Janet WILLCOCK · Prevention of Future Deaths report

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Issued 9 Apr 2021•Brighton and Hove

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
3

Described in responses

Recipients and published responses

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 auscultate the chest during clinical assessment

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. University Hospitals Sussex NHS Foundation Trust

    Audit Emergency Department documentation to ensure it meets expected standards.

  2. University Hospitals Sussex NHS Foundation Trust

    Document the rationale when clinicians decide not to auscultate a patient presenting with unexplained syncope.

  3. University Hospitals Sussex NHS Foundation Trust

    Present the case at the next Governance Meeting to share learning and highlight the importance of auscultation for patients with unexplained syncope.

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

  1. University Hospitals Sussex NHS Foundation Trust

    Earlier intervention could not have influenced the outcome because death resulted from a documented complication of necessary surgery.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. University Hospitals Sussex NHS Foundation Trust

    Existing clinical training, experience and real-time individual judgement are considered sufficient to determine examinations and investigations, including cardiac auscultation.

    Existing 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 auscultate the chest during clinical assessment

Wider context from the report

“On 12th August 20 Mrs Willcock presented at A&E, Princess Royal Hospital having fainted and fallen. (1) She had a head injury and a fractured wrist. There is no evidence that her chest was auscultated. (2) On the 28th August 2020 Mrs Willcock attended for day surgery (fixation of her wrist fracture). Again, there is no evidence that her chest was auscultated. (3) The evidence I heard informed me that if it had been a new heart murmur it would have been heard which, taken with the syncope, should have resulted in an immediate referral to Cardiology. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 Emergency Department documentation to ensure it meets expected standards.

Verbatim wording from the response

“There will be an audit of the Emergency Department documentation to ensure standards are to the level expected.”

Source location

2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Page 2 · response
Published 14 April 2021

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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

Document the rationale when clinicians decide not to auscultate a patient presenting with unexplained syncope.

Verbatim wording from the response

“case is presented at the next Governance Meeting, to ensure learning and to highlight the importance of auscultation in all patients presenting, like Mrs Willcock with unexplained syncope. Furthermore, if a clinical decision is taken not to auscultate, the rationale should be documented in the records.”

Source location

2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Page 2 · response
Published 14 April 2021

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

Present the case at the next Governance Meeting to share learning and highlight the importance of auscultation for patients with unexplained syncope.

Verbatim wording from the response

“However, having personally reviewed Mrs Willcock's clinical records and in discussion with our Emergency Department Governance Lead, I have recommended that Mrs Willcock's”

Source location

2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Page 1 · response
Published 14 April 2021

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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

Earlier intervention could not have influenced the outcome because death resulted from a documented complication of necessary surgery.

Verbatim wording from the response

“We acknowledge that there is no evidence in Mrs Willcock's clinical records of her heart being auscultated when she attended the hospital during August 2020. However, we agree with you that this did not change the outcome for Mrs Willcock, who died of a documented complication that could not have been influenced by any earlier intervention.”

Source location

2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Page 1 · response
Published 14 April 2021

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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 clinical training, experience and real-time individual judgement are considered sufficient to determine examinations and investigations, including cardiac auscultation.

Verbatim wording from the response

“We do not believe that there are issues with the Trust’s systems or processes in relation to cardiac examination – and specifically auscultation. Clinical training and experience determine the examinations and investigations that are undertaken in all our patients; whether or not the heart is examined in a particular patient is always an individual clinical judgement, determined in real time by the specific clinical presentation.”

Source location

2021-0105-Response-from-Royal-Sussex-County-Hospital_Published
Page 1 · response
Published 14 April 2021

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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