PFD report

Kim Georgina STROUD · Prevention of Future Deaths report

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Issued 22 Feb 2024•Norfolk

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
3

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 raised3

  1. Failure to accurately record medication administration
    Part of recurring concern: Unsafe medication administration
  2. Failure to provide timely continence and personal hygiene care
    Part of recurring concern: Unsafe continence care and management
  3. Failure to safely administer and supervise medication for delirious patients
    Part of recurring concern: Unsafe medication administration
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

    Apply the Patient Safety Incident Response Framework to assess incidents, identify learning and address wider patient-safety themes.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.
  2. Action

    Reintroduce the Matrons’ Ward Assurance Toolkit across the Trust, including audits of safe medication storage and unattended bedside medicines.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.

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 accurately record medication administration

Wider context from the report

“Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication. Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table. These had been signed for as given. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being poisoned, clearly not supervised in taking these either. It was extremely unsafe to give tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked them up. On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves. Also wash faeces from her body. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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 provide timely continence and personal hygiene care

Wider context from the report

“Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication. Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table. These had been signed for as given. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being poisoned, clearly not supervised in taking these either. It was extremely unsafe to give tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked them up. On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves. Also wash faeces from her body. ”

Is this part of a recurring concern?

Yes — Unsafe continence care and management.

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 safely administer and supervise medication for delirious patients

Wider context from the report

“Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication. Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table. These had been signed for as given. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being poisoned, clearly not supervised in taking these either. It was extremely unsafe to give tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked them up. On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves. Also wash faeces from her body. ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

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

Apply the Patient Safety Incident Response Framework to assess incidents, identify learning and address wider patient-safety themes.

Verbatim wording from the response

“Under the new Patient Safety Incident Response Framework (PSIRF), if an incident is brought to our attention, we now consider whether there is any learning to be taken from the incident, and review this in a number of different ways, rather than our investigation being guided by the level of harm or potential harm. If a patient safety risk is identified, under PSIRF we now look to identify wider themes to prevent future patient safety incidents, rather than focusing on an incident as an isolated event. If an incident such as this had been reported on Datix, depending on the issues identified at our initial review, we might look to review our medication round processes across the Trust. We might have identified an issue within a specific area, e.g. the ward itself, or we may be able to identify another root cause requiring a different approach.”

Source location

Response from The Queen Elizabeth Hospital King's Lynn
Page 4 · response
Published 26 February 2024

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

Reintroduce the Matrons’ Ward Assurance Toolkit across the Trust, including audits of safe medication storage and unattended bedside medicines.

Verbatim wording from the response

“The Matrons’ Ward Assurance Toolkit has also been reintroduced across the Trust, providing guidance around what to look out for and audit tools to confirm compliance. This includes a Medicines Management audit which specifically asks the auditor to document whether medications have been stored safely, and in particular, whether any have been left on patient bedside cabinets or tables. A copy of this Toolkit is attached for your information.”

Source location

Response from The Queen Elizabeth Hospital King's Lynn
Page 5 · response
Published 26 February 2024

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.3

  1. 1

    Establish a new leadership team on Stanhoe Ward comprising a Band 7 Ward Manager and four Band 6 Junior Sisters.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.
  2. 2

    Provide new ward staff with Caring with Kindness training accredited for continuing professional development.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
  3. 3

    Provide daily and weekend senior nurse coverage across wards and departments to maintain standards and address patient and relative concerns promptly.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2024.

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

Establish a new leadership team on Stanhoe Ward comprising a Band 7 Ward Manager and four Band 6 Junior Sisters.

Verbatim wording from the response

“Since the time of Mrs Stroud’s admission, Stanhoe Ward also has an entire new leadership team including the Band 7 Ward Manager and her four Band 6 Junior Sisters. We have seen a significant decrease in the number of concerns and complaints reported to our Patient Advice and Liaison Service for both Necton and Stanhoe Ward since these measures including staffing changes and the emphasis on Caring With Kindness have been implemented.”

Source location

Response from The Queen Elizabeth Hospital King's Lynn
Page 5 · response
Published 26 February 2024

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

Provide new ward staff with Caring with Kindness training accredited for continuing professional development.

Verbatim wording from the response

“We fully recognise that the experience reported by Mrs Stroud’s family both during her admission and as part of the inquest process, was not what we would want for our patients and their families, and we deeply regret that this is the impression they have been left with when remembering Mrs Stroud’s last weeks. We sincerely apologise for this. The Trust is always looking for opportunities to improve the service we provide, and we are committed to continuous improvement in this respect, in line with the Trust’s core values of kindness, wellness and fairness. Since the incidents highlighted, many of the staff that would have been involved in Mrs Stroud’s care have left the Trust and new staff are in place on the wards where we know Mrs Stroud’s care did not meet our expectations.”

Source location

Response from The Queen Elizabeth Hospital King's Lynn
Page 4 · response
Published 26 February 2024

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

Provide daily and weekend senior nurse coverage across wards and departments to maintain standards and address patient and relative concerns promptly.

Verbatim wording from the response

“We recognise how distressing it can be when patients or their families have unanswered questions, and we wanted to address the wider issue of improving access to raising complaints and concerns. This will help ensure we retain this opportunity wherever possible, for the benefit of both our patients and their families. To ensure that patients and relatives are able to raise concerns much more easily, we now have a matron or senior nurse on site until 21.30 every day and during 08.00-16.30 on weekends and bank holidays, who visit every ward and department to ensure that standards are maintained and that any concerns are dealt with promptly.”

Source location

Response from The Queen Elizabeth Hospital King's Lynn
Page 5 · response
Published 26 February 2024

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