PFD report

Lauren Elizabeth Bridges · Prevention of Future Deaths report

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Issued 19 Sep 2023•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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

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Concerns raised3

  1. Failure to record out-of-area patients’ identity and relevant circumstances timeously and correctly
    Part of recurring concern: Unreliable out-of-area patient bed allocation and repatriation arrangements
  2. Failure to assess out-of-area patients for available beds when vacancies arise
    Part of recurring concern: Unreliable out-of-area patient bed allocation and repatriation arrangements
  3. Failure to record discussions about allocating available beds to out-of-area patients
    Part of recurring concern: Unreliable out-of-area patient bed allocation and repatriation arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 record out-of-area patients’ identity and relevant circumstances timeously and correctly

Wider context from the report

“During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate. Among other things, 1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU. 2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim. During the course of the inquest Dorset Health made the following admission, Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed. Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest. a) the omission to update the Hospital Overview timeously and correctly. b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place. ”

Is this part of a recurring concern?

Yes — Unreliable out-of-area patient bed allocation and repatriation arrangements.

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 assess out-of-area patients for available beds when vacancies arise

Wider context from the report

“During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate. Among other things, 1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU. 2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim. During the course of the inquest Dorset Health made the following admission, Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed. Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest. a) the omission to update the Hospital Overview timeously and correctly. b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place. ”

Is this part of a recurring concern?

Yes — Unreliable out-of-area patient bed allocation and repatriation arrangements.

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 record discussions about allocating available beds to out-of-area patients

Wider context from the report

“During the course of the inquest it was apparent that Dorset Healthcare NHS Trust’s standard of record keeping was inadequate. Among other things, 1. Lauren’s name dd not appear on the Out-of-Area Hospital Overview document until 19.11.21 and then she was listed in as being in an acute bed not a PICU. 2. There was a complete absence of records of purported discussions with regard to allocating/denying Lauren one of the many beds available over the 5 months following her readiness for step-down to a rehabilitation unit and readiness for repatriation to a local bed in the interim. During the course of the inquest Dorset Health made the following admission, Dorset Healthcare NHS Trust have admitted that there were shortcomings in its systems for recording the identity and relevant circumstances of its out of area patients, and in its processes for assessing those patients when a bed becomes vacant. As a result, there may have been missed opportunities to offer Lauren a bed. Dorset Healthcare were unable to provide a witness to deal with this issue and, having recognised the seriousness of these omission, stated via correspondence an intention to carry out a further review upon conclusion of the inquest. a) the omission to update the Hospital Overview timeously and correctly. b) it can be inferred from the absence of any documentation regarding discussions about Lauren’s repatriation to an available bed that no such discussion took place. ”

Is this part of a recurring concern?

Yes — Unreliable out-of-area patient bed allocation and repatriation arrangements.

Open source report
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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