PFD report

David WOOD · Prevention of Future Deaths report

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Issued 7 Jun 2023•Milton Keynes

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

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 raised4

  1. Failure to provide advice on when to seek further medical assistance
    Part of recurring concern: Inadequate safety-netting advice for patients and carers
  2. Failure to plan discharge from hospital
    Part of recurring concern: Unreliable hospital discharge processes
  3. Failure to highlight delirium symptoms to the GP
    Part of recurring concern: Failure to reliably recognise and manage delirium
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.1

  1. Action

    Provide a full-time heart-centre discharge coordinator using a multidisciplinary approach for discharge planning.

    Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.

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 advice on when to seek further medical assistance

Wider context from the report

“Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths. ”

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

Failure to plan discharge from hospital

Wider context from the report

“Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths. ”

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

Failure to highlight delirium symptoms to the GP

Wider context from the report

“Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and manage delirium.

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 educate relatives about the possibility of delirium

Wider context from the report

“Following the death of Mr. Wood a review was conducted by the trust and the review recognised that it would have been helpful if the symptoms of delirium had been highlighted to the GP and that it would have been useful if there had been a discussion with Mrs Wood to educate her as to the possibility of delirium, and to help plan his discharge from hospital and inform her when she should seek further medical assistance. The protocols for discharge following heart surgery should be reviewed in order to prevent similar deaths. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families; Failure to reliably recognise and manage delirium.

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

Provide a full-time heart-centre discharge coordinator using a multidisciplinary approach for discharge planning.

Verbatim wording from the response

“2. If post-operative delirium occurs, considering involving an appropriate family member in discharge discussions (with the patient’s consent), to alert them as to what to expect in the process of recovery and when to seek further medical assistance after discharge.”

Source location

Response from Oxford University Hospitals NHS Foundation Trust
Page 2 · response
Published 12 June 2023

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.5

  1. 1

    Amend the pre-operative assessment proforma to capture previous mental health and substance use histories.

    Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
  2. 2

    Educate nursing staff about NHS talking therapies and British Heart Foundation support resources.

    Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
  3. 3

    Provide patients with information about the possibility and usual transient nature of post-operative delirium.

    Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
  4. 4

    Amend cardiac-surgery consent-form stickers to include delirium among frequent or clinically significant complications.

    Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
  5. 5

    Clarify access to Psychological Medicine advice or direct clinical input through the rostered Consultant-of-the-Week by phone or bleep.

    Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.

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 the pre-operative assessment proforma to capture previous mental health and substance use histories.

Verbatim wording from the response

“1. Including a section in the Pre-Operative Assessment on previous mental health and substance use in the past medical history section, would represent best practice in highlighting patients with significant psychiatric histories so that appropriate care could be instituted during and after the admission.”

Source location

Response from Oxford University Hospitals NHS Foundation Trust
Page 2 · response
Published 12 June 2023

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

Educate nursing staff about NHS talking therapies and British Heart Foundation support resources.

Verbatim wording from the response

“Since the incident, this has been addressed via a full-time discharge coordinator for the heart centre adopting more of an MDT approach. The nursing team have also been educated about the free NHS talking therapies services plus the British Heart Foundation resources online support groups and information.”

Source location

Response from Oxford University Hospitals NHS Foundation Trust
Page 2 · response
Published 12 June 2023

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 patients with information about the possibility and usual transient nature of post-operative delirium.

Verbatim wording from the response

“The POA clerking proforma has been amended accordingly and patients are also given a leaflet explaining the small chance of post-operative delirium, and that it is usually transient.”

Source location

Response from Oxford University Hospitals NHS Foundation Trust
Page 2 · response
Published 12 June 2023

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 cardiac-surgery consent-form stickers to include delirium among frequent or clinically significant complications.

Verbatim wording from the response

“3. Amendment to consent-form stickers used to list frequent or clinically significant complications after cardiac surgery, which previously did not include delirium.”

Source location

Response from Oxford University Hospitals NHS Foundation Trust
Page 2 · response
Published 12 June 2023

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

Clarify access to Psychological Medicine advice or direct clinical input through the rostered Consultant-of-the-Week by phone or bleep.

Verbatim wording from the response

“4. The liaison process for seeking advice and/or direct clinical input from Psychological Medicine for in-patients should be clarified.”

Source location

Response from Oxford University Hospitals NHS Foundation Trust
Page 2 · response
Published 12 June 2023

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