it. 3. On the 27th May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge. 4. On the discharge summary that was printed on the 28th May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any physiotherapy.” That handwritten note is not signed or dated. ”

Is this part of a recurring concern?

Yes — Failure to reliably assess and diagnose injuries.

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 carry out requested physiotherapy or occupational therapy review before discharge

Wider context from the report

“1. On being assessed in the emergency department on the 26th May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise so x-ray was carried out in order to rule out the possibility of a fracture to his hip. 2. On the 27th May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it. 3. On the 27th May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge. 4. On the discharge summary that was printed on the 28th May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any physiotherapy.” That handwritten note is not signed or dated. ”

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 sign and date handwritten clinical notes

Wider context from the report

“1. On being assessed in the emergency department on the 26th May, despite the history of an unwitnessed fall and the fact that he was 93 years of age and had been subsequently unable to mobilise so x-ray was carried out in order to rule out the possibility of a fracture to his hip. 2. On the 27th May 2016 an x-ray of the abdomen was requested to rule out a sub-acute intestinal obstruction. Although that was an x-ray of the abdomen it covered part of the right hip, which disclosed a significant displaced fracture through the right lesser trochanter that was visible on the lower limit of the film. Despite the fracture being disclosed on the x-ray, the report made no reference to it. 3. On the 27th May a request was made for physio and O T review which was clearly documented, there was however no evidence that physio or O T was carried out prior to discharge. 4. On the discharge summary that was printed on the 28th May 2016 at 16:21 is a handwritten note “Patient off his legs. Pain ++ right hip and during movement. Physio advises x-ray to exclude hip fracture prior to any physiotherapy.” That handwritten note is not signed or dated. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Put specific measures in place to reduce the risk of further radiology reporting errors.

Verbatim wording from the response

“2. The x-ray report of 27th May (abdominal x-ray to exclude intestinal obstruction) failed to report the evident right hip fracture. The Radiologist who undertook this report is currently under restricted practice, and subject to a clinical review. I am unable to comment further on this matter, but specific measures have been put in place to ensure that the risk of further errors is reduced.”

Source location

2016-0387-Response-by-East-Lancasshire-Hospitals-NHS-Trust
Page 1 · response
Published 28 October 2016

Open published response

Other statements in published responses

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

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Use the case for junior doctor teaching and feedback to the involved ward team.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 October 2016.
  2. 2

    Develop primary-secondary care arrangements to improve discharge documentation and transfer of information.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 October 2016.
  3. 3

    Strengthen complex-frail-patient discharge communication processes, with specific emphasis on multidisciplinary team involvement.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 October 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The initial clinical presentation did not suggest a femoral-neck fracture, so an alternative diagnosis was considered more appropriate than hip radiography.

    Stated by East Lancashire Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Use the case for junior doctor teaching and feedback to the involved ward team.

Verbatim wording from the response

“As a result of the receipt of this Regulation 28 notice this case has been used as a learning case for teaching of Junior Doctors and used in feedback meetings to the Ward Team involved.”

Source location

2016-0387-Response-by-East-Lancasshire-Hospitals-NHS-Trust
Page 2 · response
Published 28 October 2016

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 primary-secondary care arrangements to improve discharge documentation and transfer of information.

Verbatim wording from the response

“3 & 4. The processes around communication relating to discharges of complex frail patients has been significantly strengthened in the past six months with specific emphasis upon the role of the Multidisciplinary Team. There have also been developments between primary and secondary care to ensure that discharge documentation and transfer of information is improved.”

Source location

2016-0387-Response-by-East-Lancasshire-Hospitals-NHS-Trust
Page 1 · response
Published 28 October 2016

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

Strengthen complex-frail-patient discharge communication processes, with specific emphasis on multidisciplinary team involvement.

Verbatim wording from the response

“3 & 4. The processes around communication relating to discharges of complex frail patients has been significantly strengthened in the past six months with specific emphasis upon the role of the Multidisciplinary Team. There have also been developments between primary and secondary care to ensure that discharge documentation and transfer of information is improved.”

Source location

2016-0387-Response-by-East-Lancasshire-Hospitals-NHS-Trust
Page 1 · response
Published 28 October 2016

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The initial clinical presentation did not suggest a femoral-neck fracture, so an alternative diagnosis was considered more appropriate than hip radiography.

Verbatim wording from the response

“I have reviewed the Emergency Department notes of this patient and the clinical picture presented to the Doctor did not suggest a fractured femoral neck as the patient was moving all limbs and not complaining of specific hip pain. An alternative diagnosis to explain the reduced mobility was felt to be more appropriate.”

Source location

2016-0387-Response-by-East-Lancasshire-Hospitals-NHS-Trust
Page 1 · response
Published 28 October 2016

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026