PFD report

Margaret Mary Gleeson · Prevention of Future Deaths report

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Issued 15 Jul 2016•Manchester West

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
1

Of 1 recipient

Stated actions
14

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 raised3

  1. Lack of understanding of MEWS tool use
  2. Insufficient weekend staffing capacity
    Part of recurring concern: Insufficient safe staffing and senior cover out of hours
  3. Failure to accurately score MEWS tools on medical charts
    Part of recurring concern: Unreliable clinical Early Warning Score systems for deterioration
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.7

  1. Action

    Operate a monthly Task and Finish Group to oversee MEWS use, audit findings, compliance and scoring accuracy.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  2. Action

    Continue monthly deterioration, MEWS and fluid-balance training for staff involved in patient care.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2016.
  3. Action

    Provide extensive staff training on accurate MEWS and fluid-balance recording and recognition and response to patient deterioration, including sepsis.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.

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 understanding of MEWS tool use

Wider context from the report

“2. The scoring of the MEWS tool on the medical charts had been done inaccurately, and the use of the MEWS tools did not appear to be clearly understood. It would appear that refresher training would assist ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 weekend staffing capacity

Wider context from the report

“1. At the weekend on the call team had to do the job of 4 teams and that it was not possible to provide patients with the care they deserve. In those circumstances, I consider that staffing levels should be reviewed. ”

Is this part of a recurring concern?

Yes — Insufficient safe staffing and senior cover out of hours.

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 accurately score MEWS tools on medical charts

Wider context from the report

“2. The scoring of the MEWS tool on the medical charts had been done inaccurately, and the use of the MEWS tools did not appear to be clearly understood. It would appear that refresher training would assist ”

Is this part of a recurring concern?

Yes — Unreliable clinical Early Warning Score systems for deterioration.

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

Operate a monthly Task and Finish Group to oversee MEWS use, audit findings, compliance and scoring accuracy.

Verbatim wording from the response

“In addition to this, the Trust’s Director of Nursing, ████████, has established since the inquest, and is currently chair of, a dedicated Task and Finish Group to oversee the use of the MEWS Tool. The Group meets on a monthly basis to discuss the audit findings and to monitor compliance and accuracy of scoring.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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

Continue monthly deterioration, MEWS and fluid-balance training for staff involved in patient care.

Verbatim wording from the response

“Since the conclusion of the inquest in June 2016 the Trust has provided extensive training programmes both in the accuracy and recording of MEWS and fluid balance, but also in recognising and responding appropriately to the early signs of deterioration in patients, including sepsis. The enclosed Action Plan provides extensive evidence of the training sessions held to date, and those sessions will continue on a monthly basis for all Trust staff involved in patient care.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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 extensive staff training on accurate MEWS and fluid-balance recording and recognition and response to patient deterioration, including sepsis.

Verbatim wording from the response

“Since the conclusion of the inquest in June 2016 the Trust has provided extensive training programmes both in the accuracy and recording of MEWS and fluid balance, but also in recognising and responding appropriately to the early signs of deterioration in patients, including sepsis. The enclosed Action Plan provides extensive evidence of the training sessions held to date, and those sessions will continue on a monthly basis for all Trust staff involved in patient care.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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

Conduct monthly audits of nursing compliance with MEWS standards and feed results back to ward and nursing managers.

Verbatim wording from the response

“Firstly, with regards to training of the MEWS tool this has been led by the Trust’s Critical Care Outreach Lead, ████████, through the QUEST programme. This programme trains nursing staff on the use of the MEWS tool, and highlights the importance of accurate scoring. A dedicated Critical Care Outreach Nurse also undertakes monthly audits of compliance with MEWS standards. Copies of these audits are embedded within the enclosed Action Plan and the results are fed back to Ward Managers and Heads of Nursing for action to be taken, wherever necessary. They are also monitored through the Trust’s Harm Free Care Board.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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

Recruit two clinical fellows to provide sufficient clinicians for the additional weekend ward rounds.

Verbatim wording from the response

“To ensure there are sufficient clinicians to cover the additional ward rounds, the Trust is in the process of recruiting 2 clinical fellows. One appointment has already been made, and it is hopeful the second appointment will be filled in the upcoming weeks.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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

Deliver the QUEST programme to train nursing staff in MEWS use and accurate scoring.

Verbatim wording from the response

“Firstly, with regards to training of the MEWS tool this has been led by the Trust’s Critical Care Outreach Lead, ████████, through the QUEST programme. This programme trains nursing staff on the use of the MEWS tool, and highlights the importance of accurate scoring. A dedicated Critical Care Outreach Nurse also undertakes monthly audits of compliance with MEWS standards. Copies of these audits are embedded within the enclosed Action Plan and the results are fed back to Ward Managers and Heads of Nursing for action to be taken, wherever necessary. They are also monitored through the Trust’s Harm Free Care Board.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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 four-hour weekend ward rounds by middle-grade surgeons for elective surgical patients, with concerns reported to on-call consultants.

Verbatim wording from the response

“During the inquest evidence was heard that at weekends the surgical on call team were extremely busy which led to patients, on occasions, not always receiving the standard of treatment they should expect. The Directorate of General Surgery recognised the variation in patient care that existed between weekends and weekdays, and action has been taken accordingly.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 1 · response
Published 15 July 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-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. 1

    Make sepsis training mandatory for all nursing staff.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
  2. 2

    Monitor the additional weekend surgical working through the Surgical Clinical Cabinet.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  3. 3

    Provide the AIMS course on recognising and managing acutely unwell deteriorating patients, including sepsis training.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  4. 4

    Provide monthly updates on the listed actions to the Quality and Safety Committee.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2016.
  5. 5

    Conduct sepsis drop-in sessions for nursing staff on Swinley Ward covering recognition, screening-tool use and management.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  6. 6

    Provide sepsis recognition and response training through the Sepsis Study Day, led by a dedicated Sepsis Specialist Nurse.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.
  7. 7

    Conduct monthly audits of sepsis management and report results through Sepsis Dashboards.

    Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2016.

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

Make sepsis training mandatory for all nursing staff.

Verbatim wording from the response

“Secondly, extensive training programmes have also been held in recognising and responding appropriately to early signs of deterioration in patients, including sepsis, which was relevant in Mrs Gleeson’s case. This training has been led by the Trust’s dedicated Sepsis Specialist Nurse, Ms ████████, through attendance at the Trust’s Sepsis Study Day. Evidence of staff attendance at this programme is contained within the enclosed Action Plan, and arrangements are in place to make this training mandatory for all nursing staff.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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

Monitor the additional weekend surgical working through the Surgical Clinical Cabinet.

Verbatim wording from the response

“The changes brought about by the additional weekend working is being monitored through the Trust’s Surgical Clinical Cabinet. The Cabinet is chaired by the Trust’s Medical Director and is attended by senior representatives of the Surgical Division responsible for implementing these changes.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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 the AIMS course on recognising and managing acutely unwell deteriorating patients, including sepsis training.

Verbatim wording from the response

“In addition to the above, the Trust also has in place the Acute Illness Management (AIMS) course that focuses on the recognition of the acutely unwell deteriorating patient, and how they should be managed. Training on sepsis is also contained within this course.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 3 · response
Published 15 July 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 monthly updates on the listed actions to the Quality and Safety Committee.

Verbatim wording from the response

“The above actions will be monitored via the Trust’s Quality and Safety Committee which is chaired by a Non-Executive Director and attended by several members of the Executive team, including the Director of Nursing. Every month updates will be provided to the Committee on the actions listed above.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 3 · response
Published 15 July 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

Conduct sepsis drop-in sessions for nursing staff on Swinley Ward covering recognition, screening-tool use and management.

Verbatim wording from the response

“████████ has also conducted a number of Sepsis ‘Drop-In’ sessions specifically for nursing staff on Swinley Ward where Mrs Gleeson was being cared for. These sessions have focused on sepsis recognition, understanding the sepsis screening tool and sepsis management.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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 sepsis recognition and response training through the Sepsis Study Day, led by a dedicated Sepsis Specialist Nurse.

Verbatim wording from the response

“Secondly, extensive training programmes have also been held in recognising and responding appropriately to early signs of deterioration in patients, including sepsis, which was relevant in Mrs Gleeson’s case. This training has been led by the Trust’s dedicated Sepsis Specialist Nurse, Ms ████████, through attendance at the Trust’s Sepsis Study Day. Evidence of staff attendance at this programme is contained within the enclosed Action Plan, and arrangements are in place to make this training mandatory for all nursing staff.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 2 · response
Published 15 July 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

Conduct monthly audits of sepsis management and report results through Sepsis Dashboards.

Verbatim wording from the response

“Management of sepsis is audited on a monthly basis and the results are contained within the attached Sepsis Dashboards. ████████ has confirmed that these audits show improvements in sepsis screening, and also with the use of the Sepsis Six pathway within the Trust’s A&E Department.”

Source location

2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
Page 3 · response
Published 15 July 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