PFD report

Leslie Clewarth · Prevention of Future Deaths report

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Issued 10 Nov 2020•West Yorkshire Eastern

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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. Failure to account for unused drugs
  2. Lack of adequate records documenting care provided and dosages administered
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.2

  1. Action

    Revise the syringe pump policy and prescription/administration chart to clarify recording of residual and discarded medication and prompt timely syringe changes.

    Stated by Mid Yorkshire Teaching NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 December 2020.
  2. Action

    Deliver further training to support use of the revised syringe pump policy and prescription/administration chart after governance approval.

    Stated by Mid Yorkshire Teaching NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 December 2020.

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 account for unused drugs

Wider context from the report

“(1) Without adequate records showing the care provided or dosage administered, it was not possible to corroborate the testimony of nurses who had attended to Mr Clewarth on the afternoon he died. This fuelled the suspicions raised by his daughter and her husband. (2) Drugs which were left unused after Mr Clewarth’s death were not accounted for. Without proper records there is a risk that essential care may not be provided or is erroneously duplicated, thus potentially putting a patient's safety or health at risk. ”

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

Lack of adequate records documenting care provided and dosages administered

Wider context from the report

“(1) Without adequate records showing the care provided or dosage administered, it was not possible to corroborate the testimony of nurses who had attended to Mr Clewarth on the afternoon he died. This fuelled the suspicions raised by his daughter and her husband. (2) Drugs which were left unused after Mr Clewarth’s death were not accounted for. Without proper records there is a risk that essential care may not be provided or is erroneously duplicated, thus potentially putting a patient's safety or health at risk. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Revise the syringe pump policy and prescription/administration chart to clarify recording of residual and discarded medication and prompt timely syringe changes.

Verbatim wording from the response

“In light of the above reviews we have determined that the syringe pump policy and the prescription / administration chart should be revised to provide clearer guidance and support adherence to the policy. In particular this relates to the recording of any medication remaining in the syringe at each check and the amount discarded at the change or end of the use of the syringe driver and a prompt to support staff in recognising when the next syringe change will be required. Once the revised policies have gone through the appropriate governance routes in the Trust there will be further training delivered to support their use.”

Source location

2020-0229-Response-from-Mid-Yorkshire-Hospitals-NHS-Trust-1.pdf
Page 2 · response
Published 23 December 2020

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

Deliver further training to support use of the revised syringe pump policy and prescription/administration chart after governance approval.

Verbatim wording from the response

“In light of the above reviews we have determined that the syringe pump policy and the prescription / administration chart should be revised to provide clearer guidance and support adherence to the policy. In particular this relates to the recording of any medication remaining in the syringe at each check and the amount discarded at the change or end of the use of the syringe driver and a prompt to support staff in recognising when the next syringe change will be required. Once the revised policies have gone through the appropriate governance routes in the Trust there will be further training delivered to support their use.”

Source location

2020-0229-Response-from-Mid-Yorkshire-Hospitals-NHS-Trust-1.pdf
Page 2 · response
Published 23 December 2020

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