PFD report

Gwendoline Edith Halfpenny · Prevention of Future Deaths report

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Issued 5 Dec 2017•Staffordshire 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
5

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. Inconsistency between County Hospital and RSUH policies
  2. Lack of surgical cover at County Hospital
    Part of recurring concern: Insufficient clinical staffing capacity for timely surgical carePart of recurring concern: Unreliable and delayed surgical referral and review
  3. Inconsistency between County Hospital and RSUH equipment
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.3

  1. Action

    Introduce and operate a surgical referral procedure providing on-site consultant coverage, same-day review efforts, and direct referral access to the responsible consultant.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  2. Action

    Standardise and formalise processes and policies across the integrated hospitals, taking account of their different surgical functions and available funds.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  3. Action

    Realign surgical services so County Hospital has no inpatient general surgery and senior surgeons remain available on site through continuing day-case services.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.

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

  1. Position

    Full consistency between County Hospital and Royal Stoke policies and equipment is limited by their different surgical functions and available funds.

    Stated by University Hospitals of North Midlands 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

Inconsistency between County Hospital and RSUH policies

Wider context from the report

“2. Back in September 2016 when this death occurred the MEWS systems operated at County Hospital and RSUH differed. This has subsequently been remedied. However I was told at the Inquest that there are still different policies and equipment at County Hospital than those at RSUH. The hospitals have been part of the same Trust for a considerable period now and I wonder if there should be greater efforts to achieve consistency. ”

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

Lack of surgical cover at County Hospital

Wider context from the report

“1. Soon after her arrival at County Hospital Mrs Halfpenny would have benefitted from surgical input. There was no surgical cover at County Hospital. Remote advice from RSUH is not the same as a surgical presence and I wonder if there should be a mid-grade surgical doctor at County Hospital. ”

Is this part of a recurring concern?

Yes — Insufficient clinical staffing capacity for timely surgical care; Unreliable and delayed surgical referral and review.

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

Inconsistency between County Hospital and RSUH equipment

Wider context from the report

“2. Back in September 2016 when this death occurred the MEWS systems operated at County Hospital and RSUH differed. This has subsequently been remedied. However I was told at the Inquest that there are still different policies and equipment at County Hospital than those at RSUH. The hospitals have been part of the same Trust for a considerable period now and I wonder if there should be greater efforts to achieve consistency. ”

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

Introduce and operate a surgical referral procedure providing on-site consultant coverage, same-day review efforts, and direct referral access to the responsible consultant.

Verbatim wording from the response

“In February 2015 a Standard Operating Procedure (SOP) to address the surgical referral system was introduced and provides the following:”

Source location

2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Standardise and formalise processes and policies across the integrated hospitals, taking account of their different surgical functions and available funds.

Verbatim wording from the response

“2. As outlined above, on integrating what were two separate hospitals, much work was undertaken to standardise and formalise processes and policies as far as possible with the assistance of external agencies. Nevertheless, it is recognised that this is an on-going process. It should also be noted that County Hospital and Royal Stoke University Hospital have very different surgical functions so efforts regarding consistency need to be balanced against these functions taking to account the available funds.”

Source location

2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Realign surgical services so County Hospital has no inpatient general surgery and senior surgeons remain available on site through continuing day-case services.

Verbatim wording from the response

“1. At the time of the integration of UHNS and MFST and the re-modelling of services following the closure of MFST, the University Hospitals of North Midlands undertook a substantial amount of work to ensure that services were reviewed and realigned to those sites more suitable to provide the best environment. As a result of this, with effect from 9 February 2015 there were to be no in-patient services at the County Hospital under the care of general surgery (including gastro-intestinal (GI), breast and vascular surgery). However, day case surgeries under other specialties continue to provide a service from this site, so senior surgeons are available.”

Source location

2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Full consistency between County Hospital and Royal Stoke policies and equipment is limited by their different surgical functions and available funds.

Verbatim wording from the response

“2. As outlined above, on integrating what were two separate hospitals, much work was undertaken to standardise and formalise processes and policies as far as possible with the assistance of external agencies. Nevertheless, it is recognised that this is an on-going process. It should also be noted that County Hospital and Royal Stoke University Hospital have very different surgical functions so efforts regarding consistency need to be balanced against these functions taking to account the available funds.”

Source location

2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Existing consultant surgeons and the surgical referral procedure provide surgical availability at County Hospital, so additional mid-grade surgical cover is not indicated.

Verbatim wording from the response

“1. At the time of the integration of UHNS and MFST and the re-modelling of services following the closure of MFST, the University Hospitals of North Midlands undertook a substantial amount of work to ensure that services were reviewed and realigned to those sites more suitable to provide the best environment. As a result of this, with effect from 9 February 2015 there were to be no in-patient services at the County Hospital under the care of general surgery (including gastro-intestinal (GI), breast and vascular surgery). However, day case surgeries under other specialties continue to provide a service from this site, so senior surgeons are available.”

Source location

2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 11 February 2018

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

    Appoint a Deputy Medical Director with specific responsibility for County Hospital.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  2. 2

    Re-share and re-communicate the surgical referral procedure to all staff through daily and weekly communications.

    Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.

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

Appoint a Deputy Medical Director with specific responsibility for County Hospital.

Verbatim wording from the response

“We have now appointed a Deputy Medical Director with specific responsibility for County Hospital and it is hoped that this will speed up any remaining issues.”

Source location

2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 3 · response
Published 11 February 2018

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

Re-share and re-communicate the surgical referral procedure to all staff through daily and weekly communications.

Verbatim wording from the response

“In light of the concerns that you have raised, this SOP will be re-shared and re-communicated to all staff via our daily and weekly communications.”

Source location

2017-0353-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 11 February 2018

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