PFD report

Jean Helen Hannon · Prevention of Future Deaths report

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Issued 30 Sep 2015•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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised1

  1. Failure of medical records to sufficiently highlight a previous diagnosis of a potentially life-threatening condition
    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.2

  1. Action

    Pilot daily problem lists to document ongoing clinical concerns during ward rounds and assessments, with evaluation before rollout to other areas.

    Stated by East Lancashire Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2015.
  2. Action

    Provide GP case summaries through EMIS Web in urgent, emergency and planned admission records.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The records do not substantiate autonomic dysreflexia; autonomic instability is considered the more accurate diagnosis.

    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 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 of medical records to sufficiently highlight a previous diagnosis of a potentially life-threatening condition

Wider context from the report

“That the medical records retained at the Royal Blackburn Hospital failed to sufficiently highlight the previous diagnosis of a condition that is potentially life threatening. ”

Is this part of a recurring concern?

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

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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

Pilot daily problem lists to document ongoing clinical concerns during ward rounds and assessments, with evaluation before rollout to other areas.

Verbatim wording from the response

“2. ████████ a consultant geriatrician, is piloting the use of daily problem lists as a technique for documenting on-going concerns during ward rounds and daily assessments. This has been used in other hospitals specifically to address the issue of relevant clinical information not being passed on. This is currently in the pilot phase and will be rolled out to other areas after evaluation.”

Source location

2015-0458-Response-by-East-Lancashire-Hospitals-NHS-Trust
Page 2 · response
Published 30 September 2015

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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 GP case summaries through EMIS Web in urgent, emergency and planned admission records.

Verbatim wording from the response

“1. The Trust now has access to a case summary from the patients GP notes via an electronic system called ‘EMIS web’. This means that a printed summary of the case record is included as part of the patients case notes for every urgent and emergency admission. For planned admissions this information is gathered during the pre-admission processes. These arrangements have now been in place since April 2015.”

Source location

2015-0458-Response-by-East-Lancashire-Hospitals-NHS-Trust
Page 2 · response
Published 30 September 2015

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 records do not substantiate autonomic dysreflexia; autonomic instability is considered the more accurate diagnosis.

Verbatim wording from the response

“It is the belief of ████████ that Jean Hannon did not have autonomic dysreflexia, and that there is no substantiating evidence in the case-note to say that she did.”

Source location

2015-0458-Response-by-East-Lancashire-Hospitals-NHS-Trust
Page 1 · response
Published 30 September 2015

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