PFD report

Margaret Clement · Prevention of Future Deaths report

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Issued 14 May 2024•Lancashire and Blackburn with Darwen

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
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised6

  1. Failure to seek urgent clinical assistance for significant per rectum bleeding
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Failure to take timely escalation action when safety thresholds are breached
  2. Inadequate nursing handovers failing to ensure appropriate risks are managed and prioritised
    Part of recurring concern: Unreliable clinical handover processes
  3. Inadequate nursing records
    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.11

  1. Action

    Use the approved divisional report template to govern PSII action plans through the Corporate Patient Safety Group and escalate delays or problems for discussion and support.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
  2. Action

    Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
  3. Action

    Provide daily multidisciplinary meetings and twice-daily medical-team handovers to the Acute Care Team to identify concerned patients and support timely deterioration management.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.

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 seek urgent clinical assistance for significant per rectum bleeding

Wider context from the report

“(5) Nursing staff failed to seek urgent clinical assistance when presented with a significant per rectum bleed ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it; Failure to take timely escalation action when safety thresholds are breached.

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

Inadequate nursing handovers failing to ensure appropriate risks are managed and prioritised

Wider context from the report

“(2)Evidence was heard that nursing handovers were inadequate and did not ensure appropriate risks were managed and prioritised ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover 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

Inadequate nursing records

Wider context from the report

“(1) Evidence was heard that nursing records on Reedyford ward were inadequate in a number of respects including recording the wrong medication, requesting a medical review for the wrong patient and not recording when an urgent review was needed in the doctor's task book ”

Is this part of a recurring concern?

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

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

Inadequate assessment of compliance with procedural changes and expectations

Wider context from the report

“(6) Inadequate measures have been taken to assess compliance with procedural changes and expectations that have been set following the Trust investigation into this matter ”

Is this part of a recurring concern?

Yes — Failure to verify compliance and effectiveness of implemented safety changes.

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 doctors to prioritise work by reviewing the task book for urgent tasks

Wider context from the report

“(3)Evidence was heard that doctors on the ward did not effectively prioritise work by reviewing the task book in order to identify more urgent tasks ”

Is this part of a recurring concern?

Yes — Unreliable clinical task management and follow-through.

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 request medical review verbally when appropriate

Wider context from the report

“(4)Nurs staff failed to request medical review verbally where it was appropriate to do so, relying on a task book. ”

Is this part of a recurring concern?

Yes — Failure to reliably escalate requests for medical review.

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

Use the approved divisional report template to govern PSII action plans through the Corporate Patient Safety Group and escalate delays or problems for discussion and support.

Verbatim wording from the response

“To support the change to PSG agenda and TOR a new divisional report template has been designed and approved. The report includes a section on PSII action plans, and these will be governed by the Corporate PSG. Any delays or issues with actions plans not being completed within timescales will be escalated within the report to PSG for discussion and support.”

Source location

Response from East Lancashire Hospitals
Page 4 · response
Published 15 May 2024

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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

Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.

Verbatim wording from the response

“Firstly, since 21 June 2024, the doctors’ tasks book on Reedyford has been removed. I can confirm that now all doctors’ tasks (non-urgent) are requested via the Whiteboard on Cerner (the Trust’s Clinical Electronic Record system) during core hours. Urgent actions are communicated verbally and escalated directly to medical staff during core hours and to the Acute Care Team out of hours.”

Source location

Response from East Lancashire Hospitals
Page 2 · response
Published 15 May 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

Provide daily multidisciplinary meetings and twice-daily medical-team handovers to the Acute Care Team to identify concerned patients and support timely deterioration management.

Verbatim wording from the response

“There is now a daily MDT (multidisciplinary team meeting) and a twice daily planned handover from the medical team to the Acute Care Team (ACT) to ensure seamless handovers to ensure that any patients who are of concern are identified. The ACT are highly experienced with the skills needed to provide timely interventions to stabilise patients whose clinical condition deteriorates unexpectedly. This level of advanced clinical decision making and problem solving enables a more comprehensive and encompassing package of care and increases support for the workload of the medical teams, particularly if needed in the out of hours period. All doctors’ tasks (non-urgent) are requested via the Whiteboard on Cerner during core hours. Urgent actions are now communicated verbally and escalated directly to medical staff during core hours and to the Acute Care Team out of hours.”

Source location

Response from East Lancashire Hospitals
Page 3 · response
Published 15 May 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

Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.

Verbatim wording from the response

“Firstly, the Trust has arranged simulation training for all staff on the community wards. The staff are presented with a history of the patient and are asked to detail how they would assess that individual; this is repeated a number of times looking at the appropriate and most effective ways to identify any concerns or deteriorations in a patient. The staff are expected to complete full assessments of clinical observations, a physical examination of the patient, discuss handover and who they would escalate to. Detailed documentation is also discussed, including Incident reporting and the importance of accurate timely documentation.”

Source location

Response from East Lancashire Hospitals
Page 4 · response
Published 15 May 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

Update the central action-monitoring process by adding Patient Safety Group assurance requirements and informing divisions to include PSII action-plan monitoring in governance meetings.

Verbatim wording from the response

“Since the conclusion of Margaret’s inquest, the Trust has updated its central process around monitoring of actions by adding assurance regarding completion of action plans to the PSG [Patient Safety Group] TOR (Terms of Reference) and agenda and all divisions have been informed that they must ensure that they have PSII action plans assurance monitoring included within the governance meetings. On agreement of all actions being completed, evidence will then be uploaded on the Trusts Incident Management System DATIX.”

Source location

Response from East Lancashire Hospitals
Page 4 · response
Published 15 May 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

Display the ward escalation plan with staged escalation requirements, observation frequencies and staff responsibilities, supported by staff awareness and training.

Verbatim wording from the response

“Secondly, the SOP091 Pendle Community Hospital Ward Escalation Plan which was referred to at the inquest, includes a nurse escalation process, outlines the Early Warning Score, the frequency of observations and an escalation protocol, and has been printed/laminated and attached to the clinical observation equipment, so it is visibly available on the ward. A hard copy of the SOP is also available on the ward and all staff are aware of the escalation pathway which contains the staged process, outlining what action needs to be taken and by when. I have received assurance from the Ward Manager that all staff are now compliant with the awareness and training of the nurse escalation process on the ward.”

Source location

Response from East Lancashire Hospitals
Page 2 · response
Published 15 May 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

Update SOP046 to require medical and nursing staff to verify completion of doctors’ tasks before leaving the ward.

Verbatim wording from the response

“The SOP046 MDT will be updated to reflect the requirement that both medical and nursing staff check that the doctor’s tasks have been completed before they leave the ward. An audit of this SOP has been undertaken and was presented at the Clinical Effectiveness Group in July 2024, which identified recommendations. These have been transferred to a SMART action plan which will be monitored by the Clinical Audit team within the Trust.”

Source location

Response from East Lancashire Hospitals
Page 3 · response
Published 15 May 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

Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.

Verbatim wording from the response

“With regards to the above concern, I am aware that nursing staff on the ward relied heavily on the doctor’s task book to escalate to actions. In addition to the removal of the task books, nursing staff now accompany the doctors on their ward rounds and make use of the daily MDT to escalate concerns and immediate actions where necessary.”

Source location

Response from East Lancashire Hospitals
Page 3 · response
Published 15 May 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

Administer and update medications through Cerner scanners, with senior-nurse observations and governance monitoring of wristband and medication-administration compliance.

Verbatim wording from the response

“I can also confirm that all medications are now administered and updated via Cerner. All Reedyford Ward computers have scanners attached to them to administer medications and these are now being used by the Registered Nurses during the medicine rounds. To provide assurance that this action is being taken, the use of wrist bands and the administration of correct medication will be routinely monitored through senior nurse observations and reported back to the Division if any concerns are identified. I am pleased to advise that following an audit undertaken on 24 June 2024 no concerning medication incidents were identified and we will continue to monitor this through the appropriate governance forums, including the Trust’s Quality and Safety Committee.”

Source location

Response from East Lancashire Hospitals
Page 2 · response
Published 15 May 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

Monitor recommendations from the SOP046 audit through a SMART action plan overseen by the Trust Clinical Audit team.

Verbatim wording from the response

“The SOP046 MDT will be updated to reflect the requirement that both medical and nursing staff check that the doctor’s tasks have been completed before they leave the ward. An audit of this SOP has been undertaken and was presented at the Clinical Effectiveness Group in July 2024, which identified recommendations. These have been transferred to a SMART action plan which will be monitored by the Clinical Audit team within the Trust.”

Source location

Response from East Lancashire Hospitals
Page 3 · response
Published 15 May 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

Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.

Verbatim wording from the response

“Since the conclusion of the inquest work has been undertaken to ensure that there is a standardised approach for the measurement and management, and communication, of clinical risks between shifts.”

Source location

Response from East Lancashire Hospitals
Page 2 · response
Published 15 May 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

    Update doctors’ guidance documents to reflect the revised ward escalation and task-management processes.

    Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 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

Update doctors’ guidance documents to reflect the revised ward escalation and task-management processes.

Verbatim wording from the response

“In addition to the above, the doctors’ guidance documents have been updated to include these updated processes so that clinicians on the ward are familiar with the updated ways of working.”

Source location

Response from East Lancashire Hospitals
Page 2 · response
Published 15 May 2024

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