PFD report

Gladys May Sayles · Prevention of Future Deaths report

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Issued 26 Jul 2019•West Yorkshire (Western)

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
3

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
3

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 raised3

  1. Inadequate guidelines for the use of Aspen collars
    Part of recurring concern: Unsafe cervical-collar provision and management
  2. Inadequate training for applying and fixing collars to patients' needs
    Part of recurring concern: Unsafe cervical-collar provision and management
  3. Ineffective communications about collar fitting and patients' general care
    Part of recurring concern: Unsafe cervical-collar provision and management
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.3

  1. Action

    Maintain qualified orthotist training, probationary mentoring and mock fittings to assess competence in Aspen-collar application and fixing.

    Stated by Taycare Medical LimitedStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
  2. Action

    Supply each Aspen collar with applicable manufacturer instructions and leave those instructions with the patient after fitting.

    Stated by Taycare Medical LimitedStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
  3. Action

    Complete a review of communication effectiveness between CHFT, LTHT and TayCare regarding Aspen-collar fitting and patient care.

    Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    TayCare follows manufacturer fitting guidelines and does not create clinical guidelines; treating doctors decide whether an Aspen collar is used.

    Stated by Taycare Medical LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 guidelines for the use of Aspen collars

Wider context from the report

“• To review the existing guidelines with respect to the use of Aspen collars. • To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs. • To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care. ”

Is this part of a recurring concern?

Yes — Unsafe cervical-collar provision and management.

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 training for applying and fixing collars to patients' needs

Wider context from the report

“• To review the existing guidelines with respect to the use of Aspen collars. • To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs. • To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care. ”

Is this part of a recurring concern?

Yes — Unsafe cervical-collar provision and management.

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

Ineffective communications about collar fitting and patients' general care

Wider context from the report

“• To review the existing guidelines with respect to the use of Aspen collars. • To review training with respect to the application and fixing of the collar in order to make it bespoke to the patient's needs. • To consider the effectiveness of the existing communications between Leeds General neurological unit, Huddersfield Royal Infirmary and the suppliers of the collar's with respect to the fitting of the collar and patients general care. ”

Is this part of a recurring concern?

Yes — Unsafe cervical-collar provision and management.

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

Maintain qualified orthotist training, probationary mentoring and mock fittings to assess competence in Aspen-collar application and fixing.

Verbatim wording from the response

“To be an orthotist you need a recognised qualification from a national body called, The British Association of Prosthetists and Orthotists (BAPO). To gain this qualification you have to complete and pass a 3 year specialist course run by one of two universities – Salford and Strathclyde. During the course of that qualification the orthotist learns how fit hard collars. The BAPO website (www.bapo.com) gives further details, and confirms that:”

Source location

2019-0253-Responses
Page 5 · response
Published 9 September 2019

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

Supply each Aspen collar with applicable manufacturer instructions and leave those instructions with the patient after fitting.

Verbatim wording from the response

“Guidelines in terms of the fitting of the collar are provided by the manufacturer. I enclose instruction sheets for the Aspen Collar and Aspen Vista Collar. These are the guidelines we follow.”

Source location

2019-0253-Responses
Page 5 · response
Published 9 September 2019

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

Complete a review of communication effectiveness between CHFT, LTHT and TayCare regarding Aspen-collar fitting and patient care.

Verbatim wording from the response

“CHFT have considered the effectiveness of communication between CHFT, LTHT and TML. From the Trust perspective communication has been timely, there have been no delays from calling TML to them being on site to offer recommendations and advice, and communication with LTHT has been clear, concise and informative.”

Source location

2019-0253-Responses
Page 3 · response
Published 9 September 2019

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

TayCare follows manufacturer fitting guidelines and does not create clinical guidelines; treating doctors decide whether an Aspen collar is used.

Verbatim wording from the response

“1. To review the existing guideline with respect to use of Aspen collars.”

Source location

2019-0253-Responses
Page 4 · response
Published 9 September 2019

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

Bespoke training provided by TayCare when required is considered the safest model because Calderdale and Huddersfield NHS Foundation Trust sees few Aspen-collar patients.

Verbatim wording from the response

“CHFT does not offer any formal training for application of Aspen Collars; however, bespoke training is provided by TML when a patient, who requires an Aspen Collar, is being cared for under CHFT. TML will also leave written instructions with the patient in relation to the application of the Aspen Collar, which CHFT staff will follow.”

Source location

2019-0253-Responses
Page 2 · response
Published 9 September 2019

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

TayCare has no authority to order, arrange or provide training for NHS staff.

Verbatim wording from the response

“TayCare has no power to order, arrange or give training to NHS Staff.”

Source location

2019-0253-Responses
Page 6 · response
Published 9 September 2019

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

Manufacturer instructions and qualified orthotists are considered sufficient to achieve appropriate patient-specific collar fitting and training.

Verbatim wording from the response

“Aspen collars are an off the shelf product. There is no bespoke element to their construction and TayCare is not involved with their construction.”

Source location

2019-0253-Responses
Page 5 · response
Published 9 September 2019

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

Existing communication between the Trusts and TayCare is considered timely, clear, concise and informative, with no delays requiring further work.

Verbatim wording from the response

“CHFT have considered the effectiveness of communication between CHFT, LTHT and TML. From the Trust perspective communication has been timely, there have been no delays from calling TML to them being on site to offer recommendations and advice, and communication with LTHT has been clear, concise and informative.”

Source location

2019-0253-Responses
Page 3 · response
Published 9 September 2019

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 decision to use an Aspen collar rests with Leeds Teaching Hospitals NHS Trust, not Calderdale and Huddersfield NHS Foundation Trust.

Verbatim wording from the response

“CONCERN 1 – GUIDANCE RELATING TO USE OF ASPEN COLLAR: The use of an Aspen collar for treatment in a patient with a spinal injury is a decision that is made by LTHT.”

Source location

2019-0253-Responses
Page 2 · response
Published 9 September 2019

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

  1. 1

    TayCare has no authority to monitor the collar’s ongoing use, removal, refitting or adjustment after NHS care resumes.

    Stated by Taycare Medical LimitedOutside remitThe respondent said that this matter was outside its role or authority.
  2. 2

    Current communication arrangements between Leeds and referring hospitals are considered appropriate and responsive, so no changes are proposed.

    Stated by Leeds Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

TayCare has no authority to monitor the collar’s ongoing use, removal, refitting or adjustment after NHS care resumes.

Verbatim wording from the response

“The collar purchased by the NHS is then NHS property and the patient remains under the care of the NHS. TayCare has no power to monitor the ongoing use, removal, refitting and adjustment of the collar thereafter.”

Source location

2019-0253-Responses
Page 6 · response
Published 9 September 2019

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

Current communication arrangements between Leeds and referring hospitals are considered appropriate and responsive, so no changes are proposed.

Verbatim wording from the response

“Having reviewed the communications between the referring team and the Leeds Neurosurgical Unit, I have come to the conclusion that the discussions were had in a timely fashion and that the appropriate advice was given. It is recognised that an electronic system such as this can be somewhat frustrating for the referring team but it does allow for robust data capture and to ensure a proper audit trail. I am satisfied that the current arrangements are appropriate and responsive.”

Source location

2019-0253-Response-by-Leeds-Teaching-Hospital-NHS-Trust
Page 4 · response
Published 9 September 2019

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