PFD report

Dorothy Doreen BREISLIN · Prevention of Future Deaths report

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Issued 4 Dec 2017•Lincolnshire

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
4

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. Failure to implement incident action plans
    Part of recurring concern: Failure to implement identified safety actions
  2. Delays in receiving incident review reports
    Part of recurring concern: Unreliable completion and receipt of incident review reports
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

    Clear the backlog of serious incident reports under oversight from the Medical Director and Director of Nursing.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.

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 implement incident action plans

Wider context from the report

“3 ████████ confirmed on oath that none of the Action Plan referred to in the Appendices at 3 have been implemented. If not, in view of the Incident Date why not? ”

Is this part of a recurring concern?

Yes — Failure to implement identified safety actions.

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 receiving incident review reports

Wider context from the report

“1 The incident date was 27th January 2015. The Incident Review Report was not received in this office until 10th August 2017. Why the delay? ”

Is this part of a recurring concern?

Yes — Unreliable completion and receipt of incident review reports.

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

Clear the backlog of serious incident reports under oversight from the Medical Director and Director of Nursing.

Verbatim wording from the response

“I can only apologise for the unacceptable delay in not only recognising that this was an SI but for the delay in forwarding the final report to you. The Trust recognises that the SI process at that time was poor. We are working hard to clear our backlog of SI reports, which is being overseen by myself and the Director of Nursing and we are also implementing a new SI process. This incorporates training across the Trust on undertaking SI investigations.”

Source location

2017-0348-Response-United-Lincolnshire-Hospitals-NHS-Trust
Page 1 · response
Published 11 February 2018

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.3

  1. 1

    Update, reprint and circulate the revised clerking proforma venous thromboembolism risk assessment to clinical teams.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  2. 2

    Implement a new serious incident process, including Trust-wide training on conducting serious incident investigations.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  3. 3

    Appoint a new Risk Manager to support the serious incident process.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.

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, reprint and circulate the revised clerking proforma venous thromboembolism risk assessment to clinical teams.

Verbatim wording from the response

“The VTE Nurse Manager and the Consultant Haematologist met up in August 2017 to discuss the changes and these were agreed. This was to be discussed at the September 2017 Thrombosis Committee meeting but the meeting was cancelled as both the Chair and Vice Chair were unable to attend. Unfortunately, due to an oversight the matter was not put onto the November agenda.”

Source location

2017-0348-Response-United-Lincolnshire-Hospitals-NHS-Trust
Page 2 · response
Published 11 February 2018

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 new serious incident process, including Trust-wide training on conducting serious incident investigations.

Verbatim wording from the response

“I can only apologise for the unacceptable delay in not only recognising that this was an SI but for the delay in forwarding the final report to you. The Trust recognises that the SI process at that time was poor. We are working hard to clear our backlog of SI reports, which is being overseen by myself and the Director of Nursing and we are also implementing a new SI process. This incorporates training across the Trust on undertaking SI investigations.”

Source location

2017-0348-Response-United-Lincolnshire-Hospitals-NHS-Trust
Page 1 · response
Published 11 February 2018

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 a new Risk Manager to support the serious incident process.

Verbatim wording from the response

“We currently have an Interim Director of Governance in post who is leading on this project and a new Risk Manager will be starting in February 2018.”

Source location

2017-0348-Response-United-Lincolnshire-Hospitals-NHS-Trust
Page 1 · response
Published 11 February 2018

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