PFD report

Christopher Allen MacMORLAND · Prevention of Future Deaths report

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Issued 16 Nov 2016•Portsmouth and South East Hampshire

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised1

  1. Failure to implement consultants' requests for patient transfer to specialist wards
    Part of recurring concern: Failure to ensure timely transfer to an appropriate hospital care environmentPart of recurring concern: Inadequate specialist placement arrangements for people requiring specialist carePart of recurring concern: Unreliable healthcare patient transfer 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.1

  1. Action

    Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.

    Stated by Portsmouth Hospitals University NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.

    Stated by Portsmouth Hospitals University NHS 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 to implement consultants' requests for patient transfer to specialist wards

Wider context from the report

“I was told in evidence at the Inquest that despite Mr MacMORLAND being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward - even though the consultants had during that time requested such a transfer on five separate occasions. Given the nature of his medical problems, from the evidence I heard, I am of the opinion that he could have benefited from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome. I was also told that it is common for consultants' requests for patient transfer to specialist wards not to be implemented. ”

Is this part of a recurring concern?

Yes — Failure to ensure timely transfer to an appropriate hospital care environment; Inadequate specialist placement arrangements for people requiring specialist care; Unreliable healthcare patient transfer processes.

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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

Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.

Verbatim wording from the response

“By way of further assurance, since this death in 2015, the Hospital has begun a ‘buddy’ ward system whereby patients of a certain specialty are cohorted only into the appropriate specialist ward or a specific buddy ward. This means that consultants will have their patients only on one other ward if their own base ward is full.”

Source location

2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 2017

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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

Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.

Verbatim wording from the response

“The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon. The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised.”

Source location

2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 2017

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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