PFD report

Mr John Dodd · Prevention of Future Deaths report

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Issued 2 Apr 2014•Black Country

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised4

  1. Failure to report a documented temperature rise to medical staff
    Part of recurring concern: Failure to reliably communicate clinically significant patient observations to medical staffPart of recurring concern: Unreliable communication of patient-care information between clinical staff
  2. Failure to check INR for a patient taking Warfarin
  3. Failure to medically reassess the patient before discharge
    Part of recurring concern: Unreliable clinical review and authorisation of discharge decisionsPart of recurring concern: Unreliable hospital discharge processes
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

    Hold regular Emergency Department board rounds so each patient is discussed with senior medical staff.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2014.
  2. Action

    Reconfigure the electronic clinical information system to create a visible consultant alert when vital signs fall outside normal parameters.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 April 2014.
  3. Action

    Develop a guideline requiring routine INR checks for patients taking vitamin-K antagonist anticoagulants after a fall.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 April 2014.

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 report a documented temperature rise to medical staff

Wider context from the report

“The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”

Is this part of a recurring concern?

Yes — Failure to reliably communicate clinically significant patient observations to medical staff; Unreliable communication of patient-care information between clinical staff.

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 check INR for a patient taking Warfarin

Wider context from the report

“The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”

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 medically reassess the patient before discharge

Wider context from the report

“The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”

Is this part of a recurring concern?

Yes — Unreliable clinical review and authorisation of discharge decisions; Unreliable hospital discharge 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

Delays in first assessment by medically qualified staff in A&E

Wider context from the report

“The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”

Is this part of a recurring concern?

Yes — Unreliable admission assessment of patients.

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

Hold regular Emergency Department board rounds so each patient is discussed with senior medical staff.

Verbatim wording from the response

“• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.”

Source location

2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Page 2 · response
Published 2 April 2014

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

Reconfigure the electronic clinical information system to create a visible consultant alert when vital signs fall outside normal parameters.

Verbatim wording from the response

“• The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patient’s vital signs fall outside normal parameters.”

Source location

2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Page 2 · response
Published 2 April 2014

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

Develop a guideline requiring routine INR checks for patients taking vitamin-K antagonist anticoagulants after a fall.

Verbatim wording from the response

“• A written guideline will be developed to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants, such as warfarin.”

Source location

2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Page 2 · response
Published 2 April 2014

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

Use an electronic-system prompt to indicate when abnormal observations need communicating to senior staff.

Verbatim wording from the response

“• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.”

Source location

2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Page 2 · response
Published 2 April 2014

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.2

  1. 1

    Develop an audit process reviewing appropriate referral of Emergency Department patients for senior review.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 April 2014.
  2. 2

    Present an implementation report to the Clinical Quality, Safety and Patient Experience Board Sub-Committee.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 April 2014.

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 an audit process reviewing appropriate referral of Emergency Department patients for senior review.

Verbatim wording from the response

“• The Emergency Department will develop an audit process to review the appropriate referral of patients for senior review when presenting to the Emergency Department. Additionally;”

Source location

2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Page 2 · response
Published 2 April 2014

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 an implementation report to the Clinical Quality, Safety and Patient Experience Board Sub-Committee.

Verbatim wording from the response

“A report will be presented by the Medical Director & Director of Nursing to the Clinical Quality, Safety & Patient Experience Board Sub-Committee, which will be responsible for ensuring that actions are implemented.”

Source location

2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
Page 3 · response
Published 2 April 2014

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