PFD report

Robert James GOODMAN · Prevention of Future Deaths report

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Issued 15 Dec 2020•Hampshire, Portsmouth and Southampton

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
4

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 maintain awareness of revised National Institute for Health and Care Excellence guidance on head-injury scanning
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuriesPart of recurring concern: Unsafe updating of clinical policies and guidance
  2. Failure of the head-injury policy to include patients receiving low-dose anticoagulants within the 8-hour computerised tomography scan criterion
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuriesPart of recurring concern: Unsafe updating of clinical policies and guidance
  3. Failure of the head-injury policy to reflect revised National Institute for Health and Care Excellence guidance
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuriesPart of recurring concern: Unsafe updating of clinical policies and guidance
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.3

  1. Action

    Continue ensuring CT scanning within eight hours for patients receiving prophylactic enoxaparin who develop clinical signs or symptoms after a fall, and for patients receiving therapeutic anticoagulants.

    Stated by University Hospital Southampton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
  2. Action

    Amend and launch the head-injury policy to require CT scanning within eight hours for patients receiving therapeutic anticoagulants, including DOACs.

    Stated by University Hospital Southampton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
  3. Action

    Disseminate the updated head-injury policy and key NICE changes to clinical teams and publish it on the staff intranet.

    Stated by University Hospital Southampton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Patients receiving prophylactic enoxaparin are not routinely scanned after falls without clinical signs suggesting bleeding.

    Stated by University Hospital Southampton NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 awareness of revised National Institute for Health and Care Excellence guidance on head-injury scanning

Wider context from the report

“When found on the floor the deceased stated that he had a head injury. The Trust has a policy for the assessment and early management of head injuries. The policy was, on the evidence, drafted in 2016. The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries. The deceased was receiving the anticoagulant enoxaparine whilst in hospital. The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment. The evidence suggests that enoxaparine is a “low dose anticoagulant” which did not place the deceased within the Trust policy where a computerised tomography scan should be provided within 8 hours of a head injury. The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury. The Trust’s policy does not presently reflect the National Institute for Health and Care Excellence revised guidance, in place since September 2019. It was accepted in evidence that the deceased would have had a computerised tomography scan within 8 hours of a head injury if the revised National Institute for Health and Care Excellence guidance had been applied and reflected in the Trust policy. The deceased’s computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries; Unsafe updating of clinical policies and guidance.

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 of the head-injury policy to include patients receiving low-dose anticoagulants within the 8-hour computerised tomography scan criterion

Wider context from the report

“When found on the floor the deceased stated that he had a head injury. The Trust has a policy for the assessment and early management of head injuries. The policy was, on the evidence, drafted in 2016. The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries. The deceased was receiving the anticoagulant enoxaparine whilst in hospital. The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment. The evidence suggests that enoxaparine is a “low dose anticoagulant” which did not place the deceased within the Trust policy where a computerised tomography scan should be provided within 8 hours of a head injury. The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury. The Trust’s policy does not presently reflect the National Institute for Health and Care Excellence revised guidance, in place since September 2019. It was accepted in evidence that the deceased would have had a computerised tomography scan within 8 hours of a head injury if the revised National Institute for Health and Care Excellence guidance had been applied and reflected in the Trust policy. The deceased’s computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries; Unsafe updating of clinical policies and guidance.

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 of the head-injury policy to reflect revised National Institute for Health and Care Excellence guidance

Wider context from the report

“When found on the floor the deceased stated that he had a head injury. The Trust has a policy for the assessment and early management of head injuries. The policy was, on the evidence, drafted in 2016. The Trust policy is said to reflect the National Institute for Health and Care Excellence guidance on the assessment and early management of head injuries. The deceased was receiving the anticoagulant enoxaparine whilst in hospital. The present Trust policy states that a computerised tomography scan of the head should be undertaken within 8 hours of the injury if a patient is receiving anticoagulant treatment. The evidence suggests that enoxaparine is a “low dose anticoagulant” which did not place the deceased within the Trust policy where a computerised tomography scan should be provided within 8 hours of a head injury. The Trust were not aware of the September 2019 variation in National Institute for Health and Care Excellence guidance which now advises that patients who are on any anticoagulant should have a computerised tomography scan within 8 hours of a head injury. The Trust’s policy does not presently reflect the National Institute for Health and Care Excellence revised guidance, in place since September 2019. It was accepted in evidence that the deceased would have had a computerised tomography scan within 8 hours of a head injury if the revised National Institute for Health and Care Excellence guidance had been applied and reflected in the Trust policy. The deceased’s computerised tomography scan was undertaken 30 hours after the deceased had suffered a head injury. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries; Unsafe updating of clinical policies and guidance.

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

Continue ensuring CT scanning within eight hours for patients receiving prophylactic enoxaparin who develop clinical signs or symptoms after a fall, and for patients receiving therapeutic anticoagulants.

Verbatim wording from the response

“Finally, I would like to assure you that, whilst further guidance from NICE is awaited, the Trust will continue to ensure that all patients receiving a prophylactic dose of Enoxaparin, who develop clinical signs and symptoms following a fall, will undergo a CT scan within 8 hours of a suspected head injury in addition to all those patients who have received a therapeutic dose of DOAC’s, Warfarin etc.”

Source location

2020-0285-Response-from-Southampton-General-Hospital-Redacted
Page 3 · response
Published 7 January 2021

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

Amend and launch the head-injury policy to require CT scanning within eight hours for patients receiving therapeutic anticoagulants, including DOACs.

Verbatim wording from the response

“In respect of NICE Clinical Guideline [CG176], I can confirm that the Trust’s policy has now been amended so that it is clear that patients receiving therapeutic anticoagulant treatment including Direct Oral Anticoagulants (DOACs) should undergo a CT scan within 8 hours of a suspected head injury.”

Source location

2020-0285-Response-from-Southampton-General-Hospital-Redacted
Page 1 · response
Published 7 January 2021

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

Disseminate the updated head-injury policy and key NICE changes to clinical teams and publish it on the staff intranet.

Verbatim wording from the response

“The Trust launched the updated policy on the 26th January 2021, our head of patient safety emailed out to the clinical teams (including consultants, nursing, pharmacy and therapy staff) to notify them of the updated policy and highlight the key changes including the NICE guidance. We also included the updated policy on the clinical updates section on our staff intranet.”

Source location

2020-0285-Response-from-Southampton-General-Hospital-Redacted
Page 2 · response
Published 7 January 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Patients receiving prophylactic enoxaparin are not routinely scanned after falls without clinical signs suggesting bleeding.

Verbatim wording from the response

“On the basis of the current medical literature on the subject, patients who are receiving a prophylactic dose of Enoxaparin are not routinely given a CT scan following a fall unless they are exhibiting clinical signs that are suggestive of a bleed.”

Source location

2020-0285-Response-from-Southampton-General-Hospital-Redacted
Page 2 · response
Published 7 January 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Universal CT scanning for patients receiving prophylactic enoxaparin could overwhelm scanning capacity and delay scans for patients who require them.

Verbatim wording from the response

“The consensus opinion among Medicine for Older People colleagues is that providing a CT scan for all patients on a prophylactic dose of enoxaparin, without other clinical signs and symptoms being evident, would not influence the outcomes for those patients. However, it could overwhelm a hospital’s scanning capacity, meaning that there is a risk that other patients, who do require a CT scan, may face a delay in obtaining this to the potential detriment of their health.”

Source location

2020-0285-Response-from-Southampton-General-Hospital-Redacted
Page 2 · response
Published 7 January 2021

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NICE is expected to clarify whether prophylactic anticoagulants should trigger the same scanning requirements as therapeutic anticoagulants.

Verbatim wording from the response

“Unfortunately, NICE’s Clinical Guideline [CG176] fails to provide specific guidance on this point. We, therefore, contacted the National Falls Lead at NHSE/I who confirmed that “we are aware that concordance with the guidelines by acute providers is problematic”. We understand that there is to be a full review of the evidence, undertaken by NICE, in order to clarify whether prophylactic anticoagulants should trigger the same requirements as therapeutic doses of DOACs and Warfarin.”

Source location

2020-0285-Response-from-Southampton-General-Hospital-Redacted
Page 2 · response
Published 7 January 2021

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.1

  1. 1

    Highlight the omission concerning prophylactic anticoagulants to the British Geriatric Society Falls Special Interest Group to support development of a national consensus approach.

    Stated by University Hospital Southampton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.

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

Highlight the omission concerning prophylactic anticoagulants to the British Geriatric Society Falls Special Interest Group to support development of a national consensus approach.

Verbatim wording from the response

“We have also contacted the Falls Special Interest Group Lead in the British Geriatric Society to highlight this omission in NICE guidance not least so that a consensus approach can be developed nationally for these patients in the meantime.”

Source location

2020-0285-Response-from-Southampton-General-Hospital-Redacted
Page 3 · response
Published 7 January 2021

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