PFD report

Maureen Harrop · Prevention of Future Deaths report

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Issued 14 Sep 2022•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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised4

  1. Failure to provide surgery within 36 hours
    Part of recurring concern: Delays in progressing time-critical surgical treatment
  2. Lack of support for patients during prolonged emergency department waits
    Part of recurring concern: Failure to provide safe ongoing care during prolonged emergency-department stays
  3. Lack of theatre capacity
    Part of recurring concern: Insufficient hospital theatre capacity for timely surgery
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.6

  1. Action

    Submit daily hip-fracture data to the National Hip Fracture Database to support quality improvement and guideline-aligned care.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  2. Action

    Implement and monitor a divisional fractured-neck-of-femur improvement programme through senior leadership and quality-governance oversight.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  3. Action

    Implement an enhanced bed-allocation pathway to identify hip-fracture patients and support timely transfer from the Emergency Department to trauma and orthopaedics beds.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.

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 provide surgery within 36 hours

Wider context from the report

“2. The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs Harrop’s case that was not achieved due to a lack of theatre capacity. The impact of the delay on her overall physiological reserves was significant ”

Is this part of a recurring concern?

Yes — Delays in progressing time-critical surgical treatment.

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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 support for patients during prolonged emergency department waits

Wider context from the report

“1. The inquest heard that Mrs Harrop had a prolonged stay in the ED at the Hospital because of lack of bed capacity. The Inquest heard that given her age and the fracture the impact of the prolonged wait on her was significant particularly in light of the lack of support available to her; ”

Is this part of a recurring concern?

Yes — Failure to provide safe ongoing care during prolonged emergency-department stays.

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 theatre capacity

Wider context from the report

“2. The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs Harrop’s case that was not achieved due to a lack of theatre capacity. The impact of the delay on her overall physiological reserves was significant ”

Is this part of a recurring concern?

Yes — Insufficient hospital theatre capacity for timely surgery.

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 emergency department bed capacity

Wider context from the report

“1. The inquest heard that Mrs Harrop had a prolonged stay in the ED at the Hospital because of lack of bed capacity. The Inquest heard that given her age and the fracture the impact of the prolonged wait on her was significant particularly in light of the lack of support available to her; ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely 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

Submit daily hip-fracture data to the National Hip Fracture Database to support quality improvement and guideline-aligned care.

Verbatim wording from the response

“The Trust also submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement, in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma coordinators daily.”

Source location

Response from NHS England
Page 3 · response
Published 5 October 2022

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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

Implement and monitor a divisional fractured-neck-of-femur improvement programme through senior leadership and quality-governance oversight.

Verbatim wording from the response

“In addition to this, the Trust has implemented a Divisional fractured neck of femur improvement programme, which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance.”

Source location

Response from NHS England
Page 3 · response
Published 5 October 2022

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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

Implement an enhanced bed-allocation pathway to identify hip-fracture patients and support timely transfer from the Emergency Department to trauma and orthopaedics beds.

Verbatim wording from the response

“The Surgical and Medical Division have worked closely together to design and implement an enhanced bed allocation process. The process supports those patients with hip fractures from the moment that the patient has had their fracture confirmed in the ED, through to admission to a trauma and orthopaedics bed. The pathway redesign has included both in and out of hours actions required by the clinical teams, with support from the Trust’s patient flow team. Each Trust bed meeting, which occurs five times per day, highlights any patient within the ED who will require a Trauma and Orthopaedic bed due to a hip fracture.”

Source location

Response from NHS England
Page 2 · response
Published 5 October 2022

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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

Report surgery delays, complete root-cause analyses, review findings weekly, and monitor compliance through internal returns.

Verbatim wording from the response

“Where the Trust is not able to meet the 36 hour timeframe for surgery for a patient with a hip fracture, a clinical incident report is submitted. Following the incident, a root cause analysis (RCA) is completed by the trauma coordinators to identify the reasons for the delay and opportunities for learning. The RCA investigations are reviewed weekly in the “Neck Of Femur (NOF) Review Meeting” for comment, action and approval. This meeting is attended by the Clinical Lead for Neck of Femur, the Matron for Trauma and Orthopaedics and the Directorate Manager. Compliance is monitored through regular internal returns.”

Source location

Response from NHS England
Page 2 · response
Published 5 October 2022

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

Operate daily trauma and surgical bed-planning processes to identify patients awaiting hip-fracture surgery, agree care plans, and track waiting times and required pre-operative tests.

Verbatim wording from the response

“The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.”

Source location

Response from NHS England
Page 2 · response
Published 5 October 2022

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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

Schedule clinically suitable hip-fracture patients for surgery within 36 hours and escalate unavailable theatre capacity through urgent trauma and elective-list review and divisional approval.

Verbatim wording from the response

“In response to your second concern, the Trust recognises that best practice and NICE guidance states that patients that have sustained a hip fracture should have timely surgery to repair the injury within 36 hours of admission, where the patient is clinically stable to undergo surgery - Overview | Hip fracture: management | Guidance | NICE. To manage these patients within the appropriate timeframe alongside competing priorities within the trauma and elective services, the Division of Surgery, Women’s and Children’s services (SWC) have reviewed and strengthened their processes.”

Source location

Response from NHS England
Page 2 · response
Published 5 October 2022

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.2

  1. 1

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning and insights nationally and regionally.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  2. 2

    Reinstate pre-pandemic care pathways and increase the trauma and orthopaedics bed base toward pre-pandemic levels.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.

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

Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning and insights nationally and regionally.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHSE work taking place around the Reports to Prevent Future Deaths generally. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Maureen, are shared across the NHS at both a national and regional level, and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 3 · response
Published 5 October 2022

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

Reinstate pre-pandemic care pathways and increase the trauma and orthopaedics bed base toward pre-pandemic levels.

Verbatim wording from the response

“At the time of Maureen’s admission to Tameside General Hospital, the Trust, like other Trusts nationwide, was experiencing sustained and significant operational pressures within the Emergency Department (ED) and wider hospital, and was responding to continuous Covid challenges and pressures. The Trust had separate areas for Covid positive and non-Covid patients, as set out in NHS England national planning guidance, which contributed to delays in Maureen being triaged and subsequently transferred to an appropriate bed. The Trust has now been able to reinstate previous”

Source location

Response from NHS England
Page 1 · response
Published 5 October 2022

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