PFD report

Terence Douglas Thornton · Prevention of Future Deaths report

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Issued 3 Apr 2019•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.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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 raised4

  1. Insufficient radiology clinician staffing
    Part of recurring concern: Insufficient medical staffing capacity for timely patient care
  2. Failure to transfer prescribed medication to the community hospital
    Part of recurring concern: Failure to ensure patients receive the correct prescribed medication at hospital discharge
  3. Failure to transfer complete discharge documentation to the community hospital
    Part of recurring concern: Unreliable healthcare patient transfer processesPart of recurring concern: Unreliable hospital discharge documentation
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

    Review estimated radiology demand against capacity through business planning.

    Stated by University Hospitals Plymouth NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2019.
  2. Action

    Increase the radiology establishment by four posts and further expand it.

    Stated by University Hospitals Plymouth NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 June 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The vacant neuroradiologist post was not a contributory factor in the incident.

    Stated by University Hospitals Plymouth NHS 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 radiology clinician staffing

Wider context from the report

“(1) At the Inquest I heard evidence from ████████ Clinical Director for Radiology at Derriford Hospital. He told me that, currently, there are 44 radiologists working within the Trust. He told me that he believed there was a need for up to a further 16 clinicians across a range of specialities. (2) I also heard evidence from ████████ who felt that work pressures may have caused or contributed to the error that occurred in this instance. (3) It is not the first time that shortages of radiology clinicians has been brought to my attention at Inquest. I am aware that there are difficulties in this regard nationally but I am concerned that the problems in Derriford appear to be worsening with the consequent risk that similar fatalities may occur in the future. In the circumstances, it is my duty to report this situation to you so that you may consider what action needs to be taken to address the situation. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care.

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 transfer prescribed medication to the community hospital

Wider context from the report

“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”

Is this part of a recurring concern?

Yes — Failure to ensure patients receive the correct prescribed medication at hospital discharge.

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 transfer complete discharge documentation to the community hospital

Wider context from the report

“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes; Unreliable hospital discharge documentation.

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

Lack of medical cover at the community hospital during out-of-hours admissions

Wider context from the report

“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care; Insufficient safe staffing and senior cover out of hours.

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

Review estimated radiology demand against capacity through business planning.

Verbatim wording from the response

“You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.”

Source location

2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
Page 2 · response
Published 6 June 2019

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

Increase the radiology establishment by four posts and further expand it.

Verbatim wording from the response

“You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.”

Source location

2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
Page 2 · response
Published 6 June 2019

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 vacant neuroradiologist post was not a contributory factor in the incident.

Verbatim wording from the response

“You were informed at the inquest at that time University Hospitals Plymouth NHS Trust had 6 consultant vacancies (out of an establishment of 44 consultants). Although one of those vacancies was for a Neuroradiologist, it was not a contributory factor to the incident. We can clarify that the 6 vacancies referred to were new posts and the department is planning to increase its establishment by a further 4 posts this year. When we benchmark ourselves against other similar Trusts we compare favourably with the number of radiologists in post and we are planning to further increase our establishment. As part of the organisation’s business planning process we review the estimated demand against our capacity to ensure that we have the correct number of radiologists.”

Source location

2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
Page 2 · response
Published 6 June 2019

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.2

  1. 1

    Share investigation lessons with the Radiology team.

    Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.
  2. 2

    Submit the incident case for departmental audit and discrepancy review.

    Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 June 2019.

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

Share investigation lessons with the Radiology team.

Verbatim wording from the response

“Subsequent to the incident, the Consultant Neuroradiologist submitted the case for review at the departmental audit meeting. It was also discussed at the departmental discrepancy meeting on 2 November and it was noted that whilst the findings on the CT head were subtle, the use of multi-planar reformatting (looking at it from different angles) and selected windows (reviewing the image on different settings) would have improved the chances of identifying the subtle subdural haematoma. The lessons from the investigation have been shared with the Radiology team.”

Source location

2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
Page 1 · response
Published 6 June 2019

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

Submit the incident case for departmental audit and discrepancy review.

Verbatim wording from the response

“Subsequent to the incident, the Consultant Neuroradiologist submitted the case for review at the departmental audit meeting. It was also discussed at the departmental discrepancy meeting on 2 November and it was noted that whilst the findings on the CT head were subtle, the use of multi-planar reformatting (looking at it from different angles) and selected windows (reviewing the image on different settings) would have improved the chances of identifying the subtle subdural haematoma. The lessons from the investigation have been shared with the Radiology team.”

Source location

2019-0114-Response-by-University-Hospitals-Plymouth-NHS-Trust
Page 1 · response
Published 6 June 2019

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