PFD report

Barbara Joan Harrison · Prevention of Future Deaths report

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Issued 13 Mar 2015•Manchester South

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
5

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 raised5

  1. Lack of clear authorisation for postoperative physiotherapy
    Part of recurring concern: Unreliable physiotherapy provision for patients requiring care
  2. Unsafe physiotherapy involving forceful blowing after surgery
  3. Failure to monitor and respond promptly to postoperative neck and facial swelling
    Part of recurring concern: Failure to reliably recognise and respond to acute clinical deteriorationPart of recurring concern: Unreliable postoperative clinical review and complication response
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

Lack of clear authorisation for postoperative physiotherapy

Wider context from the report

“1. After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter. This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site. It is unclear as to who ordered this physiotherapy, as ████████ the surgeon and ████████ the anaesthetist both indicated that they did not do so and would not have done so. ”

Is this part of a recurring concern?

Yes — Unreliable physiotherapy provision for patients requiring care.

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 physiotherapy involving forceful blowing after surgery

Wider context from the report

“1. After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter. This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site. It is unclear as to who ordered this physiotherapy, as ████████ the surgeon and ████████ the anaesthetist both indicated that they did not do so and would not have done so. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 monitor and respond promptly to postoperative neck and facial swelling

Wider context from the report

“5. After the first surgery had taken place, the family noticed there was a rapid and very obvious swelling around the neck and face of Mrs Harrison. Why did the nurses not note this and act upon it earlier? ”

Is this part of a recurring concern?

Yes — Failure to reliably recognise and respond to acute clinical deterioration; Unreliable postoperative clinical review and complication response.

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

Unavailability of a functioning fibre-optic endoscopic light source during critical surgery

Wider context from the report

“2. During surgery to repair the oesophageal pouch, there were a total of three attempts to site an endo-tracheal tube and on each occasion it failed. Part of the reason for this was that it was found that the batteries for the fibre optic tube were flat and inoperable. No replacement could be found. 3. ████████ averred that “we never got a light source at all” during the operation. This is an unacceptable situation during a critical operative procedure. He then went on to say “ The need for an endoscope was critical and this is now a panic situation with the possibility of something going catastrophically wrong” ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 maintain appropriate communication and privacy around critical incidents

Wider context from the report

“4. Whilst the patient was in theatre for the emergency procedure, her family were advised to wait in the restaurant or reception areas of the hospital. As they were waiting, they heard one of the porters shout out “we have got a cardiac arrest in theatre.” This caused them extreme distress and alarm.” ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families.

Open source report
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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