PFD report

Thomas Henry SMYTH · Prevention of Future Deaths report

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Issued 28 Oct 2019•Milton Keynes

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
1

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 raised1

  1. Failure to ensure vital information in electronic notes is accessible to staff making care decisions
    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.

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

    Reinforce daily medication-chart and observation review during routine clinical rounding through staff training, including additional Emergency Department and Trauma and Orthopaedics training.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
  2. Action

    Deliver and maintain eCARE training, materials and post-implementation support for clinical and temporary staff.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Proposed actions and the existing eCARE governance structure appropriately mitigate the risk of recurrence.

    Stated by Milton Keynes University Hospital 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 ensure vital information in electronic notes is accessible to staff making care decisions

Wider context from the report

“During the course of the evidence I heard from consultants and more junior staff that they were unaware of certain facts relating to Mr. Smyth at the time that they were dealing with him and making decisions relating to his care, and yet the information was recorded in the electronic notes and records. It appears to me that staff are having difficulty accessing vital information that should be clearly available to them. I would ask that you carry out a review of the notes system to see whether or not it is being used correctly, whether staff members have been adequately trained with regard to its use and whether changes should be made as to how information is recorded and retrieved. Unless the system is working effectively I anticipate that further lives will be put at risk. ”

Is this part of a recurring concern?

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

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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

Reinforce daily medication-chart and observation review during routine clinical rounding through staff training, including additional Emergency Department and Trauma and Orthopaedics training.

Verbatim wording from the response

“In this particular case, it is clear that important and relevant information was indeed recorded in the clinical record. Members of staff did not consistently review key elements of the record when assessing Mr Smyth; for example, the medication chart does not seem to have been reviewed daily when clinicians assessed Mr Smyth’s condition. Review of the medication chart and observations is a key element of routine rounding and this will be reinforced with staff. This will be addressed in training – with additional training in ED and Trauma and Orthopaedics. This specific case will be used for learning in plenary sessions during the year to reach a wide medical and multidisciplinary audience.”

Source location

2019-0505-Response-from-Milton-Keynes-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 14 May 2020

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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

Deliver and maintain eCARE training, materials and post-implementation support for clinical and temporary staff.

Verbatim wording from the response

“To ensure the system was introduced safely, and with the minimum of disruption to patients and patient care, we undertook an extensive programme of staff training in the lead up to the eCARE system going live across hospital inpatient areas (including the Emergency Department and Maternity – some areas, including Critical Care and Paediatrics, are in the next phase of the roll-out). This programme included individual and team training; dedicated staff to support wards and departments on the use of the system after go-live; training for all temporary staff; and training materials, including videos, as well as individual and team support remaining readily available.”

Source location

2019-0505-Response-from-Milton-Keynes-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 14 May 2020

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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

Proposed actions and the existing eCARE governance structure appropriately mitigate the risk of recurrence.

Verbatim wording from the response

“I am satisfied that with the actions proposed, and the governance structure in place to manage the use of and risks associated with eCARE, the risk of future recurrence is appropriately mitigated.”

Source location

2019-0505-Response-from-Milton-Keynes-NHS-Foundation-Trust-Redacted
Page 4 · response
Published 14 May 2020

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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

Important information was recorded in the electronic record; the issue was inconsistent staff review rather than inability to access it.

Verbatim wording from the response

“In this particular case, it is clear that important and relevant information was indeed recorded in the clinical record. Members of staff did not consistently review key elements of the record when assessing Mr Smyth; for example, the medication chart does not seem to have been reviewed daily when clinicians assessed Mr Smyth’s condition. Review of the medication chart and observations is a key element of routine rounding and this will be reinforced with staff. This will be addressed in training – with additional training in ED and Trauma and Orthopaedics. This specific case will be used for learning in plenary sessions during the year to reach a wide medical and multidisciplinary audience.”

Source location

2019-0505-Response-from-Milton-Keynes-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 14 May 2020

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

    Provide clinical oversight of eCARE through appointed Chief Clinical Information and Chief Nursing Information Officers.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  2. 2

    Operate governance oversight for eCARE development, implementation, performance, training, risks and issues through the Health Informatics Programme Board.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
  3. 3

    Use the case for learning in plenary sessions for a broad medical and multidisciplinary audience.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.

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 clinical oversight of eCARE through appointed Chief Clinical Information and Chief Nursing Information Officers.

Verbatim wording from the response

“The Trust also appointed a Chief Clinical Information Officer (a consultant vascular surgeon) and a Chief Nursing Information Officer (an experienced senior nurse), to ensure appropriate clinical oversight and input into all aspects of eCARE – from its introduction to ongoing training and future developments.”

Source location

2019-0505-Response-from-Milton-Keynes-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 14 May 2020

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

Operate governance oversight for eCARE development, implementation, performance, training, risks and issues through the Health Informatics Programme Board.

Verbatim wording from the response

“We have a robust governance process and structure in place to oversee the development, implementation and continued performance of eCARE, including staff training and use of the system. This structure reports to a main board (the Health Informatics Programme Board) which I chair as Chief Executive. This board has oversight of risks and issues and works to ensure that these are mitigated and managed appropriately.”

Source location

2019-0505-Response-from-Milton-Keynes-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 14 May 2020

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

Use the case for learning in plenary sessions for a broad medical and multidisciplinary audience.

Verbatim wording from the response

“In this particular case, it is clear that important and relevant information was indeed recorded in the clinical record. Members of staff did not consistently review key elements of the record when assessing Mr Smyth; for example, the medication chart does not seem to have been reviewed daily when clinicians assessed Mr Smyth’s condition. Review of the medication chart and observations is a key element of routine rounding and this will be reinforced with staff. This will be addressed in training – with additional training in ED and Trauma and Orthopaedics. This specific case will be used for learning in plenary sessions during the year to reach a wide medical and multidisciplinary audience.”

Source location

2019-0505-Response-from-Milton-Keynes-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 14 May 2020

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