PFD report

Paul Vincent Reynolds · Prevention of Future Deaths report

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Issued 21 Sep 2020•Plymouth, Torbay and South Devon

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
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 raised2

  1. Failure to fully appreciate and understand patients' underlying medical conditions before anaesthesia
  2. Unavailability of full patient medical records before anaesthesia
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
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

Failure to fully appreciate and understand patients' underlying medical conditions before anaesthesia

Wider context from the report

“A Root Cause Analysis by an Independent Anaesthetist found:- Root Cause There was an incomplete appreciation and understanding of the patients underlying medical condition which led to an incorrect choice of monitoring and anaesthetic. The unavailability of the full patient record meant that the anaesthetic team were reliant on the patient history and the admission clerking record to assess the patient. Lessons Learned The full set of patient medical records must be obtained as soon as possible following admission particularly when a procedure involving anaesthesia is planned. The safe conduct of anaesthesia is reliant on being fully conversant with the patient's pre-existing medical conditions and patients should not be anaesthetised before the medical records have been obtained and reviewed. Recommendations 1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk. 2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available. 3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 full patient medical records before anaesthesia

Wider context from the report

“A Root Cause Analysis by an Independent Anaesthetist found:- Root Cause There was an incomplete appreciation and understanding of the patients underlying medical condition which led to an incorrect choice of monitoring and anaesthetic. The unavailability of the full patient record meant that the anaesthetic team were reliant on the patient history and the admission clerking record to assess the patient. Lessons Learned The full set of patient medical records must be obtained as soon as possible following admission particularly when a procedure involving anaesthesia is planned. The safe conduct of anaesthesia is reliant on being fully conversant with the patient's pre-existing medical conditions and patients should not be anaesthetised before the medical records have been obtained and reviewed. Recommendations 1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk. 2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available. 3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

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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