PFD report

David Barnet WILSON · Prevention of Future Deaths report

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Issued 8 Jun 2023•West Yorkshire (Eastern)

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
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 raised5

  1. Failure to provide statistical ratings for identified procedural risks
  2. Failure to communicate the risk of death in the consent form
  3. Obtaining consent signatures while patients are under morphine sedation
    Part of recurring concern: Inadequate informed-consent processes for medical treatment
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.4

  1. Action

    Update procedure-specific consent forms to include statistical frequency ranges for identified risks as each form undergoes review.

    Stated by Mid Yorkshire Teaching NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
  2. Action

    Work with clinical teams to ensure patients’ capacity to consent is considered, taken into account, and properly documented.

    Stated by Mid Yorkshire Teaching NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
  3. Action

    Refresh the consent policy to require documentation of patient-specific increased risks, earlier discussion of death risk, and consideration and documentation of capacity.

    Stated by Mid Yorkshire Teaching NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Time and resource constraints make listing all staff involved throughout a patient's consent process impracticable.

    Stated by Mid Yorkshire Teaching NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 statistical ratings for identified procedural risks

Wider context from the report

“(1) The Consent form signed by Mr Wilson was a standard pre-printed form. It did not attempt to provide any statistical rating for the risks identified, which would have enabled Mr Wilson to evaluate the risks. ”

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 communicate the risk of death in the consent form

Wider context from the report

“(3) The Consent Form did not refer to the risks of death, which befell him. He was thus not in a position to make a truly informed consent to undergo the sigmoidoscopy. ”

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

Obtaining consent signatures while patients are under morphine sedation

Wider context from the report

“(4) The Consent Form did not identify those clinicians involved in discussing the decision with him, save for ████████ who obtained his signature at a time when he was under the influence of morphine sedation. ”

Is this part of a recurring concern?

Yes — Inadequate informed-consent processes for medical treatment.

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 identify clinicians involved in consent discussions

Wider context from the report

“(4) The Consent Form did not identify those clinicians involved in discussing the decision with him, save for ████████ who obtained his signature at a time when he was under the influence of morphine sedation. ”

Is this part of a recurring concern?

Yes — Failure to accurately record the identities of clinicians involved in patient care; Inadequate informed-consent processes for medical treatment.

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 tailor procedural risks to the patient's medical history and co-morbidities

Wider context from the report

“(2) No attempt was made to interpret or tailor the risks inherent in the procedure in the light of his extensive medical history and co-morbidities. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Update procedure-specific consent forms to include statistical frequency ranges for identified risks as each form undergoes review.

Verbatim wording from the response

“The Trust utilises a bank of consent forms for the most common procedures performed. The consent forms used in MYTT are based on national guidance issued by the Department of Health and Social Care. Of note, we currently have generic forms and hundreds of procedure-specific consent forms across all specialties. The procedure-specific consent forms are pre-populated with the most frequently associated risks for the particular procedure. The forms are reviewed and amended as required to align with contemporary medical knowledge and practice.”

Source location

Response from Mid Yorkshire Teaching NHS Trust
Page 2 · response
Published 12 June 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

Work with clinical teams to ensure patients’ capacity to consent is considered, taken into account, and properly documented.

Verbatim wording from the response

“In relation to the capacity to consent, the Trust will work with clinical teams to ensure that as part of the consent process, the question of a patient’s capacity – regardless of the circumstances – is considered, taken into account, and properly documented. The issues surrounding capacity will also be further highlighted in the Trust’s internal policy (see below).”

Source location

Response from Mid Yorkshire Teaching NHS Trust
Page 3 · response
Published 12 June 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

Refresh the consent policy to require documentation of patient-specific increased risks, earlier discussion of death risk, and consideration and documentation of capacity.

Verbatim wording from the response

“As it is proposed to include risk ranges, to a certain degree these will inherently account for varying medical histories and co-morbidities of patients. But in instances where a specific risk is greater due to a particular patient’s unique circumstances, this medical advice will be clearly noted. We will also update and strengthen our consent process through our internal policy to reflect this requirement (see below).”

Source location

Response from Mid Yorkshire Teaching NHS Trust
Page 2 · response
Published 12 June 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

Introduce death as a specific risk that clinicians must canvass during the consent process.

Verbatim wording from the response

“The Trust also appreciates that the risk of death is a possibility in every procedure that is undertaken, and that even if it is a remote possibility, the risk of death would be a material consideration for patients in assessing whether to go ahead with a procedure.²”

Source location

Response from Mid Yorkshire Teaching NHS Trust
Page 2 · response
Published 12 June 2023

Open published response

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

Time and resource constraints make listing all staff involved throughout a patient's consent process impracticable.

Verbatim wording from the response

“Ideally the final consent form would list all MYTT staff who have been involved throughout the entire consenting process of the patient for a particular procedure. Unfortunately, time and resource constraints make this suggestion impracticable for implementation by the Trust.”

Source location

Response from Mid Yorkshire Teaching NHS Trust
Page 3 · response
Published 12 June 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