PFD report

Richard John Lockley · Prevention of Future Deaths report

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Issued 10 Jan 2019•Staffordshire South

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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 raised2

  1. Poor communication during transfers between County Hospital and Royal Stoke
    Part of recurring concern: Unreliable healthcare patient transfer processesPart of recurring concern: Unreliable multi-agency communication procedures
  2. Difficulties in finding gastroenterology beds at Royal Stoke
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

    Communicate that suitable acute medical wards can facilitate feeding procedures when gastroenterology beds are unavailable.

    Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 May 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Existing cross-site bed-management, transfer and escalation arrangements are considered sufficient to minimise treatment delays.

    Stated by University Hospitals of North Midlands NHS 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

Poor communication during transfers between County Hospital and Royal Stoke

Wider context from the report

“(1) Mr Lockley’s condition was a complex one but following discussions it was decided that he should be admitted to a gastroenterology ward at the Royal Stoke University Hospital for a radiologically inserted gastrostomy. Mr Lockley was at County Hospital. There appears to have been very poor communication between County Hospital and Royal Stoke in respect of the transfer. I wonder if this could be improved generally where patients need to be transferred between County Hospital and Royal Stoke. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes; Unreliable multi-agency communication procedures.

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

Difficulties in finding gastroenterology beds at Royal Stoke

Wider context from the report

“(2) I am always cautious about making reports involving resources but there also appears to have been difficulties in actually finding a gastroenterology bed at Royal Stoke for Mr Lockley. I raise this just in case anything can be realistically be done about this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Communicate that suitable acute medical wards can facilitate feeding procedures when gastroenterology beds are unavailable.

Verbatim wording from the response

“b. When reviewing this case retrospectively, it is not imperative that a patient has a bed on the gastroenterology ward for RIG placement and feeding – many of the acute medical wards at the Royal Stoke site should be able to facilitate this method of feeding and this should be considered in the future if there is a shortage of beds on a particular ward. We will ensure that this is communicated to other areas via our communications page. Mr Lockley could have been transferred in a more timely manner had an alternative ward been considered.”

Source location

2019-0010-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 24 May 2019

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-site bed-management, transfer and escalation arrangements are considered sufficient to minimise treatment delays.

Verbatim wording from the response

“2. Managing available beds across both sites is a task which requires constant adjustment and supervision and the Trust has various measures to ensure that patients receive the appropriate treatment with minimal delay. This includes the measures below:”

Source location

2019-0010-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 24 May 2019

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 gastroenterology ward bed is not imperative for RIG placement and feeding; suitable acute medical wards can facilitate this instead.

Verbatim wording from the response

“b. When reviewing this case retrospectively, it is not imperative that a patient has a bed on the gastroenterology ward for RIG placement and feeding – many of the acute medical wards at the Royal Stoke site should be able to facilitate this method of feeding and this should be considered in the future if there is a shortage of beds on a particular ward. We will ensure that this is communicated to other areas via our communications page. Mr Lockley could have been transferred in a more timely manner had an alternative ward been considered.”

Source location

2019-0010-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 24 May 2019

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

    Develop a red-amber-green system for rating patient-transfer requests by clinical need and waiting time.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.

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 red-amber-green system for rating patient-transfer requests by clinical need and waiting time.

Verbatim wording from the response

“In addition to the above, the Trust is currently looking to ‘RAG rate’ all requests to transfer a patient based on clinical need and the wait for transfer, to support decision making and appropriate use of resources.”

Source location

2019-0010-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 24 May 2019

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