PFD report

Thelma Patricia JONES · Prevention of Future Deaths report

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Issued 12 Aug 2015•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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of joined-up care and discharge planning in the Acute Medical Unit
    Part of recurring concern: Unreliable care-planning processesPart of recurring concern: Unreliable hospital discharge processes
  2. Failure to complete National Early Warning System scoring after acute deterioration
    Part of recurring concern: Failure to reliably recognise and respond to acute clinical deteriorationPart of recurring concern: Unreliable clinical Early Warning Score systems for deterioration
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    NEWS scores were not expected during the medical emergency because the early warning system had already fulfilled its function.

    Stated by University Hospitals Sussex NHS Foundation TrustDisputes 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

Lack of joined-up care and discharge planning in the Acute Medical Unit

Wider context from the report

“This report once again, concerns the Acute Medical Unit (AMU) where Mrs. JONES was admitted from the 16th - 23rd February 2015 when she became acutely unwell and was moved to ITU having been intubated on AMU. • firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU and I would certainly like to have seen that. • The second matter is once again the question of the National Early Warning System (NEWS), which had been reasonably well completed until we come to the day of her acute deterioration, when after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23rd February 2015, the scoring is not completed. This is extremely poor; it is a matter that I have raised before and it must, please, be addressed. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes; 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 complete National Early Warning System scoring after acute deterioration

Wider context from the report

“This report once again, concerns the Acute Medical Unit (AMU) where Mrs. JONES was admitted from the 16th - 23rd February 2015 when she became acutely unwell and was moved to ITU having been intubated on AMU. • firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU and I would certainly like to have seen that. • The second matter is once again the question of the National Early Warning System (NEWS), which had been reasonably well completed until we come to the day of her acute deterioration, when after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23rd February 2015, the scoring is not completed. This is extremely poor; it is a matter that I have raised before and it must, please, be addressed. ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration; Unreliable clinical Early Warning Score systems for deterioration.

Open source report

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

NEWS scores were not expected during the medical emergency because the early warning system had already fulfilled its function.

Verbatim wording from the response

“In summary it would not be expected that NEWS scores would be calculated from the observations during a medical emergency response as the focus is on rapidly treating and managing the patient. The NEWS is an early warning system and it had fulfilled its function at the point a MET call was made.”

Source location

2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 3 · response
Published 12 August 2015

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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

No remedial action was considered necessary because the medical records contained appropriate detail about AMU care and NEWS scores.

Verbatim wording from the response

“As with all cases we have carefully reflected on the issues in this situation and are open and committed to learning from such events. In this particular case, the Trust believes that the medical notes contain appropriate detailed information on the care and treatment given within AMU and in relation to the NEWS scores. To that end we do not believe that remedial action is necessary on the part of the Trust in this respect.”

Source location

2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 3 · response
Published 12 August 2015

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 records show suitable care and treatment were provided, with discharge arrangements planned and coordinated.

Verbatim wording from the response

“Having reviewed the medical records we consider that there is evidence that suitable care and treatment were provided and that discharge arrangements were planned and coordinated.”

Source location

2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 12 August 2015

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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