PFD report

Sara Anest JONES · Prevention of Future Deaths report

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Issued 15 Mar 2023•Stoke-on-Trent and North Staffordshire

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
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

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 raised5

  1. Unavailability of a fully staffed major trauma consultant function
  2. Failure to follow up on radiological signs of possible bowel injury
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable radiology processes for communicating findings and initiating required follow-up
  3. Failure to assess polytrauma patients as a whole across specialty boundaries
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

    Redefine the Major Trauma Service so the Major Trauma Consultant leads whole-patient review and liaises with specialty teams.

    Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 April 2023.
  2. Action

    Consider approval for a business case expanding the Major Trauma service to provide weekend and out-of-hours cover.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 April 2023.
  3. Action

    Place an additional major trauma consultant into post to increase trauma rota capacity.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 April 2023.

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

Unavailability of a fully staffed major trauma consultant function

Wider context from the report

“The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole. At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient. Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury. Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time. ”

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

Failure to follow up on radiological signs of possible bowel injury

Wider context from the report

“A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th March 2021. The deceased was then transferred to the Royal Stoke University Hospital, Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was available. Because of this the patient was transferred without the radiologist's report. The radiologist's report became available shortly before 1:00am on 31st March 2021, but was not sent to the Royal Stoke University Hospital until 5:35am that day. It was not clear that safe receipt of the report in Stoke-on-Trent was ever confirmed. Doctors in Stoke-on-Trent then failed to follow up on signs of a possible bowel injury which were indicated in the radiologist's report on the CT scan. During the inquest I was told that the circumstances of this case were unusual and that there was not a protocol in place to ensure the prompt and secure delivery of radiology reports in circumstances like this. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable radiology processes for communicating findings and initiating required follow-up.

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 polytrauma patients as a whole across specialty boundaries

Wider context from the report

“The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole. At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient. Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury. Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time. ”

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

Lack of prompt and secure delivery of radiology reports during interhospital transfers

Wider context from the report

“A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th March 2021. The deceased was then transferred to the Royal Stoke University Hospital, Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was available. Because of this the patient was transferred without the radiologist's report. The radiologist's report became available shortly before 1:00am on 31st March 2021, but was not sent to the Royal Stoke University Hospital until 5:35am that day. It was not clear that safe receipt of the report in Stoke-on-Trent was ever confirmed. Doctors in Stoke-on-Trent then failed to follow up on signs of a possible bowel injury which were indicated in the radiologist's report on the CT scan. During the inquest I was told that the circumstances of this case were unusual and that there was not a protocol in place to ensure the prompt and secure delivery of radiology reports in circumstances like this. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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 establish clear cross-specialty responsibility for review and escalation

Wider context from the report

“The patient was admitted to Royal Stoke University Hospital, Stoke-on-Trent as a “polytrauma” patient who had sustained serious injuries in a road traffic collision. Following her admission, she was treated by doctors from several different specialisms, but it was apparent that some doctors involved in her care concentrated on only the injuries which fell within their specialty and did not consider the patient as a whole. At an important stage in her treatment the general surgeons thought that the orthopaedic surgeons would alert them to any intervention which was needed from their specialty, whilst the orthopaedic surgeons expected the general surgeons to regularly review the patient. Partly as a result of doctors concentrating only on the injuries which fell within their specialty signs of a bowel injury which the patient had sustained were missed. The patient subsequently died as a result of complications of the undiagnosed bowel injury. Evidence was given during the inquest that a major trauma consultant role was in the process of being developed at the Royal Stoke University Hospital, Stoke-on-Trent to address issues like this, but that the role was only 50% filled at the current time. ”

Is this part of a recurring concern?

Yes — Failure to maintain clear clinical responsibility for patient care.

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

Redefine the Major Trauma Service so the Major Trauma Consultant leads whole-patient review and liaises with specialty teams.

Verbatim wording from the response

“In order to fulfil this, an internal recruitment process has already been initiated. One additional consultant is now in post, and negotiations are underway with a further three consultants which will fill our Monday-Friday rota. We intend to have this rota staffed by the beginning of August 2023. Approval for the development of a business case is under consideration for the expansion of the Major Trauma service, to include weekend and out of hours cover. We intend to remove any potential confusion around team responsibilities by redefining the Major Trauma Service. This will mean that the Major Trauma Consultant is primarily responsible for the whole patient review and will liaise with specialty teams as appropriate. The timescale for this redesign is within the next 12 months.”

Source location

Response from University Hospitals of North Midlands
Page 2 · response
Published 20 April 2023

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

Consider approval for a business case expanding the Major Trauma service to provide weekend and out-of-hours cover.

Verbatim wording from the response

“In order to fulfil this, an internal recruitment process has already been initiated. One additional consultant is now in post, and negotiations are underway with a further three consultants which will fill our Monday-Friday rota. We intend to have this rota staffed by the beginning of August 2023. Approval for the development of a business case is under consideration for the expansion of the Major Trauma service, to include weekend and out of hours cover. We intend to remove any potential confusion around team responsibilities by redefining the Major Trauma Service. This will mean that the Major Trauma Consultant is primarily responsible for the whole patient review and will liaise with specialty teams as appropriate. The timescale for this redesign is within the next 12 months.”

Source location

Response from University Hospitals of North Midlands
Page 2 · response
Published 20 April 2023

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

Place an additional major trauma consultant into post to increase trauma rota capacity.

Verbatim wording from the response

“In order to fulfil this, an internal recruitment process has already been initiated. One additional consultant is now in post, and negotiations are underway with a further three consultants which will fill our Monday-Friday rota. We intend to have this rota staffed by the beginning of August 2023. Approval for the development of a business case is under consideration for the expansion of the Major Trauma service, to include weekend and out of hours cover. We intend to remove any potential confusion around team responsibilities by redefining the Major Trauma Service. This will mean that the Major Trauma Consultant is primarily responsible for the whole patient review and will liaise with specialty teams as appropriate. The timescale for this redesign is within the next 12 months.”

Source location

Response from University Hospitals of North Midlands
Page 2 · response
Published 20 April 2023

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 and appoint further consultants to staff the trauma rota and provide consultant review within 24 hours of admission.

Verbatim wording from the response

“1. At the time of the inquest the Court heard that the current trauma rota was 50% filled and that the Trust were seeking to appoint further consultant cover so that all trauma patients are reviewed by a trauma consultant within 24 hours of their admission. In order to progress this, the Trust requires a further 6 consultants to be included on the rota.”

Source location

Response from University Hospitals of North Midlands
Page 2 · response
Published 20 April 2023

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

Send unreported radiology reports by email and confirm safe receipt by telephone when patients leave emergency departments.

Verbatim wording from the response

“We have now established a process that if a patient leaves our emergency departments without a report, which is very rare, then the report will be sent by email and its safe receipt will be confirmed by telephone.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 20 April 2023

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

Include the unreported-report process in major trauma standard operating procedures and checklists.

Verbatim wording from the response

“This process is being included in our major trauma standard operating procedure and checklists by the end of May 2023 by our Trauma Network Manager. This will ensure staff are clear on the actions they need to take.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 20 April 2023

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 Trauma Group oversight and ongoing audit of the new unreported-report process.

Verbatim wording from the response

“All trauma transfers are discussed and reviewed at our Trauma Group, so this group will have oversight of this new procedure and will ensure this new process is subject to ongoing audit to give assurance.”

Source location

Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 20 April 2023

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