PFD report

Mr Derek Weaver · Prevention of Future Deaths report

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Issued 15 Oct 2019•Inner South London

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
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
6

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. Lack of capacity for regional referrals during surges
    Part of recurring concern: Insufficient hospital capacity to maintain timely care during demand surges
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.5

  1. Action

    Keep thoracic surgery pathway performance and access under review.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 November 2019.
  2. Action

    Introduce a consultant-of-the-week system to triage and manage all thoracic surgery referrals.

    Stated by Guy'S and St Thomas' NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 November 2019.
  3. Action

    Audit the consultant-of-the-week system to assess whether it improves transfer management.

    Stated by Guy'S and St Thomas' NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 November 2019.

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

  1. Position

    Peer review and surveillance identified no serious quality or safety concerns in London thoracic services.

    Stated by Department of Health and Social CareDisputes 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

Lack of capacity for regional referrals during surges

Wider context from the report

“A consultant thoracic surgeon who was involved in his care after transfer said that had a higher chance of death because surgery was at a time of SIRS. If he had been transferred earlier he would have had surgery when he was not septic. It would have been two stages, the first being key hole surgery, with mortality of only 1 in 100. That may have obviated the necessity of second stage decortication surgery, with mortality of 5%, but it was probably needed anyway. The delay in transfer related to a surge in referrals, limiting capacity. Most regional referrals of this sort needed to be treated at weekends to maintain treatment of cancer cases in the week. There had been pressure to secure greater resources. The risk of potentially preventable deaths will recur whenever there is such a surge in referrals and be mitigated by provision of more beds. ”

Is this part of a recurring concern?

Yes — Insufficient hospital capacity to maintain timely care during demand surges.

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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

Keep thoracic surgery pathway performance and access under review.

Verbatim wording from the response

“Within London we do have other thoracic providers (eg. University College Hospitals and Imperial Hospitals amongst others) so there is the possibility to change the thoracic surgery pathway for both lung cancer patients and patients with conditions such as empyema that require urgent surgery too, if we felt insufficient progress was being made on meeting the nationally set response standards. We can confirm we will keep this under review as we recognise the importance of making sure that all patients needing thoracic surgery can get quick access to high quality services.”

Source location

2019-0345-Response-from-NHS-England-Redacted-1
Page 2 · response
Published 17 November 2019

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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

Introduce a consultant-of-the-week system to triage and manage all thoracic surgery referrals.

Verbatim wording from the response

“In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a “consultant of the week” system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service. The “consultant of the week” system will be audited to ascertain whether it has improved the management of transfers in.”

Source location

2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
Page 2 · response
Published 17 November 2019

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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

Audit the consultant-of-the-week system to assess whether it improves transfer management.

Verbatim wording from the response

“In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a “consultant of the week” system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service. The “consultant of the week” system will be audited to ascertain whether it has improved the management of transfers in.”

Source location

2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
Page 2 · response
Published 17 November 2019

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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

Increase Guy’s Hospital thoracic surgery bed capacity by switching wards and completing necessary estate works.

Verbatim wording from the response

“The Trust is looking towards an electronic referral system that allows local specialist services to manage their own tertiary referrals and gives the Site Management Team an overview of the current waiting list. In addition, the Trust Operational Board is currently looking to increase the number of beds on the Guy’s Hospital site for Thoracic Surgery patients. This will be achieved through switching the wards on which services are provided and undertaking the necessary estate works. It is expected that the increased capacity will be available during the first quarter of 2020.”

Source location

2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
Page 3 · response
Published 17 November 2019

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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

Transfer bed allocation and urgent thoracic surgery transfers to the Site Management Team using a three-level urgency and transfer process.

Verbatim wording from the response

“In October 2019, to mitigate the risk of capacity issues impacting on transfers, the Directorate Management Team transferred the management of the Thoracic Surgery Service’s beds and urgent transfer process to the Site Management Team. This change aligned the Thoracic Surgery Service with other services across the Trust. The process, set out in the UTCI Flow Chart (appendix 1), enables the Thoracic Surgery Service to triage its patients into three categories (1) Admission not urgent, (2) Urgent – Needs admission within 48 hours and (3) Urgent – Needs admission immediately and for the appropriate transfer to be arranged.”

Source location

2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
Page 2 · response
Published 17 November 2019

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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

Peer review and surveillance identified no serious quality or safety concerns in London thoracic services.

Verbatim wording from the response

“I am advised that NHS England’s national Specialised Commissioning Quality Team has undertaken peer review and surveillance activities of thoracic services in London, including at the Guy’s and St Thomas’ NHS Foundation Trust where no serious quality or safety concerns were identified. I am further advised that NHSEI will maintain oversight to ensure patients requiring thoracic surgery can access the service in a timely way, according to their clinical condition. This will include reviews of bed capacity in response to the ambition set out in the NHS Long Term Plan, for earlier and faster diagnosis of cancer¹ and the impact this might have on related services such as critical care beds.”

Source location

2019-0345-Response-from-the-Department-of-Health
Page 1 · response
Published 17 November 2019

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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

    Review future lung cancer demand and critical-care bed capacity in response to national early-diagnosis pilots and identified concerns.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 November 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    Existing legal duties of candour and duties to provide relevant information are presented as addressing coronial information delays.

    Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    Commissioners oversee GSTT’s failure to meet the 62-day cancer target and manage its compliance action plan.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 future lung cancer demand and critical-care bed capacity in response to national early-diagnosis pilots and identified concerns.

Verbatim wording from the response

“With the new national pilots to identify lung cancer at an earlier stage we recognise that we will need to review capacity and ensure that we have sufficient critical care beds to support what we know will be more patients accessing treatment. We will be actioning this in the light of new policy and due to the concerns raised by yourself as a result of Mr Weaver’s death.”

Source location

2019-0345-Response-from-NHS-England-Redacted-1
Page 2 · response
Published 17 November 2019

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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

Existing legal duties of candour and duties to provide relevant information are presented as addressing coronial information delays.

Verbatim wording from the response

“Finally, I note from your report that it took several months to receive medical records and other material from the East Sussex Healthcare NHS Trust. While I do not know the circumstances in this case, I want to provide assurance that NHS trusts have a legal duty of candour² to act in an open and honest way when there are investigations into the death of a patient in their care, as well as legal duties to provide all relevant information to support coronial processes. This was reinforced in a communication by NHS Improvement to NHS trusts in 2016³.”

Source location

2019-0345-Response-from-the-Department-of-Health
Page 2 · response
Published 17 November 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

Commissioners oversee GSTT’s failure to meet the 62-day cancer target and manage its compliance action plan.

Verbatim wording from the response

“Please note no immediate risks were identified in the service at GSTT following this review. Furthermore, later assessments in 2018/19 by the QST team and through our annual surveillance exercise also did not identify any ongoing serious quality or safety concerns at GSTT. Although not specific to assessing the overall bed balance and its appropriateness the review did look at pathways and patient flow, that is, from a district general hospital to a specialist (tertiary) care hospital. However, that being said we would recognise that currently GSTT is not meeting national targets for the 62-day cancer target and this failure is subject to oversight by commissioners with an action plan designed to ensure compliance.”

Source location

2019-0345-Response-from-NHS-England-Redacted-1
Page 2 · response
Published 17 November 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