PFD report

Robert Graham TAYLOR · Prevention of Future Deaths report

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Issued 8 Sep 2022•Hampshire, Portsmouth and Southampton

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
2

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. Lack of awareness of the importance of checking the back of the throat in patients with a history of epistaxis or facial fractures
    Part of recurring concern: Unsafe assessment and management of facial fractures
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

    Add guidance to surgical senior house officer induction sessions on checking the oropharynx for ongoing posterior bleeding in facial trauma and epistaxis cases.

    Stated by University Hospital Southampton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  2. Action

    Disseminate learning to ENT, OMFS and cross-covering senior house officers on recognising continuing anterior or posterior epistaxis after facial trauma and nasal packing.

    Stated by University Hospital Southampton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.

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

  1. Position

    The Trust disputes that routine oropharyngeal inspection after traumatic epistaxis is clinically valuable or supported by national guidance.

    Stated by University Hospital Southampton NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 awareness of the importance of checking the back of the throat in patients with a history of epistaxis or facial fractures

Wider context from the report

“The deceased suffered facial fractures and had episodes of epistaxis. I heard evidence that when a clot forms within the nose the bleeding can continue and is only visible if the back of the patient's throat is looked at. I heard evidence that, in the Emergency Department and Trauma Admission Unit, the importance of checking the back of the throat of a patient with a history of epistaxis or facial fractures was not widely known. ”

Is this part of a recurring concern?

Yes — Unsafe assessment and management of facial fractures.

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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

Add guidance to surgical senior house officer induction sessions on checking the oropharynx for ongoing posterior bleeding in facial trauma and epistaxis cases.

Verbatim wording from the response

“The case was discussed at the ENT M&M meeting on 10th November 2022. The department were content that the management by the SHO was clinically appropriate. It was clearly documented that the posterior bleeding, once identified, stopped after the was pack inserted. It was agreed to raise awareness of epistaxis in facial trauma in OMFS and ED teams managing them. Specific guidance to check the oropharynx in these situations has been added to the surgical SHO induction sessions.”

Source location

Response from University Hospital Southampton NHS Foundation Trust
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

Disseminate learning to ENT, OMFS and cross-covering senior house officers on recognising continuing anterior or posterior epistaxis after facial trauma and nasal packing.

Verbatim wording from the response

“The actions that I support coming out of my discussion with the team is that the clinicians treating such patients would build into their education programme that patients should be explicitly asked to report an unpleasant taste or sensation. Following the meeting I chaired, the following was disseminated to all ENT, OMFS (oral-maxilla facial surgeons) and the cross covering senior house officers.”

Source location

Response from University Hospital Southampton NHS Foundation Trust
Page 2 · response
Published 5 October 2022

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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

The Trust disputes that routine oropharyngeal inspection after traumatic epistaxis is clinically valuable or supported by national guidance.

Verbatim wording from the response

“We reviewed the national guidance available for the management of epistaxis, currently the only guidance is from NICE (https://cks.nice.org.uk/topics/epistaxis-nosebleeds/management/acute-epistaxis/) this is for when epistaxis have started spontaneously and is not applicable for Traumatic injury such as the case of Mr Taylor. This highlights that there are no national guidelines that suggest the review of the back of a patient throat is advised.”

Source location

Response from University Hospital Southampton NHS Foundation Trust
Page 2 · response
Published 5 October 2022

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

  1. 1

    The Trust disputes the evidential basis for the inspection recommendation because the advising witness lacked specific ENT training or qualifications.

    Stated by University Hospital Southampton NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

The Trust disputes the evidential basis for the inspection recommendation because the advising witness lacked specific ENT training or qualifications.

Verbatim wording from the response

“I fully appreciate that your recommendations came from witnesses interviewed in the hearing, however, perhaps the witnessing giving this advice was not the most suitably qualified or experienced person to do so? Whilst this was a qualified doctor, with skills and experience sufficient to cross cover ENT, they had not even completed surgical training and had no specific ENT experience or qualifications. Hence, I have turned to a team of experts to advise me, led by an experienced consultant not only in ENT but with a specialist interest in rhinology. I hope then that this input is valuable.”

Source location

Response from University Hospital Southampton NHS Foundation Trust
Page 2 · 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