PFD report

Neil Thomas Westerman · Prevention of Future Deaths report

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Issued 11 Mar 2015•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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised3

  1. Failure to record and account for equipment and materials used during procedures
  2. Insufficient junior doctor staffing to cover patient needs
    Part of recurring concern: Insufficient medical staffing capacity for timely patient carePart of recurring concern: Insufficient qualified healthcare staffing capacityPart of recurring concern: Insufficient safe staffing and senior cover out of hours
  3. Failure to ensure the operating consultant is informed of vital information during pre-operative assessment
    Part of recurring concern: Unreliable pre-operative assessment arrangements delaying or compromising 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

    Take steps with the operating surgeon to prevent recurrence of consultant-unaware pre-operative assessment.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2015.
  2. Action

    Consider broadening advanced nurse practitioner roles to undertake basic junior doctor duties.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2015.
  3. Action

    Reiterate across Surgery and Critical Care the requirement to record equipment and material details in operative notes.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Junior doctors conducting pre-operative assessments is not standard organisational practice and was unique to the operating surgeon concerned.

    Stated by Stockport 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

Failure to record and account for equipment and materials used during procedures

Wider context from the report

“2. The operation notes did not contain details of the equipment and materials used during the procedure and it was agreed that this should be the case and that all such items should be fully recorded and accounted for at the conclusion of the procedure. ”

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

Insufficient junior doctor staffing to cover patient needs

Wider context from the report

“3. I heard evidence, as I have on previous occasions, that there were simply too few junior doctors on duty to cover the needs of the patients, especially at night. It was not suggested that the numbers were not in compliance with the set guidelines, but rather that in practice there simply weren’t enough doctors available. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care; Insufficient qualified healthcare staffing capacity; Insufficient safe staffing and senior cover out of hours.

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 ensure the operating consultant is informed of vital information during pre-operative assessment

Wider context from the report

“1. During the course of the inquest I heard evidence that the pre-operative assessment was performed by a junior doctor and not by the consultant who was to perform the procedure. This meant that the consultant was unaware of certain vital information. ”

Is this part of a recurring concern?

Yes — Unreliable pre-operative assessment arrangements delaying or compromising surgery.

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

Take steps with the operating surgeon to prevent recurrence of consultant-unaware pre-operative assessment.

Verbatim wording from the response

“A concern regarding the pre-operative assessment being carried out by a junior doctor and not the consultant who was to perform the operation, meaning the consultant was unaware of vital information. This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation. The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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 broadening advanced nurse practitioner roles to undertake basic junior doctor duties.

Verbatim wording from the response

“Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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

Reiterate across Surgery and Critical Care the requirement to record equipment and material details in operative notes.

Verbatim wording from the response

“The operating notes did not contain details of the equipment and materials used during the procedure. In this case this was an error; it is standard practice to document and record all relevant information for the related surgery, including the recording of equipment and the numbers of items used. In this case there was clearly an omission to record such details and the requirement for vigilance in this respect has been reiterated across the Surgery and Critical Care Business Group.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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

Discuss the case at General Surgery Morbidity and Mortality meetings and with the assessing junior doctor.

Verbatim wording from the response

“A concern regarding the pre-operative assessment being carried out by a junior doctor and not the consultant who was to perform the operation, meaning the consultant was unaware of vital information. This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation. The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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

Review general surgical junior doctor rotas, including surgical assessment unit presence and distribution across the working week.

Verbatim wording from the response

“Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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

Increase junior doctor presence on the surgical assessment unit and distribute doctors more evenly across the working week.

Verbatim wording from the response

“Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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

Junior doctors conducting pre-operative assessments is not standard organisational practice and was unique to the operating surgeon concerned.

Verbatim wording from the response

“A concern regarding the pre-operative assessment being carried out by a junior doctor and not the consultant who was to perform the operation, meaning the consultant was unaware of vital information. This is not standard practice in the organisation and was unique to the particular operating surgeon concerned. Steps have been taken with the individual to ensure that there is not a repeat of this situation. The case has also been discussed at a General Surgery Morbidity & Mortality meeting and with the junior doctor who carried out the pre-operative assessment.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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

Omitting equipment and material details from operating notes was an error; standard practice requires recording all relevant surgical information.

Verbatim wording from the response

“The operating notes did not contain details of the equipment and materials used during the procedure. In this case this was an error; it is standard practice to document and record all relevant information for the related surgery, including the recording of equipment and the numbers of items used. In this case there was clearly an omission to record such details and the requirement for vigilance in this respect has been reiterated across the Surgery and Critical Care Business Group.”

Source location

2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015

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