PFD report

Andrew James Tizard-Varcoe · Prevention of Future Deaths report

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Issued 31 Mar 2025•Devon, Plymouth and Torbay

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

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 raised4

  1. Delays in outpatient follow-up for ear infections
    Part of recurring concern: Unreliable tracking and follow-up of outpatient appointments
  2. Failure to prescribe oral antibiotics at discharge despite microbiology advice
    Part of recurring concern: Unsafe medication prescribing
  3. Failure to establish clear responsibility for patient care
    Part of recurring concern: Failure to maintain clear clinical responsibility for patient carePart of recurring concern: Failure to provide continuity of patient care
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.8

  1. Action

    Work with Somerset Integrated Care Board and the national team to develop an integrated electronic health record across Somerset services.

    Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
  2. Action

    Monitor the ENT waiting list through daily oversight, weekly tracking meetings and fortnightly booking and operational reviews, with activity changes discussed to address demand.

    Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
  3. Action

    Continue collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.

    Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Existing ENT waiting-list monitoring and patient-service correspondence are considered sufficient for effective outpatient follow-up.

    Stated by Somerset NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 outpatient follow-up for ear infections

Wider context from the report

“(2) In addition, the evidence revealed that there were three occasions when Mr Tizard-Varcoe was not followed up as an outpatient in a timely manner (August 2021, November 2021 and February 2022). On one occasion Mr Tizard-Varcoe possibly ran out of antibiotic medication and on another Mr Tizard-Varcoe was discharged without antibiotic medication. The lack of timely follow up appointments resulted in reduced monitoring and assessment and a poor understanding of the effectiveness of treatment and the progression of his ear infection. ”

Is this part of a recurring concern?

Yes — Unreliable tracking and follow-up of outpatient appointments.

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 prescribe oral antibiotics at discharge despite microbiology advice

Wider context from the report

“(3) In addition, on 1 November 2021, Mr Tizard-Varcoe was discharged from the Royal and Devon Hospital without a prescription for oral antibiotics despite advice from microbiologists to do so; the evidence showed that this was a clinical decision made by a junior ear nose and throat doctor against an improving clinical picture. The discharge was overseen by a consultant from a different specialism due to Mr Tizard-Varcoe’s health needs at the time. Evidence at the inquest from the responsible ear nose and throat consultant, indicated that he would probably have prescribed antibiotics on advice of microbiologists. Due to the progression of the infection from the ear canal into the bone at the base of the skull there is a real possibility that the clinical presentation did not reflect the true situation and this was a missed opportunity to provide continuity of treatment. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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 establish clear responsibility for patient care

Wider context from the report

“(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care. It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe. ”

Is this part of a recurring concern?

Yes — Failure to maintain clear clinical responsibility for patient care; Failure to provide continuity of patient care.

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 of separate hospital trusts to provide clinicians with access to each other’s medical records

Wider context from the report

“(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care. It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe. ”

Is this part of a recurring concern?

Yes — Failure to reliably transfer medical records between healthcare organisations; 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

Work with Somerset Integrated Care Board and the national team to develop an integrated electronic health record across Somerset services.

Verbatim wording from the response

“Funding for integrated IT systems across organisations is something beyond the control of SFT but we are working with the NHS Somerset Integrated Care Board and the national team to develop an integrated Electronic Health Record across acute, community and mental health services in Somerset which will support better integration and interaction across our services as well as with neighbouring trusts and systems.”

Source location

Response from NHS Somerset
Page 1 · response
Published 14 July 2025

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

Monitor the ENT waiting list through daily oversight, weekly tracking meetings and fortnightly booking and operational reviews, with activity changes discussed to address demand.

Verbatim wording from the response

“Our ENT waiting list is monitored daily with close working between our Admissions/Booking Team and the ENT operational team. There is a weekly Patient Tracking List meeting where the waiting list is reviewed in a wider group. There is also a biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and Operational management) around the outpatient demands and the areas of concerns. Discussions are then had with our operational team, rota coordinator and the clinicians around changing activity to meet the demand where possible. We have undertaken a review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it can be demonstrated that regular correspondence is occurring with less than 4 weeks between patient and service contact over a 6–8-month period.”

Source location

Response from NHS Somerset
Page 2 · response
Published 14 July 2025

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

Continue collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.

Verbatim wording from the response

“It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.”

Source location

Response from NHS Somerset
Page 1 · response
Published 14 July 2025

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

Introduce virtual ticket scheduling through MyCare, with appointment notifications, patient self-booking and letters for patients without the application.

Verbatim wording from the response

“Ticket scheduling is another change due to be brought in which will be a virtual booking system on our MyCare app. This feature will send out notifications to the patients inviting them to book an appointment, the app will present all available slots to the patient for booking. All bookings are completed and confirmed via the app. Any patients without the app will be sent standard letters inviting them to clinic. This will avoid patients having to call into the office for an appointment which will be much faster.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025

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

Use the EPR fast-pass system to offer suitable vacant outpatient slots to patients through the MyCare application.

Verbatim wording from the response

“Another one of the changes that has been implemented is that the use of the EPR system has been further developed to include a “fast pass” and “ticket scheduling system” that sends out any vacant slots to the patients suitable for booking up to 6 times daily via the MyCare (EPR app) until the slots are filled. Patients can bring pre-booked appointments forward to a closer date.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025

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

Appoint two permanent ENT consultants and provide daily named-consultant ward rounds with senior review of discharges and ongoing treatment plans.

Verbatim wording from the response

“At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant that not every discharge could be reviewed by a named Consultant. Since 2022, a further two permanent ENT Consultants have been appointed. This has allowed the team to have a named consultant ward round on a daily basis and this means there is now senior supervision of decision making on every ward round. This includes reviewing all patients due to be discharged as well as their management plan on discharge. With this now in place, I am assured that there would be senior oversight of ongoing treatment and patients such as Mr Tizard-Varcoe would be discharged with appropriate treatment plans in place.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 4 · response
Published 14 July 2025

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

Implement a single electronic patient record across the merged Trust sites to improve coordination and continuity of care.

Verbatim wording from the response

“In April 2022, the two Trusts formally merged creating Royal Devon University Healthcare NHS Foundation Trust and by July 2022, both sites and all staff were using the same electronic records system (EPIC). This use of the one combined patient record has significantly improved care for patients receiving care across both sites and this has been a significant and important change since Mr Tizard-Varcoe’s death.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025

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 ENT outpatient follow-up monitoring through booking validation, waiting-list dashboards, overdue-date tracking, additional booking-office staffing and routine capacity reviews.

Verbatim wording from the response

“At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings were made. I can reassure you that over the past few years, a significant amount of work has gone into improving booking processes and waiting list (workqueue) monitoring. There is now much more robust ongoing validation/ assurance of booking processes and waiting lists.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025

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

Existing ENT waiting-list monitoring and patient-service correspondence are considered sufficient for effective outpatient follow-up.

Verbatim wording from the response

“Our ENT waiting list is monitored daily with close working between our Admissions/Booking Team and the ENT operational team. There is a weekly Patient Tracking List meeting where the waiting list is reviewed in a wider group. There is also a biweekly 1:1 meeting with the booking teams (Outpatient booking supervisors and Operational management) around the outpatient demands and the areas of concerns. Discussions are then had with our operational team, rota coordinator and the clinicians around changing activity to meet the demand where possible. We have undertaken a review of all patients within the service with the same diagnosis as Mr Tizard-Varcoe, it can be demonstrated that regular correspondence is occurring with less than 4 weeks between patient and service contact over a 6–8-month period.”

Source location

Response from NHS Somerset
Page 2 · response
Published 14 July 2025

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

Funding integrated information technology systems across organisations is beyond the Trust’s control.

Verbatim wording from the response

“Funding for integrated IT systems across organisations is something beyond the control of SFT but we are working with the NHS Somerset Integrated Care Board and the national team to develop an integrated Electronic Health Record across acute, community and mental health services in Somerset which will support better integration and interaction across our services as well as with neighbouring trusts and systems.”

Source location

Response from NHS Somerset
Page 1 · response
Published 14 July 2025

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

Existing cross-organisational clinical collaboration generally provides sufficient coordination, with shared care used where specifically requested.

Verbatim wording from the response

“It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.”

Source location

Response from NHS Somerset
Page 1 · response
Published 14 July 2025

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

Named consultant ward rounds and discharge-plan reviews are considered sufficient to provide senior oversight of ongoing treatment at discharge.

Verbatim wording from the response

“At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant that not every discharge could be reviewed by a named Consultant. Since 2022, a further two permanent ENT Consultants have been appointed. This has allowed the team to have a named consultant ward round on a daily basis and this means there is now senior supervision of decision making on every ward round. This includes reviewing all patients due to be discharged as well as their management plan on discharge. With this now in place, I am assured that there would be senior oversight of ongoing treatment and patients such as Mr Tizard-Varcoe would be discharged with appropriate treatment plans in place.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 4 · response
Published 14 July 2025

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

Merged services, a shared electronic record and planned Devon-wide integration are considered sufficient to improve coordination across sites.

Verbatim wording from the response

“I am assured that since the merger of the two Trusts and the implementation of Epic in across both sites and, continuity of care and patient safety has been improved.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025

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

Enhanced booking validation, waiting-list monitoring, staffing and electronic scheduling are considered sufficient to monitor ENT outpatient follow-ups efficiently.

Verbatim wording from the response

“At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings were made. I can reassure you that over the past few years, a significant amount of work has gone into improving booking processes and waiting list (workqueue) monitoring. There is now much more robust ongoing validation/ assurance of booking processes and waiting lists.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025

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

    Review whether complex patients receiving multiple specialties within the Trust can receive vascular care in Exeter.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Commissioners decide where Northern patients requiring vascular care are referred; that referral decision is outside the respondent’s influence.

    Stated by Royal Devon University Healthcare NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Introducing a nationwide records system is outside the respondent’s remit and should be addressed to NHS England.

    Stated by Royal Devon University Healthcare NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.

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 whether complex patients receiving multiple specialties within the Trust can receive vascular care in Exeter.

Verbatim wording from the response

“At the moment, patients attending our Northern services who require vascular care are referred to Musgrove Park Hospital in Taunton and not to the RD&E in Exeter. This is a commissioning decision and so the decision of where to refer such patients sits with the commissioners and is not something I have influence over. However, we will review whether complex patients like Mr Tizard-Varcoe (who are receiving care under numerous specialities within RDUH) can be seen in Exeter for vascular issues.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025

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

Commissioners decide where Northern patients requiring vascular care are referred; that referral decision is outside the respondent’s influence.

Verbatim wording from the response

“At the moment, patients attending our Northern services who require vascular care are referred to Musgrove Park Hospital in Taunton and not to the RD&E in Exeter. This is a commissioning decision and so the decision of where to refer such patients sits with the commissioners and is not something I have influence over. However, we will review whether complex patients like Mr Tizard-Varcoe (who are receiving care under numerous specialities within RDUH) can be seen in Exeter for vascular issues.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025

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

Introducing a nationwide records system is outside the respondent’s remit and should be addressed to NHS England.

Verbatim wording from the response

“The introduction of nationwide records system it is outside of my remit and this should be addressed to NHS England. However, I can reassure you that there has been and there is ongoing significant change across the whole of Devon which will improve coordination, collaboration and optimal treatment of patients across the county.”

Source location

Response from Royal Devon University Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025

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