PFD report

Mrs Macrae · Prevention of Future Deaths report

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Issued 16 Jun 2017•Northamptonshire

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.

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Concerns
2

Raised in this report

Recipients
6

Named on the report

Responses found
4

Of 6 recipients

Stated actions
14

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 seek attendance by the attending spinal surgeon for postoperative instability
    Part of recurring concern: Failure to escalate significant clinical concerns to appropriately senior clinicians
  2. Failure to consider internal haemorrhage as a cause of instability after elective spinal surgery
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

    Share the hospital's learning from the case with all consultants through the Consultant Newsletter.

    Stated by Woodland HospitalStated plannedThe respondent said that this action was planned when they made their response on 15 September 2017.
  2. Action

    Install a bedside Haemocue machine in recovery for haemoglobin testing by recovery staff.

    Stated by Woodland HospitalStated completedThe respondent said that this action was complete when they made their response on 15 September 2017.
  3. Action

    Require both the Consultant Surgeon and Consultant Anaesthetist to attend when either is recalled or a deteriorating patient requires escalation.

    Stated by Woodland HospitalStated completedThe respondent said that this action was complete when they made their response on 15 September 2017.

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 attendance by the attending spinal surgeon for postoperative instability

Wider context from the report

“1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ”

Is this part of a recurring concern?

Yes — Failure to escalate significant clinical concerns to appropriately senior clinicians.

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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 consider internal haemorrhage as a cause of instability after elective spinal surgery

Wider context from the report

“1) Mrs Macrae was admitted to the Woodlands Hospital Kettering on 11th June 2016 for routine left lumbar L4/L5 decompression and discectomy under the care of a specialist neurosurgeon. Whilst in recovery her blood pressure dropped on occasion. She was cared for by attending anaesthetists but her attending spinal surgeon was not asked to attend. Those caring for Mrs Macrae did not consider internal haemorrhage as a cause of her instability. 2) All persons having care for a patient having undergone a similar elective spinal surgery should be aware that internal haemorrhage is a rare but recognised complication of this surgery. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Share the hospital's learning from the case with all consultants through the Consultant Newsletter.

Verbatim wording from the response

“• The spinal neuro surgeons and Consultant anaesthetists working at the hospital are very aware of this case and now have a high suspicion to exclude post-operative internal bleeding. The hospital learning from this case will be shared with all Consultants following the Medical Advisory Committee meeting on the 20th September 2017 via our Consultant Newsletter.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 2 · response
Published 15 September 2017

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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

Install a bedside Haemocue machine in recovery for haemoglobin testing by recovery staff.

Verbatim wording from the response

“• A bed side Haemocue machine has been installed in recovery, to allow patient bedside testing of haemoglobin by recovery staff. This enables recovery staff to initiate this test as part of their observations to inform attending clinicians of the haemoglobin level in the instance of a deteriorating patient.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 2 · response
Published 15 September 2017

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 both the Consultant Surgeon and Consultant Anaesthetist to attend when either is recalled or a deteriorating patient requires escalation.

Verbatim wording from the response

“• As standard practice now since this tragic outcome, if an anaesthetist or surgeon is re-called to the hospital, both Consultant Surgeon and Consultant Anaesthetist are asked to attend. The Senior Management Team (SMT) who provide on call support 24/7 are all very clear on this and ensure this happens as part of the escalation process for any deteriorating patient, or when a Consultant is asked to return to the hospital.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 1 · response
Published 15 September 2017

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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

Review and finalise education standards incorporating standards on patient assessment, management of deterioration, and surgery-related complications.

Verbatim wording from the response

“We are currently undertaking a wholesale review of our education standards, including the pre-registration standards of proficiency that nurses must meet before being registered with us. We intend that these new standards of proficiency for registered nurses will include specific standards relating to patient assessment and the management of patient deterioration. We are undertaking a full public consultation on the draft standards, which is due to conclude on 12 September 2017, following which we will carefully review the feedback we receive from our stakeholders before finalising the standards. We will also take into account the concerns you have raised in your report about complications of surgery.”

Source location

2017-0193-Response-by-NMC
Page 1 · response
Published 15 September 2017

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.10

  1. 1

    Reflect on the case and reiterate the inquest findings and conclusions at the Medical Advisory Committee.

    Stated by Woodland HospitalStated plannedThe respondent said that this action was planned when they made their response on 15 September 2017.
  2. 2

    Publish committee findings and learning in the Clinical Matters staff and Consultant Newsletter.

    Stated by Woodland HospitalStated plannedThe respondent said that this action was planned when they made their response on 15 September 2017.
  3. 3

    Establish a multidisciplinary deteriorating patient committee to discuss cases and learn from incidents and near misses.

    Stated by Woodland HospitalStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2017.
  4. 4

    Discuss the case and learning points at the theatre team meeting.

    Stated by Woodland HospitalStated completedThe respondent said that this action was complete when they made their response on 15 September 2017.
  5. 5

    Undertake an emergency skills drill.

    Stated by Woodland HospitalStated completedThe respondent said that this action was complete when they made their response on 15 September 2017.
  6. 6

    Roll out a programme of emergency skills drills through clinical areas involving Consultant Anaesthetists.

    Stated by Woodland HospitalStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2017.
  7. 7

    Include the case and learning points in a Matron-led reflective learning session.

    Stated by Woodland HospitalStated plannedThe respondent said that this action was planned when they made their response on 15 September 2017.
  8. 8

    Share the response with the Department of Health.

    Stated by Nursing and Midwifery CouncilStated plannedThe respondent said that this action was planned when they made their response on 15 September 2017.
  9. 9

    Discuss with SBNS and BASS how best to address the identified learning points.

    Stated by Royal College of Surgeons of EnglandStated completedThe respondent said that this action was complete when they made their response on 15 September 2017.
  10. 10

    Share the coroner’s letter with SBNS and BASS colleagues.

    Stated by Royal College of Surgeons of EnglandStated completedThe respondent said that this action was complete when they made their response on 15 September 2017.

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

  1. 1

    Specific clinical advice about individual cases may appropriately be provided by employers, health authorities or NICE rather than the regulator.

    Stated by Nursing and Midwifery CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Reflect on the case and reiterate the inquest findings and conclusions at the Medical Advisory Committee.

Verbatim wording from the response

“• The hospital has reflected on the case at Clinical Governance Committee, and will reiterate the findings and conclusion of the inquest at the next Medical Advisory Committee, 20th September 2017.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 1 · response
Published 15 September 2017

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

Publish committee findings and learning in the Clinical Matters staff and Consultant Newsletter.

Verbatim wording from the response

“• The new Matron is in the process of establishing a multi-disciplinary deteriorating patient committee where cases are discussed, to establish learning from incidents and near misses, the findings will also be published in the new “Clinical Matters” staff and Consultant Newsletter.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 1 · response
Published 15 September 2017

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 multidisciplinary deteriorating patient committee to discuss cases and learn from incidents and near misses.

Verbatim wording from the response

“• The new Matron is in the process of establishing a multi-disciplinary deteriorating patient committee where cases are discussed, to establish learning from incidents and near misses, the findings will also be published in the new “Clinical Matters” staff and Consultant Newsletter.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 1 · response
Published 15 September 2017

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

Discuss the case and learning points at the theatre team meeting.

Verbatim wording from the response

“• The case and the learning points were also discussed at the theatre team meeting, and will be included at a reflective learning session in the next three months, which is led by Matron.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 1 · response
Published 15 September 2017

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

Undertake an emergency skills drill.

Verbatim wording from the response

“• An emergency skills drill was undertaken in May 2017, and a programme of such drills is being rolled out through the clinical areas involving Consultant Anaesthetists.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 2 · response
Published 15 September 2017

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

Roll out a programme of emergency skills drills through clinical areas involving Consultant Anaesthetists.

Verbatim wording from the response

“• An emergency skills drill was undertaken in May 2017, and a programme of such drills is being rolled out through the clinical areas involving Consultant Anaesthetists.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 2 · response
Published 15 September 2017

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

Include the case and learning points in a Matron-led reflective learning session.

Verbatim wording from the response

“• The case and the learning points were also discussed at the theatre team meeting, and will be included at a reflective learning session in the next three months, which is led by Matron.”

Source location

2017-0193-Response-by-Woodlands-Hospital
Page 1 · response
Published 15 September 2017

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

Share the response with the Department of Health.

Verbatim wording from the response

“devolved administrations), or the National Institute for Health and Care Excellence (NICE). We will be sharing our response with the Department of Health.”

Source location

2017-0193-Response-by-NMC
Page 2 · response
Published 15 September 2017

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

Discuss with SBNS and BASS how best to address the identified learning points.

Verbatim wording from the response

“The College has followed your direction to consider what actions it could take to try to help to prevent future deaths of this kind. We have shared your letter with our colleagues in the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS) and discussed with them how best to do this. The Presidents of SBNS and BASS have jointly prepared a letter to send to their members, highlighting a number of learning points.”

Source location

2017-0193-Response-by-Royal-College-of-Surgeons
Page 1 · response
Published 15 September 2017

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

Share the coroner’s letter with SBNS and BASS colleagues.

Verbatim wording from the response

“The College has followed your direction to consider what actions it could take to try to help to prevent future deaths of this kind. We have shared your letter with our colleagues in the Society for British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS) and discussed with them how best to do this. The Presidents of SBNS and BASS have jointly prepared a letter to send to their members, highlighting a number of learning points.”

Source location

2017-0193-Response-by-Royal-College-of-Surgeons
Page 1 · response
Published 15 September 2017

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

Specific clinical advice about individual cases may appropriately be provided by employers, health authorities or NICE rather than the regulator.

Verbatim wording from the response

“Please note that as there are currently about 612,274 nurses and midwives on our register working in many different areas of practice across the UK, it is not our usual practice to issue specific clinical advice to nurses and midwives about individual cases. Such clinical advice may be appropriately raised by relevant employers or on occasion by the Department of Health, NHS England (or the NHS leadership in the”

Source location

2017-0193-Response-by-NMC
Page 1 · response
Published 15 September 2017

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