PFD report

Captain James Michael Bedford · Prevention of Future Deaths report

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Issued 18 Oct 2016•South 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
11

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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 raised11

  1. Delays and lack of clarity in prescribing deterioration monitoring
    Part of recurring concern: Failure to reliably recognise and respond to acute clinical deterioration
  2. Delays in Heparin-level testing and result availability
    Part of recurring concern: Unreliable medication-specific blood-level monitoringPart of recurring concern: Unsafe anticoagulant management
  3. Lack of clarity in recording whether Alteplase was followed by an infusion
    Part of recurring concern: Unsafe medication administration
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.6

  1. Action

    Invest in the VitalPac electronic observation system to improve recognition and response for deteriorating patients.

    Stated by Barnsley Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2016.
  2. Action

    Alter the thrombolysis pulmonary embolism guideline to prompt checking prior heparin administration and careful APTT monitoring.

    Stated by Barnsley Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2016.
  3. Action

    Audit compliance with recording the provision of patient information sheets.

    Stated by Barnsley Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Evidence does not establish that lower-leg scanning would have changed treatment, because benefits of treating isolated distal DVT remain unclear.

    Stated by Department of Health and Social CareDisputes 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

Delays and lack of clarity in prescribing deterioration monitoring

Wider context from the report

“3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance. Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter). ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration.

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

Delays in Heparin-level testing and result availability

Wider context from the report

“5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin. ”

Is this part of a recurring concern?

Yes — Unreliable medication-specific blood-level monitoring; Unsafe anticoagulant 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

Lack of clarity in recording whether Alteplase was followed by an infusion

Wider context from the report

“5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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

Unsafe use of unfractionated Heparin

Wider context from the report

“5. There was no criticism of the use of 50mg Alteplase but there was a lack of clarity as to whether this was followed by an infusion. A further expert witness (a haematologist) criticised the subsequent use of unfractionated Heparin and a test of Heparin level seems to have taken a long time from sampling to delivery to the laboratory and later result. The evidence was strongly suggestive of over-anticoagulation by Heparin. ”

Is this part of a recurring concern?

Yes — Unsafe anticoagulant 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

Clerking of acute patients by a medical student

Wider context from the report

“4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival. ”

Is this part of a recurring concern?

Yes — Unreliable admission assessment 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

Failure to consider full-leg scanning for suspected lower-leg DVT

Wider context from the report

“1. The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg. This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile. Hindsight strongly suggested that Captain Bedforth was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedforth although it was accepted that no-one could be certain of this. ”

Is this part of a recurring concern?

Yes — Failure to reliably diagnose and refer suspected DVT; Unreliable DVT diagnosis 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

Inappropriate placement of Emergency Department patients in AMU

Wider context from the report

“4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival. ”

Is this part of a recurring concern?

Yes — Failure to ensure people are placed in care settings suitable for their needs.

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

Poor safety-netting after attendance and scanning

Wider context from the report

“2. The evidence of 'safety-netting' after the first attendance (and/or subsequent attendance for scans) was poor and of considerable concern. As made clear in my written findings this was possibly of relevant as to Captain Bedforth's subsequent decision on seeking medical attention in or upon return from China. ”

Is this part of a recurring concern?

Yes — Inadequate safety-netting advice for patients and carers.

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

Poor recording of medication delivery

Wider context from the report

“6. A number of issues were raised as to note-keeping or clarity of note-keeping, most particularly as regards delivery of medications. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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

Inconsistent practice regarding lower-leg scanning for deep vein thrombosis

Wider context from the report

“The inquest heard that the scanning practice followed after the first attendance was in accordance with NICE guidelines (indeed possibly a little in excess of the guidance) which did not include scanning of the lower leg. This was said to be on the basis that not all lower leg DVTs will be visible. Yet it became apparent that there is mixed practice on this point, some hospitals clearly consider that lower leg scanning is worthwhile. Hindsight strongly suggested that Captain Bedford was developing clots in the left lower leg at the time of the first visit. The inquest found that a full leg scan might have provided the hospital with an opportunity to treat Captain Bedford although it was accepted that no-one could be certain of this. ”

Is this part of a recurring concern?

Yes — Failure to reliably diagnose and refer suspected DVT.

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

Delays in medical assessment of patients with classical DVT/PE symptoms

Wider context from the report

“3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance. Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter). ”

Is this part of a recurring concern?

Yes — Excessive emergency-department waiting times; Unreliable recognition and management of pulmonary embolism.

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

Invest in the VitalPac electronic observation system to improve recognition and response for deteriorating patients.

Verbatim wording from the response

“4. We have and continue to ensure there are sound processes in all clinical areas regarding prompt escalation of unwell patients. This is covered on the induction programme for all medical students who are very familiar with the need to escalate if they see someone who is acutely unwell. We have also recently introduced an Acute Response Team of Advanced Nurse Practitioners who rapidly attend to support wards with patients who deteriorate. We have also invested in the VitalPac electronic observation system that has been demonstrated in other Trusts to improve the recognition and response for sick patients.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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

Alter the thrombolysis pulmonary embolism guideline to prompt checking prior heparin administration and careful APTT monitoring.

Verbatim wording from the response

“5. The Trust has altered the Thrombolysis PE guideline – amongst the changes we have addressed the concerns about checking whether heparin had been administered previously and to carefully check and monitor the APTT ratio. A copy of the revised guidance is attached for your information.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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

Audit compliance with recording the provision of patient information sheets.

Verbatim wording from the response

“2. There is a Patient Information Sheet for patients who have attended hospital for investigation for deep vein thrombosis or pulmonary embolism. (Attached) This sheet is handed to all such patients at discharge, along with verbal advice provided by our specialist nurses. The Thrombosis nurses now record in their notes that an information sheet has been given to the patient. This will be audited to assess compliance.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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 consultant-led senior assessment in the START emergency assessment hub during its operating hours.

Verbatim wording from the response

“3. In the Emergency Department (ED) there is now a consultant in the new assessment hub area, which should speed up the diagnosis and management of someone presenting in this way. The Short-Term Assessment of Risk and Treatability Hub (START) runs between the hours of 09:00 and 16:00 hours and is consultant led. The START consultant will provide a senior ‘front of house’ service to assist with the initial assessment and ensure the appropriate diagnostic testing is undertaken at the earliest opportunity. The Consultant will work alongside the assessment hub staff in ensuring a safe and rapid assessment process. The consultant predominantly receives patients arriving by ambulance, however patients that also ‘self present’ can be seen on START, if they are unwell, have an elevated NEWS score or require treatment within one hour.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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

Record in thrombosis nurses’ notes when patients receive the DVT or pulmonary embolism information sheet.

Verbatim wording from the response

“2. There is a Patient Information Sheet for patients who have attended hospital for investigation for deep vein thrombosis or pulmonary embolism. (Attached) This sheet is handed to all such patients at discharge, along with verbal advice provided by our specialist nurses. The Thrombosis nurses now record in their notes that an information sheet has been given to the patient. This will be audited to assess compliance.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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

Introduce an Acute Response Team of Advanced Nurse Practitioners to rapidly support wards when patients deteriorate.

Verbatim wording from the response

“4. We have and continue to ensure there are sound processes in all clinical areas regarding prompt escalation of unwell patients. This is covered on the induction programme for all medical students who are very familiar with the need to escalate if they see someone who is acutely unwell. We have also recently introduced an Acute Response Team of Advanced Nurse Practitioners who rapidly attend to support wards with patients who deteriorate. We have also invested in the VitalPac electronic observation system that has been demonstrated in other Trusts to improve the recognition and response for sick patients.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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

Evidence does not establish that lower-leg scanning would have changed treatment, because benefits of treating isolated distal DVT remain unclear.

Verbatim wording from the response

“However, RSMVF also points out that the evidence for treating distal DVT alone is weak and cites a recent CACTUS trial (lancet haematology 2016) which showed no benefit in treating symptomatic below knee DVT. RSMVF is of the opinion that even if Captain Bedforth had had a full leg scan, and had been found to have a below knee DVT in April 2015, the evidence is not clear on whether he should have been immediately anticoagulated at that time.”

Source location

2016-0368-Response-by-Department-of-Health
Page 2 · response
Published 18 October 2016

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

NICE is responsible for considering and responding on whether lower-leg scanning should be included in relevant clinical guidance.

Verbatim wording from the response

“The inquest heard that the scanning practice followed after Captain Bedforth’s first attendance in April 2015, was in accordance with NICE guidelines which do not include scanning the lower leg. As it became apparent there is mixed clinical practice on this point, your view is that some hospitals consider that lower leg scanning is worthwhile. As most hospitals are, or should be, working to NICE guidelines, I therefore advised that you should consider inviting NICE to respond to this case directly. My officials provided you with contact details and I understand that NICE are looking into this and will respond directly to you and copy me into their reply. I have also consulted the Royal Society of Medicine Venous Forum (RSMVF) and asked for their comments on this case.”

Source location

2016-0368-Response-by-Department-of-Health
Page 2 · response
Published 18 October 2016

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 hospital will not change distal DVT ultrasound processes because additional scans may not detect all clots and empiric anticoagulation creates risks.

Verbatim wording from the response

“1. The current NICE guidance for Venous Thromboembolism advises proximal leg USS investigation for those patients who are high risk based on Wells scoring and those who are low risk with a positive D-dimer. If negative, the patient should undergo a second proximal leg USS in 6-8 days time to exclude proximal propagation of a clot from a distal DVT. The rationale behind the NICE guidance is evidence-based following multiple studies.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 1 · response
Published 18 October 2016

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 apparent 2-hour-37-minute APTT delay was actually 1 hour 20 minutes because the form was pre-prepared.

Verbatim wording from the response

““The sample for APTT testing was timed as being collected from ICU at 19.58hrs, but the sample was not taken until 21.15hrs and not received by pathology until 21.24. The results were reported to ICU at 22.35hrs, so an apparent delay of 2 hours and 37 minutes seemed to have occurred.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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

Close medical supervision after discharge following a negative scan is already triggered by the Thrombosis nurse and consultant referral.

Verbatim wording from the response

“In relation to your concern regarding the discharge of a patient like Captain Bedforth following a negative scan and whether he requires close supervision by a doctor, this practice is already in place and is triggered by the Thrombosis nurse. The process is that if the Thrombosis Service Sister has concerns regarding a patient they are referred to the consultant for review in the DVT clinic. The Thrombosis Sister has stated that Captain Bedforth’s case is the first case of its kind she has been aware of in the last 15 years. We will be interested to see whether national guidance changes following your letter and would adapt our local guidelines accordingly, if so.”

Source location

2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016

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