PFD report

Mr Harbans SINGH · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 15 Oct 2021•Warwickshire

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 raised3

  1. Failure of the discharge process
  2. Failure to act on significant hypothyroidism identified by thyroid blood tests
    Part of recurring concern: Unreliable monitoring and follow-up of clinically required laboratory tests
  3. Failure to flag significant hypothyroidism on thyroid blood tests
    Part 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.10

  1. Action

    Disseminate guidance on completing electronic discharge summaries through the Patient Safety Newsletter.

    Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
  2. Action

    Issue and disseminate a Safety Practice Alert requiring teams to discuss correct discharge-information entry at ward handovers, including with temporary staff.

    Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
  3. Action

    Establish a clinically represented steering group to develop results-requesting and acknowledgement arrangements.

    Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Laboratory flagging of suppressed thyroxine results is not recommended or proportionate because most results do not require urgent action.

    Stated by South Warwickshire University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 the discharge process

Wider context from the report

“i. During the inquest it was accepted there was a system failure regarding the discharge process and I am concerned that such a situation will not re-occur. ”

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

Failure to act on significant hypothyroidism identified by thyroid blood tests

Wider context from the report

“ii. I am concerned that the thyroid blood tests in August 2020 and April 2121 (described as demonstrating significant hypothyroidism) were seemingly not flagged nor acted upon. ”

Is this part of a recurring concern?

Yes — Unreliable monitoring and follow-up of clinically required laboratory tests.

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 flag significant hypothyroidism on thyroid blood tests

Wider context from the report

“ii. I am concerned that the thyroid blood tests in August 2020 and April 2121 (described as demonstrating significant hypothyroidism) were seemingly not flagged nor acted upon. ”

Is this part of a recurring concern?

Yes — 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

Disseminate guidance on completing electronic discharge summaries through the Patient Safety Newsletter.

Verbatim wording from the response

“A Patient Safety Newsletter was sent out to all staff in July 2021 relating to this topic. In the section titled “working safely with EPMA” the requirements for completing electronic discharge summaries is highlighted. Additionally, more detail is given on the process further down in the section titled “Reminder: Lorenzo-complete discharge summary”. The Newsletter is included as an appendix to this letter for reference.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 2 · response
Published 18 October 2021

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

Issue and disseminate a Safety Practice Alert requiring teams to discuss correct discharge-information entry at ward handovers, including with temporary staff.

Verbatim wording from the response

“3. A Safety Practice Alert (copy included as an appendix to this letter) was issued to all staff on 9 November 2021 reiterating the importance of ensuring discharge information is correctly entered onto relevant IT systems. As with all Safety Practice Alerts, this was circulated to all staff electronically via the Trust’s weekly newsletter and requires ward/department/team leaders to read out and discuss the Alert at every ward handover for two weeks after issue. Of note these alerts are now also sent to our temporary workforce staff.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 4 · response
Published 18 October 2021

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 clinically represented steering group to develop results-requesting and acknowledgement arrangements.

Verbatim wording from the response

“As a result of the recommendations from the service improvement report a Clinical Steering Group was set up with representation from clinicians, Pathology, Radiology, the Cardiac Investigations Unit, and the Digital Transformation Team. The initial remit of the Clinical Steering Group was to:”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 3 · response
Published 18 October 2021

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

Select the clinical systems to use for requesting, reporting and acknowledging results before the new electronic patient record.

Verbatim wording from the response

“Demonstrations by various suppliers of potential systems were provided to the Clinical Steering Group between July and October 2021 and a decision was made in terms of the most appropriate systems to use. These systems will be used until the new Electronic Patient Record system is in place, which is estimated to be from 2023/2024 onwards.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 3 · response
Published 18 October 2021

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

Further develop and approve a Trust-wide policy covering results requesting, reporting, review, acknowledgement, action, escalation, responsibilities and compliance monitoring.

Verbatim wording from the response

“• Develop a Trust wide policy for results acknowledgement and associated processes”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 3 · response
Published 18 October 2021

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 electronic discharge summaries and eliminate paper discharge-summary processing.

Verbatim wording from the response

“involving building links with IT systems across multiple GP practices. At the time of Mr Singh’s original discharge, the Trust still had a dual process of creating discharge summaries, whereby some were paper, and some were electronic.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 2 · response
Published 18 October 2021

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

Test and roll out DIGIT alerts for incomplete discharge-related fields, followed by compliance auditing.

Verbatim wording from the response

“4. Changes will be made to DIGIT to alert staff to any incomplete fields that require completion to ensure appropriate communication with the patient’s GP. Testing of this is now underway and will be rolled out across the Trust by April 2022. Thereafter compliance audits will roll out until use of the fields is normalised.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 4 · response
Published 18 October 2021

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

Complete a results-management service-improvement review and produce its report.

Verbatim wording from the response

“Whilst recognising that ‘flagging’ results to clinical staff by the laboratory is neither recommended nor proportionate, it is vitally important that blood results are seen, acknowledged and acted upon. Earlier this year a service improvement piece of work around results management was undertaken by the Digital Transformation Team and a report produced in May 2021. The two key recommended deliverables from the report were:”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 3 · response
Published 18 October 2021

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

Review and amend temporary-staff induction and training materials with specific discharge-summary guidance.

Verbatim wording from the response

“1. The Trust will consider more robust methods of training and supporting our temporary staff in Surge Capacity Areas¹. The Director of Nursing has directed the Staff Bank Manager within the corporate nursing team to lead on a piece of work to review and amend as necessary the temporary staff induction and training pack including specific guidance regarding the Discharge Summary process.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 4 · response
Published 18 October 2021

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

Review technical and operational issues, develop standard operating procedures, and implement the selected clinical results systems.

Verbatim wording from the response

“A draft policy has been created and circulated to the Clinical Steering Group and initial feedback has been incorporated. The draft policy takes into account requesting, reporting, reviewing, acknowledging, actioning and escalation of results and also includes roles and responsibilities and monitoring compliance with the policy. This policy will be further developed as the project progresses and clinical systems are implemented. In addition, a project team has been setup to review existing technical and operational issues, develop a set of Standard Operating Procedures, and ultimately progress implementation of the clinical system(s) related to results and their reporting. A project plan has been developed by the project team with a summary as below:”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 3 · response
Published 18 October 2021

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

Laboratory flagging of suppressed thyroxine results is not recommended or proportionate because most results do not require urgent action.

Verbatim wording from the response

“In relation to ‘flagging’ of hypothyroidism results to clinical staff, the Trust wrote to the Coventry and Warwickshire Pathology Network in June asking if a suppressed thyroxine blood result could be ‘flagged’ to the requesting clinician. The response was that it could not, as this is not recommended by the Royal College of Pathologists. A number of staff within our senior consultant team have also considered this option and agree that asking the laboratory to flag (by way we mean directly contactually by telephone) with the clinical team every time a low or suppressed thyroxine level came in would not be beneficial.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 2 · response
Published 18 October 2021

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

Directly flagging every low or suppressed thyroxine result would impose significant resource demands on the laboratory.

Verbatim wording from the response

“In relation to ‘flagging’ of hypothyroidism results to clinical staff, the Trust wrote to the Coventry and Warwickshire Pathology Network in June asking if a suppressed thyroxine blood result could be ‘flagged’ to the requesting clinician. The response was that it could not, as this is not recommended by the Royal College of Pathologists. A number of staff within our senior consultant team have also considered this option and agree that asking the laboratory to flag (by way we mean directly contactually by telephone) with the clinical team every time a low or suppressed thyroxine level came in would not be beneficial.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 2 · response
Published 18 October 2021

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 paper discharge-summary process no longer exists, so the identified discharge error could no longer occur.

Verbatim wording from the response

“As highlighted in the Trust’s root cause analysis report, and in the evidence given at the inquest, the process of using paper discharge summaries no longer exists at the Trust and TTOs are now all prepared from the electronic system, meaning this error could no longer occur.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 2 · response
Published 18 October 2021

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

    Provide IT support officers for staff working in Surge Capacity Areas.

    Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.

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 IT support officers for staff working in Surge Capacity Areas.

Verbatim wording from the response

“2. IT support officers are now available to support staff in Surge Capacity Areas. The Working Group identified two wards as needing immediate support, and this was arranged with immediate effect.”

Source location

2021-0345-Response-from-Warwick-Hospital_Published
Page 4 · response
Published 18 October 2021

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