PFD report

Jane Helen Robinson · Prevention of Future Deaths report

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Issued 10 Feb 2015•Leicester City and South Leicestershire

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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
Recipients: 1
Responses found: 1
Stated actions: 7

Recipients and published responses

University Hospitals of Leicester NHS TrustResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 08/05/2014 I commenced an investigation into the death of Jane Helen Robinson, 55. The investigation concluded at the end of the inquest on 10 February 2015. The conclusion of the inquest was Natural causes. Jane Robinson was known to have alcoholic liver disease with ascites and was admitted to the Leicester Royal Infirmary on the 16th April 2014 with shortness of breath. Despite treatment she died on the 4th May 2014 at the hospital. At the time it was believed that she had died from sepsis due to spontaneous bacterial peritonitis. However, no positive evidence of sepsis was found at the post mortem examination and there was no positive microbiology in life. The cause of her death was found to be 1a) Systemic inflammatory response syndrome 1b) Decompensated hepatic failure 1c) Hepatic cirrhosis 1d) Alcoholic liver disease and hepatitis C infection. Therefore, although she was not observed in accordance with her needs, this shortfall in her care did not contribute to her death.

Concerns and recipient responses

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Concerns raised5

Lack of written decision-making rationale for observation frequency
Lack of a reporting system for healthcare professionals who do not practise in accordance with accepted standards
Lack of ongoing senior review on each shift to detect observation shortfalls early

Responses linked to these concerns

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

Actions described in response 5

Action
Introduce and embed competency assessments for healthcare assistants performing vital-sign observations.
Stated by University Hospitals of Leicester NHS TrustStated in progress
Action
Implement electronic observation recording with mandatory respiratory-rate fields, automated Early Warning Score calculation and escalation alerts.
Stated by University Hospitals of Leicester NHS TrustStated planned
Action
Review all patients’ observation charts during clinical handover to verify accurate recording and appropriate escalation.
Stated by University Hospitals of Leicester NHS TrustStated planned

Respondent positions 1

Position
A reporting system for healthcare professionals with practice concerns already exists through capability and disciplinary policies, with professional referrals where necessary.
Stated by University Hospitals of Leicester NHS TrustDisputes the concern

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions 2

1
Make completion of required Early Warning Score documentation part of the clinical-handover check by the named responsible qualified nurse.
Stated by University Hospitals of Leicester NHS TrustStated completed
2
Provide sepsis-management training to nursing and medical staff through the Trust’s safety-improvement work.
Stated by University Hospitals of Leicester NHS TrustStated in progress

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised5

Lack of written decision-making rationale for observation frequency

Lack of a reporting system for healthcare professionals who do not practise in accordance with accepted standards

Lack of ongoing senior review on each shift to detect observation shortfalls early

Failure to record basic observations

Lack of support for healthcare professionals who report departures from accepted standards

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.5

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

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

Actions described in response 5

Respondent positions 1

Recipient-stated actions 2