PFD report

Elizabeth Oluwatofunmi AGBEJIMI · Prevention of Future Deaths report

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Issued 6 Jul 2023•Lincolnshire

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised1

  1. Failure to investigate a significantly abnormal respiratory acidosis blood gas result
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable monitoring and follow-up of clinically required laboratory tests
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.2

  1. Action

    Require ED clinicians acknowledging blood gas results to document abnormalities requiring management and the planned further management.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
  2. Action

    Have clinical audit teams in both ULHT departments audit blood gas results and documentation to assess whether the learning and actions are embedded.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 July 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

Failure to investigate a significantly abnormal respiratory acidosis blood gas result

Wider context from the report

“████████ gave evidence that following a venous blood gas sample undertaken on 12th June 2021 which showed a significant respiratory abnormal acidosis reading but no further investigation was undertaken. The deceased died 2 weeks later of a respiratory condition. Is this a training/communication issue? ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable monitoring and follow-up of clinically required laboratory tests.

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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

Require ED clinicians acknowledging blood gas results to document abnormalities requiring management and the planned further management.

Verbatim wording from the response

“1. Ensure better documentation of the identification of the abnormalities on the blood gas results”

Source location

Response from United Lincolnshire Hospitals NHS Trust
Page 2 · response
Published 10 July 2023

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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

Have clinical audit teams in both ULHT departments audit blood gas results and documentation to assess whether the learning and actions are embedded.

Verbatim wording from the response

“In order to assure that these processes have been embedded, the clinical audit team in both ULHT departments will undertake an audit of blood gas results and the documentation in them to review the learning and actions have been embedded.”

Source location

Response from United Lincolnshire Hospitals NHS Trust
Page 3 · response
Published 10 July 2023

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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

    Communicate Trisomy 21 infection-response risks and the need for lower investigation and admission thresholds to ED and other involved teams.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 10 July 2023.
  2. 2

    Continue using adverse events as learning opportunities to support ongoing patient safety and continual improvement.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A venous blood gas cannot categorically diagnose acute type 2 respiratory failure because venous oxygen levels differ from arterial levels.

    Stated by United Lincolnshire Teaching Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Communicate Trisomy 21 infection-response risks and the need for lower investigation and admission thresholds to ED and other involved teams.

Verbatim wording from the response

“2. Ensure clinicians recognise the potential altered response to infection seen amongst those affected by Trisomy 21.”

Source location

Response from United Lincolnshire Hospitals NHS Trust
Page 3 · response
Published 10 July 2023

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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

Continue using adverse events as learning opportunities to support ongoing patient safety and continual improvement.

Verbatim wording from the response

“We understand that documentation and communication between clinicians is incredibly important for patient safety and we are committed to continue to use adverse events as learning opportunities to ensure ongoing patient safety and continual improvement.”

Source location

Response from United Lincolnshire Hospitals NHS Trust
Page 3 · response
Published 10 July 2023

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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

A venous blood gas cannot categorically diagnose acute type 2 respiratory failure because venous oxygen levels differ from arterial levels.

Verbatim wording from the response

“In this case, the venous blood gas test cannot however categorically diagnose an acute Type 2 respiratory failure as the oxygen levels are always lower on a venous sample, and arterial oxygen levels are always higher.”

Source location

Response from United Lincolnshire Hospitals NHS Trust
Page 2 · response
Published 10 July 2023

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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