PFD report

Margaret Ann PILGRIM · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 10 Jun 2024•Essex

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised4

  1. Failure to book fracture clinic follow-up
    Part of recurring concern: Unreliable arrangement and communication of patient appointments and follow-upPart of recurring concern: Unreliable care and follow-up for identified fractures
  2. Failure to treat identified fractures
    Part of recurring concern: Unreliable care and follow-up for identified fractures
  3. Failure to provide pain relief and consider a care package at discharge
    Part of recurring concern: Failure to ensure safe post-discharge arrangements for vulnerable patients and residentsPart of recurring concern: Failure to provide timely and adequate pain reliefPart of recurring concern: Unreliable hospital discharge processes
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

    Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.

    Stated by the Princess Alexandra Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2024.
  2. Action

    Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The fracture was minimally displaced and would not have required restricted mobilisation or orthopaedic follow-up if identified.

    Stated by the Princess Alexandra Hospital 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 to book fracture clinic follow-up

Wider context from the report

“Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged. (1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package (2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked (3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic. ”

Is this part of a recurring concern?

Yes — Unreliable arrangement and communication of patient appointments and follow-up; Unreliable care and follow-up for identified fractures.

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 treat identified fractures

Wider context from the report

“Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged. (1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package (2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked (3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic. ”

Is this part of a recurring concern?

Yes — Unreliable care and follow-up for identified fractures.

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 provide pain relief and consider a care package at discharge

Wider context from the report

“Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged. (1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package (2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked (3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe post-discharge arrangements for vulnerable patients and residents; Failure to provide timely and adequate pain relief; Unreliable hospital discharge processes.

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 communicate identified fractures in discharge information

Wider context from the report

“Mrs Pilgrim’s collapse at home was multifactorial due to natural causes however, she sustained a fractured clavicle that was reported on her X-Ray during her admission to hospital. This was not noted, and Mrs Pilgrim was discharged. (1) The Trust did not treat the patient for the fracture who was discharged with no pain relief or consideration of care package (2) The Discharge Summary omitted to inform the patient, her family or her GP of the fracture and no follow-up in the fracture clinic was booked (3) The fracture was only confirmed when the GP raised the concerns of the family with the Trust and the GP arranged analgesia, social care contact and follow-up for the fracture clinic. ”

Is this part of a recurring concern?

Yes — Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs; Failure to involve families and carers in discharge planning and decisions; Unreliable care and follow-up for identified fractures; Unreliable hospital discharge processes; Unreliable inter-agency information sharing for coordinated care.

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

Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.

Verbatim wording from the response

“- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.”

Source location

Response from Princess Alexandra Hospital
Page 2 · response
Published 14 June 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.

Verbatim wording from the response

“- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.”

Source location

Response from Princess Alexandra Hospital
Page 2 · response
Published 14 June 2024

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 fracture was minimally displaced and would not have required restricted mobilisation or orthopaedic follow-up if identified.

Verbatim wording from the response

“- The fracture was not identified prior to the patient being discharged, due to the minimal displacement, which was reviewed by ED clinical team and not radiologist. Had the fracture been identified and orthopaedic advice sought, they would have recommended the patient to mobilise without restriction. No follow up would have been deemed necessary with this fracture.”

Source location

Response from Princess Alexandra Hospital
Page 1 · response
Published 14 June 2024

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

A care package was not considered necessary because the assessment found that the patient did not meet the relevant threshold.

Verbatim wording from the response

“- The patient was advised to stay in the ED overnight in order to be seen by the REACT (Rapid Emergency Assessment Care Team) prior to her discharge so that she could be assessed for a potential package of care. Their assessment was that at the time she did not meet the threshold for this however some additional equipment was provided and ordered for her.”

Source location

Response from Princess Alexandra Hospital
Page 2 · response
Published 14 June 2024

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

No analgesia was considered necessary because neither the patient nor her daughter requested it at discharge and shoulder pain was not subsequently reported.

Verbatim wording from the response

“- Aside from when the patient was initially admitted there was no reference to the patient complaining of pain in her shoulder by either the medical team or the therapists who”

Source location

Response from Princess Alexandra Hospital
Page 1 · response
Published 14 June 2024

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 existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.

Verbatim wording from the response

“- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.”

Source location

Response from Princess Alexandra Hospital
Page 2 · response
Published 14 June 2024

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.1

  1. 1

    Discussed the incident with the emergency department to disseminate learning and address recurrence risks.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2024.

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

Discussed the incident with the emergency department to disseminate learning and address recurrence risks.

Verbatim wording from the response

“- It is recognised that ED will miss a small percentage of fractures on initial reporting. Hence there is a process in place by which the reported images are subsequently reviewed by an ED consultant. Unfortunately, in this instance the report was filed without the patient or GP being informed. We have discussed this incident with the department and reviewed this process to assure ourselves that it is as robust a process as possible and in line with other EDs nationally. One contributing factor to the human error that occurred was noted to be our IT systems which requires our clinicians to work with multiple different programmes in order to review the images and patient notes. I would like to reassure that we are due to launch a comprehensive Electronic Health Record in November of this year which we are confident will resolve this issue and reduce the likelihood of recurrence.”

Source location

Response from Princess Alexandra Hospital
Page 2 · response
Published 14 June 2024

Open published response
Back to top

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

Data last updated 7 September 2026