PFD report

Freda Weston · Prevention of Future Deaths report

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Issued 23 Feb 2016•Manchester South

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
7

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 raised7

  1. Insufficient nursing staffing capacity
    Part of recurring concern: Insufficient qualified healthcare staffing capacity
  2. Failure to allow sufficient time to assess tolerance of a newly started drug before discharge
    Part of recurring concern: Unreliable hospital discharge processes
  3. Failure to ensure staff knowledge and adherence to IBleep escalation guidelines
    Part of recurring concern: Unreliable escalation policy for care concerns
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.4

  1. Action

    Recruit additional nursing staff, including European and international registered nurses, through quarterly cohorts to increase Medicine Business Group capacity.

    Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2016.
  2. Action

    Update and approve the iBleep escalation procedure to specify escalation by staff placing calls and reinforce registered-nurse judgement and frequent escalation.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 February 2016.
  3. Action

    Provide patient information leaflets for each medicine supplied in monitored dosage systems, including generic medicine information and access to drug advice.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Intravenous antibiotics were not indicated during the 48-hour period because the patient was clinically well and revision surgery was not planned.

    Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Insufficient nursing staffing capacity

Wider context from the report

“7. There was an acknowledged shortage of nurses at the time. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

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 allow sufficient time to assess tolerance of a newly started drug before discharge

Wider context from the report

“1. She was discharged from hospital after being started on the Septrin without allowing sufficient time to ensure that the new drug “suited” her. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

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 ensure staff knowledge and adherence to IBleep escalation guidelines

Wider context from the report

“6. The “Escalation guidelines for the IBleep system were either unknown to the staff or were not adhered to. ”

Is this part of a recurring concern?

Yes — Unreliable escalation policy for care concerns.

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 retain ward handover sheets for reference

Wider context from the report

“9. The handover sheets on the ward are “shredded by the nurses” immediately after handover. Why cannot these be kept in a folder on the ward for at least 14 days should they be needed for reference purposes? I was told of the transition from paper to electronic notes. This seems to have been happening for a very long time and one wonders when it will be complete. ”

Is this part of a recurring concern?

Yes — Failure to reliably preserve handover records; Unreliable shift handover processes.

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

Delays in administering prescribed antibiotics

Wider context from the report

“2. She was advised for teicoplanin on the 8th April at 17.10 hours yet she had not even been given the first dose thereof by 15.56 hours on the 9th April. 3. There was a 48 hour delay in her being given any antibiotics. ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed; 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

Insufficient medical staffing capacity for patient review

Wider context from the report

“4. The junior doctor gave evidence that s/he was unable to “get round to seeing” this patient as there was insufficient doctor-time to do so on that shift. The doctor went on to say “this is not an uncommon situation”. The hospital as a whole was being covered by one FY1 doctor and two SHO’s, one of whom was “clerking in” the new patients. This meant that the FY1 was covering 13 wards of the hospital. Clearly an impossible task. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care; Insufficient qualified healthcare staffing capacity.

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 precise drug and potential side-effect information when dispensing medication

Wider context from the report

“8. The pharmacy staff did not give precise details of the drug which they were dispensing and the potential side effects thereof. ”

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

Recruit additional nursing staff, including European and international registered nurses, through quarterly cohorts to increase Medicine Business Group capacity.

Verbatim wording from the response

“Nursing staff levels has been a concern, particular within the Medicine Business Group over the last 18 months. I can confirm that we are actively recruiting to nursing posts within the Trust. We are also proactively recruiting European and International nurses as part of our 5 year plan.”

Source location

Weston-Response
Page 3 · response
Published 23 February 2016

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

Update and approve the iBleep escalation procedure to specify escalation by staff placing calls and reinforce registered-nurse judgement and frequent escalation.

Verbatim wording from the response

“Please see enclosed the current standard operating procedure for the Escalation of iBleep jobs which is to be used by the iBleep Co-ordinator. This guides the staff monitoring the iBleep system to escalate to senior staff as and when required.”

Source location

Weston-Response
Page 3 · response
Published 23 February 2016

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 patient information leaflets for each medicine supplied in monitored dosage systems, including generic medicine information and access to drug advice.

Verbatim wording from the response

“Patients who are discharged with their medicines supplied in a monitored dosage system will have a Patient Information Leaflet supplied with the dosage system for each medicine”

Source location

Weston-Response
Page 3 · response
Published 23 February 2016

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 electronic handover access across Medicine Business Group wards, enabling retrospective access to patient handover information.

Verbatim wording from the response

“I can confirm that all wards in the Medicine Business Group have access to an electronic handover. Staff print these for each shift so they can be viewed as they move around the wards. The handover sheets are shredded at the end of each shift to make sure information is not taken home by staff, which would compromise patient confidentiality and make sure that incorrect information is not used on the ward. The information, per patient, can be accessed electronically retrospectively.”

Source location

Weston-Response
Page 4 · response
Published 23 February 2016

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

Intravenous antibiotics were not indicated during the 48-hour period because the patient was clinically well and revision surgery was not planned.

Verbatim wording from the response

“In Mrs Weston’s case she was clinically well, showing no signs of generalised sepsis and therefore giving intravenous antibiotics would have had no clear benefit for her at that time. ████████ had already ruled out the option of revision surgery and therefore the Trauma and Orthopaedic registrar made the decision to withhold intravenous antibiotic treatment until a definitive long term plan had been discussed with ████████ the outcome of which was likely to involve a joint washout to reduce the microbial load followed by long term oral antibiotics. ████████ Consultant Orthopaedic Surgeon, confirmed this plan with ████████ the following day and clearly documented that IV antibiotics were not indicated, as the plan was for washout followed by long term infection suppression with oral antibiotics and that IV antibiotics would only be indicated if Mrs Weston became clinically unwell.”

Source location

Weston-Response
Page 2 · response
Published 23 February 2016

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

Electronic handover records can be accessed retrospectively, so retaining shredded paper handover sheets is unnecessary and risks confidentiality and outdated information.

Verbatim wording from the response

“9) The handover sheets on the ward are “shredded by the nurses” immediately after handover. Why cannot these be kept in a folder on the ward for at least 14 days should they be needed for reference purposes? I was told of the transition from paper to electronic notes. This seems to have been happening for a very long time and one wonders when it will be complete.”

Source location

Weston-Response
Page 4 · response
Published 23 February 2016

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

Patient information leaflets supplied with monitored medicines provide drug and side-effect information, supplemented by generic medicine leaflets.

Verbatim wording from the response

“Patients who are discharged with their medicines supplied in a monitored dosage system will have a Patient Information Leaflet supplied with the dosage system for each medicine”

Source location

Weston-Response
Page 3 · response
Published 23 February 2016

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

Out-of-hours staffing arrangements, including prioritisation and access to senior clinicians, were considered adequate for urgent reviews and emergencies.

Verbatim wording from the response

“There is no on-call national guidance with regards to staffing numbers and broadly the total number of on-call doctors in Stepping Hill Hospital is the same for most district general hospitals of a similar size. Out of hours on-call work is primarily for urgent reviews and emergencies.”

Source location

Weston-Response
Page 2 · response
Published 23 February 2016

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

The Trust considers post-initiation hospital observation unnecessary because serious Septrin adverse events are more likely after prolonged treatment.

Verbatim wording from the response

“The Surgical and Critical Care Team do not feel that a period of observation in hospital after starting Septrin would be beneficial, as the most serious adverse events that can occur while taking Septrin are more likely to occur after being on Septrin for a more prolonged period. The advice recommended by the various manufacturers of Septrin is to monitor the patient’s blood results monthly, therefore the Trust will continue to abide by this recommendation. Notwithstanding this, Mrs Weston remained on the ward for a further week, prior to her discharge on 22 April 2015 and was well at the time of discharge.”

Source location

Weston-Response
Page 1 · response
Published 23 February 2016

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

The patient did not receive Teicoplanin during this admission; oral Doxycycline followed the subsequent knee washout.

Verbatim wording from the response

“On 8th April our Microbiology department contacted the Trauma and Orthopaedic registrar to advise that the aspirate taken from the knee was growing an organism, although they were unclear as to what the organism was. They therefore recommended to the registrar that the patient be given intravenous Teicoplanin (as they normally would for an infected joint).”

Source location

Weston-Response
Page 2 · response
Published 23 February 2016

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Trust will not change routine Septrin use because alternatives pose greater C. difficile and antibiotic-resistance risks.

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

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

The Trust will not change routine Septrin use because alternatives pose greater C. difficile and antibiotic-resistance risks.

Verbatim wording from the response

“We have used Septrin routinely in this Trust for step-down oral treatment for many intra-abdominal infections for about 5 years and this is the first time we have had a serious incident associated with its usage. The Antibiotic Management Team (microbiologists and antibiotic pharmacists) have discussed the future of Septrin usage and they do not feel it appropriate to change our current practice, as the alternatives would be more risky in terms of C.difficile and antibiotic resistance. We have not had a C.difficile infection associated with Septrin use, but we have had several associated with Co-amoxiclav and Ciprofloxacin, which would be the alternatives.”

Source location

Weston-Response
Page 1 · response
Published 23 February 2016

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