PFD report

LINDA ANNE RIGNALL · Prevention of Future Deaths report

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Issued 19 Sep 2014•Brighton and Hove

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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

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

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Concerns raised1

  1. Failure to escalate changes in patient condition for timely medical assessment
    Part of recurring concern: Failure to provide timely medical review of admitted patientsPart of recurring concern: Failure to reliably communicate clinically significant patient observations to medical staffPart of recurring concern: Failure to reliably escalate requests for medical reviewPart of recurring concern: Failure to reliably recognise and respond to acute clinical deteriorationPart of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Unreliable escalation by care staff for required medical attention
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 escalate changes in patient condition for timely medical assessment

Wider context from the report

“(1) At 17:33 on the 5th May 2014, Linda Rignall's condition changed and this was recorded on the NEWS Observation chart. This change in condition should have been reported to a Doctor on the Acute Medical Unit and she should have been assessed. The position worsened some 4 hours later (the next time observations were performed) and there was still no request for a medical review. From the evidence it was clear to me and I found as you will see from the Conclusion that I recorded that this failure to refer Miss Rignall for assessment resulted in the only window of opportunity available to treat her, being lost. This makes me concerned as to AMU's Fitness for Purpose at the current time. I consider this to be serious. ”

Is this part of a recurring concern?

Yes — Failure to provide timely medical review of admitted patients; Failure to reliably communicate clinically significant patient observations to medical staff; Failure to reliably escalate requests for medical review; Failure to reliably recognise and respond to acute clinical deterioration; Failure to seek medical attention when a person's condition warrants it; Unreliable escalation by care staff for required medical attention.

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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