PFD report

Ms Katie Horne · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 11 Aug 2022•Inner South London

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
1

Named on the report

Responses found
1

Of 1 recipient

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.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Delays in gastroenterology consultation on care
  2. Delays in review and follow-up of crucial blood test results
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable monitoring and follow-up of clinically required laboratory tests
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.4

  1. Action

    Provide seven-day access to specialist Gastroenterology advice and improve Registrar contactability through a dedicated DECT phone and published contact number.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  2. Action

    Implement a virtual environment for tracking outstanding patient investigations, including blood test results.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  3. Action

    Establish a Gastroenterology hot clinic to ensure jaundice patients are referred after initial assessment and ultrasound, with Registrar and Consultant support.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.

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 gastroenterology consultation on care

Wider context from the report

“Despite multiple attendances as an outpatient with deteriorating hepatitis, it took 15 days for crucial blood test results to be seen by the doctors (in part due to lab backlog but there was no evidence of any doctor prioritising or chasing the results) or for a gastroenterologist to be consulted on care. This led to a liver biopsy not being possible (in part as her blood clotting had deteriorated) and later than necessary commencement of steroid therapy and consequent later referral for liver transplantation at Kings College Hospital. ”

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

Delays in review and follow-up of crucial blood test results

Wider context from the report

“Despite multiple attendances as an outpatient with deteriorating hepatitis, it took 15 days for crucial blood test results to be seen by the doctors (in part due to lab backlog but there was no evidence of any doctor prioritising or chasing the results) or for a gastroenterologist to be consulted on care. This led to a liver biopsy not being possible (in part as her blood clotting had deteriorated) and later than necessary commencement of steroid therapy and consequent later referral for liver transplantation at Kings College Hospital. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable monitoring and follow-up of clinically required laboratory tests.

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

Provide seven-day access to specialist Gastroenterology advice and improve Registrar contactability through a dedicated DECT phone and published contact number.

Verbatim wording from the response

“Our Lead Consultant Gastroenterologist has confirmed that there are specialist staff available 7 days a week to contact for advice. Furthermore, we now have a digital enhanced cordless technology (DECT) ‘phone (in addition to the normal bleeps and mobile telephones) which the Gastroenterology Registrars carry to ensure they are contactable. The Gastroenterology Bleep number/DECT ‘phone number is in the directory on the Induction app which all junior doctors are provided with.”

Source location

Response from University Hospitals Sussex
Page 2 · response
Published 3 October 2022

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 virtual environment for tracking outstanding patient investigations, including blood test results.

Verbatim wording from the response

“2. We now have a virtual environment which allows for the tracking of outstanding patient investigations, including blood test results.”

Source location

Response from University Hospitals Sussex
Page 2 · response
Published 3 October 2022

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

Establish a Gastroenterology hot clinic to ensure jaundice patients are referred after initial assessment and ultrasound, with Registrar and Consultant support.

Verbatim wording from the response

“3. We have established a Gastroenterology ‘hot clinic’ (urgent new presentation clinic), which ensures referral of all jaundice patients after their initial assessment and ultrasound scan. This ‘hot clinic’ is run by the Gastroenterology Registrars with Consultant support.”

Source location

Response from University Hospitals Sussex
Page 2 · response
Published 3 October 2022

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

Require referral to the appropriate specialist service when a patient’s problem is unresolved after two emergency ambulatory care visits, with regular review of the rule.

Verbatim wording from the response

“Ambulatory care, instead of running out of a small room next to the Emergency Department, as it was in March 2020, is now situated in a large area connected to the Acute Medical ward, with its own dedicated nursing, administrative, and medical staff. This shares the same clinical governance and standard operating procedures as the main ambulatory care area at the Royal Sussex County Hospital in Brighton. One of the key standard operating procedures now in place is that any patient whose problem is not resolvable within two visits to the emergency ambulatory care unit, must be referred to the appropriate specialist service – this rule was operational at the Royal Sussex County Hospital in March 2020, but it had not at”

Source location

Response from University Hospitals Sussex
Page 1 · response
Published 3 October 2022

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.5

  1. 1

    Relocate ambulatory care to a larger area connected to the Acute Medical ward and provide dedicated nursing, administrative, and medical staff.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  2. 2

    Submit a business case seeking additional administrative support for the rapid access medical unit at Princess Royal Hospital.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  3. 3

    Provide substantive acute physician and geriatrician cover on weekdays and substantive general physician cover at weekends at Princess Royal Hospital.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  4. 4

    Present the case anonymously at the monthly Patient Safety Group to disseminate learning about the changes and improvements.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
  5. 5

    Have the Acute Medicine team manage the rapid access medical unit.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.

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

  1. 1

    The delays at Princess Royal Hospital did not cause the death, which resulted from COVID-19.

    Stated by University Hospitals Sussex NHS Foundation 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

Relocate ambulatory care to a larger area connected to the Acute Medical ward and provide dedicated nursing, administrative, and medical staff.

Verbatim wording from the response

“Ambulatory care, instead of running out of a small room next to the Emergency Department, as it was in March 2020, is now situated in a large area connected to the Acute Medical ward, with its own dedicated nursing, administrative, and medical staff. This shares the same clinical governance and standard operating procedures as the main ambulatory care area at the Royal Sussex County Hospital in Brighton. One of the key standard operating procedures now in place is that any patient whose problem is not resolvable within two visits to the emergency ambulatory care unit, must be referred to the appropriate specialist service – this rule was operational at the Royal Sussex County Hospital in March 2020, but it had not at”

Source location

Response from University Hospitals Sussex
Page 1 · response
Published 3 October 2022

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

Submit a business case seeking additional administrative support for the rapid access medical unit at Princess Royal Hospital.

Verbatim wording from the response

“1. The Acute Medicine team now manage the rapid access medical unit (RAMU). A business case has been submitted for additional administration support for RAMU at the Princess Royal Hospital, in line with our service at the Royal Sussex County Hospital.”

Source location

Response from University Hospitals Sussex
Page 2 · response
Published 3 October 2022

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

Provide substantive acute physician and geriatrician cover on weekdays and substantive general physician cover at weekends at Princess Royal Hospital.

Verbatim wording from the response

“The Chief of Service for the Division of Medicine confirms that the Acute Medicine service at the Princess Royal Hospital was set up in early March 2020 in response to the covid pandemic. As such, the service was predominantly run by a locum Consultant. However, we now provide, at a minimum, a substantive acute physician and geriatrician at the Princess Royal Hospital site every weekday, and the weekends the care and management is provided by the substantive general physicians.”

Source location

Response from University Hospitals Sussex
Page 1 · response
Published 3 October 2022

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

Present the case anonymously at the monthly Patient Safety Group to disseminate learning about the changes and improvements.

Verbatim wording from the response

“To ensure wider learning and sharing of the changes and improvements we have made, the case has been presented (anonymously) at our monthly Patient Safety Group which has a wide attendance of staff from all our hospitals.”

Source location

Response from University Hospitals Sussex
Page 2 · response
Published 3 October 2022

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

Have the Acute Medicine team manage the rapid access medical unit.

Verbatim wording from the response

“1. The Acute Medicine team now manage the rapid access medical unit (RAMU). A business case has been submitted for additional administration support for RAMU at the Princess Royal Hospital, in line with our service at the Royal Sussex County Hospital.”

Source location

Response from University Hospitals Sussex
Page 2 · response
Published 3 October 2022

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 delays at Princess Royal Hospital did not cause the death, which resulted from COVID-19.

Verbatim wording from the response

“Although the delays at the Princess Royal Hospital did not cause Katie’s tragic death from covid, I can assure you that Katie’s case received senior oversight prior to the inquest as part of the complaint investigation and discussion at our serious incident review group, and it continues to do so. My response below summarises the actions we have taken, and the improvements we have made.”

Source location

Response from University Hospitals Sussex
Page 1 · response
Published 3 October 2022

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