PFD report

Mary Winifred HYDEN · Prevention of Future Deaths report

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Issued 1 Jul 2015•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.

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Concerns
1

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 raised1

  1. Excessive working hours for consultant neurologists
    Part of recurring concern: Unreliable fatigue controls for prolonged safety-critical shifts
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.5

  1. Action

    Introduce a new job plan reducing the consultant’s clinical sessions.

    Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 July 2015.
  2. Action

    Stop the consultant travelling to Cannock Hospital for clinics and ward referrals.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 July 2015.
  3. Action

    Review the consultant’s job plan to address workload and work-life balance.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 July 2015.

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

  1. Position

    The consultant’s working arrangements complied with applicable regulations through the compensatory-rest regime and her job plan.

    Stated by University Hospitals of North Midlands NHS 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

Excessive working hours for consultant neurologists

Wider context from the report

“(1) At the inquest I heard helpful evidence from ████████ Consultant Neurologist. She was frank about failures in communication in 2013 and 2014 and advised me of significant changes since Cannock Hospital was transferred to the Wolverhampton Trust. However ████████ also indicated in evidence that she is working regularly 7 days a week and the day before the inquest worked 14 hours (and again this was not unusual). These do appear to be excessive hours with an increased potential for fatal errors. I should be grateful if you could look at this. ”

Is this part of a recurring concern?

Yes — Unreliable fatigue controls for prolonged safety-critical shifts.

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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

Introduce a new job plan reducing the consultant’s clinical sessions.

Verbatim wording from the response

“Nevertheless, I understand that the Medical Director and the Clinical Director for Neurosciences have reviewed ████████ job plan (July 2015) and a new job plan will be effective from 1 October 2015. In her new job plan, ████████ clinical sessions will be reduced to allow her to have better work life balance and since November 2014, Dr Summers does not travel to Cannock Hospital to undertake clinics and ward referrals and this has significantly reduced her travel requirements.”

Source location

2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2015

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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

Stop the consultant travelling to Cannock Hospital for clinics and ward referrals.

Verbatim wording from the response

“Nevertheless, I understand that the Medical Director and the Clinical Director for Neurosciences have reviewed ████████ job plan (July 2015) and a new job plan will be effective from 1 October 2015. In her new job plan, ████████ clinical sessions will be reduced to allow her to have better work life balance and since November 2014, Dr Summers does not travel to Cannock Hospital to undertake clinics and ward referrals and this has significantly reduced her travel requirements.”

Source location

2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 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 the consultant’s job plan to address workload and work-life balance.

Verbatim wording from the response

“Nevertheless, I understand that the Medical Director and the Clinical Director for Neurosciences have reviewed ████████ job plan (July 2015) and a new job plan will be effective from 1 October 2015. In her new job plan, ████████ clinical sessions will be reduced to allow her to have better work life balance and since November 2014, Dr Summers does not travel to Cannock Hospital to undertake clinics and ward referrals and this has significantly reduced her travel requirements.”

Source location

2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 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

Encourage the consultant to use available administrative support.

Verbatim wording from the response

“In addition to this, ████████ is not currently working in isolation at the County Hospital and has the support of a second Consultant. She has also been encouraged to utilise the administrative support that is available to her. As a Neurosciences Directorate we are keen to provide the right working environment for ████████ and patient safety is very high on our priorities.”

Source location

2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2015

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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

Provide the consultant with support from a second consultant at County Hospital.

Verbatim wording from the response

“In addition to this, ████████ is not currently working in isolation at the County Hospital and has the support of a second Consultant. She has also been encouraged to utilise the administrative support that is available to her. As a Neurosciences Directorate we are keen to provide the right working environment for ████████ and patient safety is very high on our priorities.”

Source location

2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 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

The consultant’s working arrangements complied with applicable regulations through the compensatory-rest regime and her job plan.

Verbatim wording from the response

“The EC Directive on Working Time for Consultants was introduced in October 1998 and from this time onwards, all consultants are covered by the entitlements afforded by the Directive. In 1998, the Central Consultants and Specialists Committee (CCSC) of the British Medical Association and the NHS Executive negotiated a collective agreement regarding the application of the Directive for senior hospital doctors, which applied derogations to inflexible hourly, daily and weekly limits under regulation 21 and in their place established the right of senior hospital doctors to take compensatory rest where the limits were exceeded. These derogations were applied to ensure that continuing responsibility to patients was maintained and the necessary protection for senior hospital doctors under the directive was retained.”

Source location

2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2015

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.1

  1. 1

    Review post-merger processes in response to the communication concerns.

    Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 July 2015.

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 post-merger processes in response to the communication concerns.

Verbatim wording from the response

“I sincerely hope that this report provides H M Coroner, Mrs Haigh, with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mary Hyden seriously. Whilst it is understood that this failure in communication occurred prior to the merger of the University Hospital of North Staffordshire and Mid Staffordshire NHS Foundation Trust, the Trust strives to provide a high standard of care to all patients and I am grateful to you for raising these matters on this occasion so that we were able to review our processes post-merger.”

Source location

2015-0251-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2015

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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