PFD report

William David Patrick HEWES · Prevention of Future Deaths report

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Issued 27 Mar 2025•Inner North London

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
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 raised1

  1. Delays in providing necessary treatment after recognition of a life-threatening condition
    Part of recurring concern: Failure to provide timely clinical care
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

    Develop and deliver closed-loop communication training for resident doctors through the Regional Trainee Teaching programme.

    Stated by Homerton Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
  2. Action

    Continue piloting Martha’s Rule, meeting other pilot sites and sharing implementation learning and data with NHS England.

    Stated by Homerton Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 March 2025.
  3. Action

    Deliver simulation training to clinical staff on closed-loop communication and direct instruction during emergency management of sepsis and shock.

    Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 March 2025.

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 providing necessary treatment after recognition of a life-threatening condition

Wider context from the report

“William’s life threatening condition was recognised immediately he attended hospital, but he did not receive the necessary treatment as promptly as he should have done. The cause of the delay was multi factorial. ”

Is this part of a recurring concern?

Yes — Failure to provide timely clinical care.

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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

Develop and deliver closed-loop communication training for resident doctors through the Regional Trainee Teaching programme.

Verbatim wording from the response

“2) One of our local actions was to deliver SIM (simulation) training to clinical staff. Simulation training is a tool used to gain practical experience, make informed decisions and refine their performance within controlled settings. The SIM training is focused on ensuring closed loop communication / direct instruction to team members when managing sepsis and shock in emergency situations. The plan is to develop this and deliver it on our Regional Trainee Teaching programme to resident doctors on managing human factors within healthcare. This course runs regularly throughout the year, we are aiming to incorporate the learning on closed loop communication into the next programme. The training runs 3 to 4 times a year.”

Source location

Response from Homerton University Hospital NHS Trust
Page 2 · response
Published 31 March 2025

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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

Continue piloting Martha’s Rule, meeting other pilot sites and sharing implementation learning and data with NHS England.

Verbatim wording from the response

“1) The Trust are one of the pilot sites for the first phase in implementing Martha’s Rule. This is a major patient safety initiative providing patients and families with a way to seek an urgent review if they are concerned about a loved one’s deterioration. Part of this first phase is to help the NHS to devise and agree a standardised approach to all three elements of Martha’s Rule (ahead of scaling up to further sites in England in the following years). Once fully”

Source location

Response from Homerton University Hospital NHS Trust
Page 1 · response
Published 31 March 2025

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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

Deliver simulation training to clinical staff on closed-loop communication and direct instruction during emergency management of sepsis and shock.

Verbatim wording from the response

“2) One of our local actions was to deliver SIM (simulation) training to clinical staff. Simulation training is a tool used to gain practical experience, make informed decisions and refine their performance within controlled settings. The SIM training is focused on ensuring closed loop communication / direct instruction to team members when managing sepsis and shock in emergency situations. The plan is to develop this and deliver it on our Regional Trainee Teaching programme to resident doctors on managing human factors within healthcare. This course runs regularly throughout the year, we are aiming to incorporate the learning on closed loop communication into the next programme. The training runs 3 to 4 times a year.”

Source location

Response from Homerton University Hospital NHS Trust
Page 2 · response
Published 31 March 2025

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

    Share the RESPOND training programme’s success at regional and national conferences and meetings.

    Stated by Homerton Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.
  2. 2

    Share William’s Story at national and regional patient safety meetings to promote learning about sepsis, deterioration recognition and listening to families.

    Stated by Homerton Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 March 2025.

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

Share the RESPOND training programme’s success at regional and national conferences and meetings.

Verbatim wording from the response

“3) Share the success of the RESPOND training programme at Regional and National conferences / meeting – the RESPOND programme provides training for nurses and nursing associates working in adult areas to support and develop knowledge and understanding in recognising early signs and need of the deteriorating patients including those with sepsis.”

Source location

Response from Homerton University Hospital NHS Trust
Page 2 · response
Published 31 March 2025

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

Share William’s Story at national and regional patient safety meetings to promote learning about sepsis, deterioration recognition and listening to families.

Verbatim wording from the response

“4) In agreement and in collaboration with William’s family share “William’s Story” at National and Regional Patient Safety meetings to support and promote learning on managing sepsis, recognition of deterioration and listening to families.”

Source location

Response from Homerton University Hospital NHS Trust
Page 2 · response
Published 31 March 2025

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