PFD report

DAVID JOHN MOUNTAIN · Prevention of Future Deaths report

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Issued 24 Dec 2014•Norfolk

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
1

Of 1 recipient

Stated actions
5

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 fully investigate recognised risks following pacemaker insertion
  2. Delayed availability of echocardiogram results
    Part of recurring concern: Failure of echocardiography services to provide timely diagnostic assessment and follow-upPart of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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

    Implement and disseminate guidance for doctors assessing patients admitted after recent permanent pacemaker insertion.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2014.
  2. Action

    Provide routine on-site Cardiology Consultant presence on Saturdays and Sundays for patient review and advice to clinical teams.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2014.
  3. Action

    Develop and implement an electronic reporting system for test results, including echocardiography.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2014.

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 fully investigate recognised risks following pacemaker insertion

Wider context from the report

“Despite having had a permanent pacemaker inserted on 20 June 2014 and Mr Mountain developing chest pain on 21 June 2014, the risks recognised on the consent form, including risk of bleeding and vascular damage were not fully investigated and an Echocardiogram was not performed until afternoon of 23 June 2014. The results, which showed a mild to moderate bleed around the heart, were not available until after Mr Mountain’s death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Delayed availability of echocardiogram results

Wider context from the report

“Despite having had a permanent pacemaker inserted on 20 June 2014 and Mr Mountain developing chest pain on 21 June 2014, the risks recognised on the consent form, including risk of bleeding and vascular damage were not fully investigated and an Echocardiogram was not performed until afternoon of 23 June 2014. The results, which showed a mild to moderate bleed around the heart, were not available until after Mr Mountain’s death. ”

Is this part of a recurring concern?

Yes — Failure of echocardiography services to provide timely diagnostic assessment and follow-up; Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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

Implement and disseminate guidance for doctors assessing patients admitted after recent permanent pacemaker insertion.

Verbatim wording from the response

“1. The Cardiology team are implementing clear guidance for all doctors within the Emergency Department, the Medical Assessment Unit and the Surgical Assessment Unit which highlights the key clinical areas which should be investigated if a patient is admitted following recent permanent pacemaker insertion. This guidance will be shared with the relevant senior clinical decision makers and in place by the end of February 2015.”

Source location

2014-0554-Response-by-The-Queen-Elizabeth-Hospital
Page 1 · response
Published 24 December 2014

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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

Provide routine on-site Cardiology Consultant presence on Saturdays and Sundays for patient review and advice to clinical teams.

Verbatim wording from the response

“3. Cardiology Consultants are now routinely present on site on a Saturday and Sunday to review cardiology patients and provide advice to all clinical teams within the Hospital.”

Source location

2014-0554-Response-by-The-Queen-Elizabeth-Hospital
Page 1 · response
Published 24 December 2014

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 and implement an electronic reporting system for test results, including echocardiography.

Verbatim wording from the response

“Alongside this, we are moving to an electronic reporting system for all test results including echocardiography. Scoping of this major IT project has commenced and we anticipate that it will be in place by the end of 2015. This will allow doctors access to reports immediately when they are entered onto the system and will eliminate the need to transfer a paper copy report from one area of the hospital to another.”

Source location

2014-0554-Response-by-The-Queen-Elizabeth-Hospital
Page 1 · response
Published 24 December 2014

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.2

  1. 1

    Require cardiac technicians to directly contact the referring clinical team or on-call Medical Registrar when abnormal results are identified.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2014.
  2. 2

    Recruit further joint QEH/Papworth appointments to support sustainable seven-day cardiology services.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2014.

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 cardiac technicians to directly contact the referring clinical team or on-call Medical Registrar when abnormal results are identified.

Verbatim wording from the response

“2. In the event that any abnormal results are identified, the cardiac technician will now directly contact the referring clinical team in hours (or the on-call Medical Registrar out of hours) thus enabling a prompt clinical response to be made.”

Source location

2014-0554-Response-by-The-Queen-Elizabeth-Hospital
Page 1 · response
Published 24 December 2014

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

Recruit further joint QEH/Papworth appointments to support sustainable seven-day cardiology services.

Verbatim wording from the response

“This is an important part of the Trust’s move to 7 day services and ensures that senior decision making can occur every day of the week. The planned recruitment in the next six months of further joint appointments (QEH/Papworth) will make 7 day cardiology services sustainable for the future at the Queen Elizabeth Hospital.”

Source location

2014-0554-Response-by-The-Queen-Elizabeth-Hospital
Page 2 · response
Published 24 December 2014

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