PFD report

Barry John TUCKER · Prevention of Future Deaths report

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Issued 17 Jan 2018•Brighton and Hove

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
8

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised8

  1. Failure to provide enhanced recovery paperwork
    Part of recurring concern: Inadequate patient information for surgical procedures
  2. Failure to provide the enhanced recovery cystectomy leaflet
    Part of recurring concern: Inadequate patient information for surgical procedures
  3. Inadequate continuity and completeness of hospital notes
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.8

  1. Action

    Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.

    Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 March 2018.
  2. Action

    Amend postoperative daily-round documentation to capture greater detail on patient progress against the care plan.

    Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2018.
  3. Action

    Use the cystectomy pathway documentation for all relevant surgical cases.

    Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 March 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Pre-operative preparation occurred through assessment by a nurse and consultant anaesthetist; the concern that no preparation occurred is disputed.

    Stated by East Sussex Healthcare 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 provide enhanced recovery paperwork

Wider context from the report

“(3) The Enhanced Recovery Nurse Specialist was also away during his admission. He never met her or received any paperwork from her ”

Is this part of a recurring concern?

Yes — Inadequate patient information for surgical procedures.

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 provide the enhanced recovery cystectomy leaflet

Wider context from the report

“(4) He never received a copy of the leaflet “Enhanced Recovery after having a Cystectomy”. ”

Is this part of a recurring concern?

Yes — Inadequate patient information for surgical procedures.

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

Inadequate continuity and completeness of hospital notes

Wider context from the report

“(5) Mr. Tucker’s hospital notes from arriving on Michelham Ward were suboptimal, lacking continuity, incomplete and unhelpful. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Unavailability of senior urology input during admission

Wider context from the report

“(2) The Urology Consultant Surgeon was away during his admission and he had no senior input. ”

Is this part of a recurring concern?

Yes — Delays in consultant review of patients.

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

Unavailability of enhanced recovery nurse specialist support during admission

Wider context from the report

“(3) The Enhanced Recovery Nurse Specialist was also away during his admission. He never met her or received any paperwork from her ”

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

Lack of a coherent urology enhanced recovery discharge planning protocol

Wider context from the report

“(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients. ”

Is this part of a recurring concern?

Yes — 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

Lack of pre-operative preparation

Wider context from the report

“(1) Mr. Tucker received no pre-op preparation. ”

Is this part of a recurring concern?

Yes — Unreliable pre-operative preparation and safety checks.

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 of the system for recalling discharged urology patients by ambulance

Wider context from the report

“(6) Eastbourne District General Hospital’s system for recalling patients to the Urology ward following discharge, if they need to go in by ambulance, is flawed. ”

Is this part of a recurring concern?

Yes — Unreliable emergency access to hospital care; Unreliable urgent recall of discharged patients requiring hospital care.

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

Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.

Verbatim wording from the response

“Trust Response There is a care pathway document for Cystectomy patients which contains detailed discharge planning information, including prompts and checks which assist in documenting the key stages of the post-operative period and plan of care. That care pathway documentation was not used and the nursing and medical notes do not contain a great deal of detail of Mr Tucker’s post-operative progress. The Trust acknowledges the learning opportunity presented here and has implemented the action plan below.”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 5 · response
Published 8 March 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

Amend postoperative daily-round documentation to capture greater detail on patient progress against the care plan.

Verbatim wording from the response

“There are daily ward round records from the medical team, which provide a comprehensive record of the post-operative round which reflects the key stages in post-operative recovery, however they contained limited detail as to how Mr Tucker progressed against the plan.”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 6 · response
Published 8 March 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

Use the cystectomy pathway documentation for all relevant surgical cases.

Verbatim wording from the response

“Recommendation: The Cystectomy Pathway patient documentation must be updated and used for all surgical cases no matter what ward to include the latest Cystectomy Enhanced Recovery Preparation Event and Recovery Pathway (CEPER) guidance and ensure clear to what patient information is provided and when (with sign off to state completed) and the discharge process/requirements;”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 5 · response
Published 8 March 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

Review funding for a second Enhanced Recovery nurse and submit the application for consideration.

Verbatim wording from the response

“Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed Review the request for funding a second ERAS nurse and if not possible ensure that appropriate mitigations and leave cover arrangements are put in place. | Ward team to be aware of ERAS nurse leave and provide the expertise. Application for second ERAS nurse to nurse division | ERAS support evident in patient notes and process for leave cover to be monitored | Head of Nursing | May 2018 |”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 4 · response
Published 8 March 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

Review the urology discharge process and maintain a discharge protocol for enhanced recovery patients.

Verbatim wording from the response

“(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 7 · response
Published 8 March 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

Assign patients to a consultant who is present or arrange consultant cover during leave.

Verbatim wording from the response

“Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed Patients must be assigned to a consultant who is present (to see the patient or cover for the consultant of the week to cover for annual or study leave) | Discussed at Clinical Governance meetings | Observed at safety huddle on ward | Clinical lead | Feb 2018 | 1 Feb 2018 Patients must be reviewed by consultant daily post-operatively. | Job plan to be amended to include daily rounds | Audit of notes in 3 months to ensure daily consultant review has taken place | Clinical lead | Job plan amended Feb 2018 for audit May 2018”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 4 · response
Published 8 March 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

Amend consultant job plans to require daily postoperative rounds.

Verbatim wording from the response

“Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed Patients must be assigned to a consultant who is present (to see the patient or cover for the consultant of the week to cover for annual or study leave) | Discussed at Clinical Governance meetings | Observed at safety huddle on ward | Clinical lead | Feb 2018 | 1 Feb 2018 Patients must be reviewed by consultant daily post-operatively. | Job plan to be amended to include daily rounds | Audit of notes in 3 months to ensure daily consultant review has taken place | Clinical lead | Job plan amended Feb 2018 for audit May 2018”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 4 · response
Published 8 March 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

Conduct a urology specialty documentation audit to identify gaps, themes and improvements.

Verbatim wording from the response

“Recommendation: Urology specialty documentation audit to identify themes and improvements in documentation.”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 8 · response
Published 8 March 2018

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

Pre-operative preparation occurred through assessment by a nurse and consultant anaesthetist; the concern that no preparation occurred is disputed.

Verbatim wording from the response

“(1) Mr Tucker received no pre-op preparation”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 3 · response
Published 8 March 2018

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

A urology enhanced-recovery discharge protocol was already in place, and the discharge process had been reviewed.

Verbatim wording from the response

“(7) There is no coherent discharge planning protocol in place for enhanced recovery procedures in respect of urology patients”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 7 · response
Published 8 March 2018

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

There was no transfer delay caused by ambulance-service communication; extrication difficulties and clinical deterioration caused the on-scene delay.

Verbatim wording from the response

“(6) Eastbourne DGH’s system for recalling patients to the Urology Ward following discharge, if they need to go by ambulance, is flawed.”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 6 · response
Published 8 March 2018

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

Senior clinical input remained available through an experienced robotic fellow and the urology consultant of the week during the responsible consultant’s leave.

Verbatim wording from the response

“(2) The urology consultant was away during his admission and he had no senior input.”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 3 · response
Published 8 March 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

    Stop the private patient unit accepting bookings for patients undergoing major urology cancer surgery.

    Stated by East Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2018.
  2. 2

    Implement senior-doctor checking of electronic discharge notifications and audit compliance.

    Stated by East Sussex Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2018.
  3. 3

    Retrain staff to record all doctor–patient contacts.

    Stated by East Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 March 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

Stop the private patient unit accepting bookings for patients undergoing major urology cancer surgery.

Verbatim wording from the response

“Recommendation: Patients undergoing major urology cancer surgery should be cared for on the urology ward, with more experienced doctors and nurses. These patients are not suitable for private patient unit.”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 8 · response
Published 8 March 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 senior-doctor checking of electronic discharge notifications and audit compliance.

Verbatim wording from the response

“Recommendation: The urology specialty to agree a robust process for ensuring Electronic Discharge notification is signed/checked by a senior doctor;”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 8 · response
Published 8 March 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

Retrain staff to record all doctor–patient contacts.

Verbatim wording from the response

“There is no record of what patient information leaflets were given. The Trust acknowledges that good record keeping was below par in this instance and has undertaken to retrain staff about the importance of recording all instances of doctor – patient contact.”

Source location

2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
Page 3 · response
Published 8 March 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