PFD report

Jake Thomas PERRY · Prevention of Future Deaths report

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Issued 1 Apr 2020•Herefordshire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
9

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. Lack of a named local hospital Consultant for patients with conditions overseen by another hospital
    Part of recurring concern: Failure to maintain clear clinical responsibility for patient care
  2. Failure to consult the overseeing hospital’s relevant specialist department when admitted patients have conditions overseen by another hospital
    Part of recurring concern: Failure to obtain timely specialist clinical advice when local expertise is insufficient
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.2

  1. Action

    Operate divisional standard operating procedures requiring named local consultants and consultation with relevant specialist departments at the overseeing hospital.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  2. Action

    Develop patient information proformas covering involved professionals and admission management plans, with annual consultant review and updating.

    Stated by Wye Valley NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.

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 named local hospital Consultant for patients with conditions overseen by another hospital

Wider context from the report

“Concern relates to the variation of the Parenteral Nutrition and communication 1. Patients with a medical condition overseen by another hospital should have a named Consultant at their local hospital. 2. Where a patient is admitted and has a medical condition overseen by another hospital the specialist department (generally involved in the patient’s care) of the overseeing hospital (in addition to any other specialist hospital or department) should be consulted. ”

Is this part of a recurring concern?

Yes — Failure to maintain clear clinical responsibility for patient care.

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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 consult the overseeing hospital’s relevant specialist department when admitted patients have conditions overseen by another hospital

Wider context from the report

“Concern relates to the variation of the Parenteral Nutrition and communication 1. Patients with a medical condition overseen by another hospital should have a named Consultant at their local hospital. 2. Where a patient is admitted and has a medical condition overseen by another hospital the specialist department (generally involved in the patient’s care) of the overseeing hospital (in addition to any other specialist hospital or department) should be consulted. ”

Is this part of a recurring concern?

Yes — Failure to obtain timely specialist clinical advice when local expertise is insufficient.

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

Operate divisional standard operating procedures requiring named local consultants and consultation with relevant specialist departments at the overseeing hospital.

Verbatim wording from the response

“1. Patients with a medical condition overseen by another hospital should have a named consultant at their local hospital.”

Source location

2020-0091-Response-from-Wye-Valley-NHS-Trust_Redacted
Page 2 · response
Published 14 May 2020

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 patient information proformas covering involved professionals and admission management plans, with annual consultant review and updating.

Verbatim wording from the response

“1. To improve the information held on patients with open access to the children’s ward.”

Source location

2020-0091-Response-from-Wye-Valley-NHS-Trust_Redacted
Page 2 · response
Published 14 May 2020

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.7

  1. 1

    Share the case findings with the National Homecare Medicines Committee and the national lead for outsourced medicines.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
  2. 2

    Provide a synopsis of lessons learned from the case to pharmacy professionals nationally.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
  3. 3

    Recommend a national standardised electronic prescribing system for Parenteral Nutrition.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  4. 4

    Implement national Homecare Medicines best-practice guidance in internal processes.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  5. 5

    Submit evidence, including lessons from the case, to the national review of aseptic-service safety and resilience.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  6. 6

    Implement the Royal College of Paediatrics and Child Health situational-awareness programme on the ward.

    Stated by Wye Valley NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
  7. 7

    Develop an open-access standard operating procedure for the children’s ward.

    Stated by Wye Valley NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The Trust cannot mandate a single electronic PN prescription format because changing the market requires an NHS England mandate.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    Standard PN bags are not suitable for home use because vitamin additions, aseptic handling and shelf-life limitations create safety and practicality constraints.

    Stated by Birmingham Women'S and Children'S NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Share the case findings with the National Homecare Medicines Committee and the national lead for outsourced medicines.

Verbatim wording from the response

“The findings will also be shared with the National Homecare Medicines Committee who have input into the national framework for the procurement of homecare products. The national lead for outsourced medicines has advised the Trust on improvements following the incident involving Jake’s Parenteral Nutrition and will also receive a copy of the lessons learnt.”

Source location

2020-0091-Response-from-Birmingham-Women-and-Childrens-NHS-Trust_Redacted
Page 3 · response
Published 14 May 2020

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

Provide a synopsis of lessons learned from the case to pharmacy professionals nationally.

Verbatim wording from the response

“Furthermore, the Trust’s Chief Pharmacist has been asked by the Chief Pharmaceutical Officer of England to provide a synopsis of the lessons learnt in Jake’s case for pharmacy professionals nationally. There are mechanisms for sharing such learning through a number of networks including the All England Chief Pharmacists’ Network, Medication Safety Officer Network and through presentations at local and national professional meetings.”

Source location

2020-0091-Response-from-Birmingham-Women-and-Childrens-NHS-Trust_Redacted
Page 3 · response
Published 14 May 2020

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

Recommend a national standardised electronic prescribing system for Parenteral Nutrition.

Verbatim wording from the response

“We have recommended a national standardised electronic prescribing system for Parenteral Nutrition as we noted that there needed to be improved communication between Trusts and suppliers, specifically with clarity on responsibilities. This issue was also highlighted within our RCA.”

Source location

2020-0091-Response-from-Birmingham-Women-and-Childrens-NHS-Trust_Redacted
Page 2 · response
Published 14 May 2020

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 national Homecare Medicines best-practice guidance in internal processes.

Verbatim wording from the response

“You are aware that immediately following this incident, the Trust commissioned an investigation into the care and treatment that we provided to Jake. Following the investigation of this incident a significant amount of work has been undertaken by the Trust to improve our own internal processes. We have ensured that national guidance such as that the best practice guidance on Homecare medicines, issued in 2011 and known as ‘the Hackett Report’, has been put into place. For ease of reference, the relevant sections within the report are reproduced below:”

Source location

2020-0091-Response-from-Birmingham-Women-and-Childrens-NHS-Trust_Redacted
Page 1 · response
Published 14 May 2020

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

Submit evidence, including lessons from the case, to the national review of aseptic-service safety and resilience.

Verbatim wording from the response

“Improvements have also been made to the National framework. There is a national review being undertaken on the safety and resilience of aseptic services, including the production of home Parenteral Nutrition. Birmingham Women’s and Children’s NHS Foundation Trust has submitted evidence to this review on various aspects of paediatric services including the lessons learnt directly from Jake’s case.”

Source location

2020-0091-Response-from-Birmingham-Women-and-Childrens-NHS-Trust_Redacted
Page 2 · response
Published 14 May 2020

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 the Royal College of Paediatrics and Child Health situational-awareness programme on the ward.

Verbatim wording from the response

“5. The “situational awareness for everyone programme”, designed by the Royal College of paediatrics and Child health would be implemented on the ward.”

Source location

2020-0091-Response-from-Wye-Valley-NHS-Trust_Redacted
Page 2 · response
Published 14 May 2020

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 an open-access standard operating procedure for the children’s ward.

Verbatim wording from the response

“4. An open access standard operating procedure would be developed.”

Source location

2020-0091-Response-from-Wye-Valley-NHS-Trust_Redacted
Page 2 · response
Published 14 May 2020

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 Trust cannot mandate a single electronic PN prescription format because changing the market requires an NHS England mandate.

Verbatim wording from the response

“As you are aware, we have reflected upon Jake’s sad and untimely death in detail and we have put measures in place in an attempt to prevent any recurrence of such an incident. In order to strengthen the measures we have put in place locally, the Trust considers that computerised prescription should be used throughout the ordering process of PN. However, unfortunately, the Trust is not in a position to effect such a change in the market; the requirement for a single format electronic prescription for PN would require a mandate by NHS England.”

Source location

2020-0091-Response-from-Birmingham-Women-and-Childrens-NHS-Trust_Redacted
Page 2 · response
Published 14 May 2020

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

Standard PN bags are not suitable for home use because vitamin additions, aseptic handling and shelf-life limitations create safety and practicality constraints.

Verbatim wording from the response

“Standard PN bags are used for children and young people in hospital on a short term basis only. This is in order to reduce the risk of ordering errors, as well as the risk of compounding errors in the hospital pharmacy, which deals with many different PN prescriptions on a daily basis. These commercially batch-produced standardised PN bags require an addition of parenteral multi-vitamins shortly before infusion. This is a limitation that requires proper handling to assure aseptic conditions and to avoid errors and as a consequence is not an option available for home use. Moreover, the inclusion of various trace elements may shorten the shelf life of the standard bag.”

Source location

2020-0091-Response-from-Birmingham-Women-and-Childrens-NHS-Trust_Redacted
Page 3 · response
Published 14 May 2020

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