Daphne Gillian AUSTIN · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 13 Aug 2024•Cumbria

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure of industrial-action contingency planning to provide safe levels of clinical cover
    Part of recurring concern: Inadequate contingency planning for safe patient care during staffing shortages

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. North Cumbria Integrated Care NHS Foundation Trust

    Embed learning from the review through immediate action to prevent recurrence and improve care safety and effectiveness.

  2. North Cumbria Integrated Care NHS Foundation Trust

    Review the causal and contributory factors behind the absence of medical input, observations and interventions during the patient’s admission.

  3. North Cumbria Integrated Care NHS Foundation Trust

    Launch a Trust-wide improvement plan for fluid and hydration management.

  4. North Cumbria Integrated Care NHS Foundation Trust

    Embed twice-daily operational team or matron touch bases with each ward during industrial action to address concerns and escalations.

  5. North Cumbria Integrated Care NHS Foundation Trust

    Issue a Trust-wide fluid-balance safety alert requiring specified adult inpatients to have charts completed, reviewed and acted upon, with compliance monitored.

  6. North Cumbria Integrated Care NHS Foundation Trust

    Embed twice-daily extraordinary safety huddles for ward multidisciplinary teams during industrial action.

  7. North Cumbria Integrated Care NHS Foundation Trust

    Maintain the existing industrial-action planning process and staffing plans for safe levels of medical cover during future industrial action.

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

  1. North Cumbria Integrated Care NHS Foundation Trust

    Existing industrial-action staffing processes and plans are considered sufficient to provide safe cover and will be maintained during future industrial action.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. North Cumbria Integrated Care NHS Foundation Trust

    The Trust considers that staffing levels during industrial action did not cause or contribute to missed opportunities in the patient’s care.

    Disputes 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 of industrial-action contingency planning to provide safe levels of clinical cover

Wider context from the report

“(1) I received evidence of the planning that had gone into preparing the trust for strikes. However, there was evidence from one of the Trust's consultants that on the day of the strike she had to "look after nearly 25 patients" and that "due to the junior doctor’s strike on 14/06/2023, Mrs Austin did not receive any medical input that day". Another consultant gave evidence that despite being listed as one of the consultants covering the unit (in the contingency planning evidence) he was probably dealing with other duties on that day. In the circumstances I am concerned that the planning that seeks to ensure safe levels of cover during periods of industrial action was insufficient to meet need and that this gave rise to a risk of future deaths. ”

Is this part of a recurring concern?

Yes — Inadequate contingency planning for safe patient care during staffing shortages.

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

Embed learning from the review through immediate action to prevent recurrence and improve care safety and effectiveness.

Verbatim wording from the response

“In view of the Trust’s assurance that there is safe levels of cover during periods of industrial action to meet patient needs, the Trust is satisfied that this did not cause or contribute to any missed opportunities within Ms Austin’s care. However, the Trust unreservedly acknowledges that there is a need to establish what the causal and/or contributory factors were in Ms Austin not receiving medical input and basic, fundamental observations and interventions during her hospital admission. The Trust will therefore carry out a review into this to identify any learning and take immediate action to embed the learning to prevent recurrence and ensure that the care we provide is safe, effective, and of a high quality.”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 6 · response
Published 13 August 2024

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 causal and contributory factors behind the absence of medical input, observations and interventions during the patient’s admission.

Verbatim wording from the response

“In view of the Trust’s assurance that there is safe levels of cover during periods of industrial action to meet patient needs, the Trust is satisfied that this did not cause or contribute to any missed opportunities within Ms Austin’s care. However, the Trust unreservedly acknowledges that there is a need to establish what the causal and/or contributory factors were in Ms Austin not receiving medical input and basic, fundamental observations and interventions during her hospital admission. The Trust will therefore carry out a review into this to identify any learning and take immediate action to embed the learning to prevent recurrence and ensure that the care we provide is safe, effective, and of a high quality.”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 6 · response
Published 13 August 2024

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

Launch a Trust-wide improvement plan for fluid and hydration management.

Verbatim wording from the response

“The cessation of this monitoring should only occur following a documented clinical decision. The Nursing Directorate will be monitoring compliance with this notice. In addition to the urgent patient safety alert, a Trust wide improvement plan for fluid/hydration is being launched.”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 1 · response
Published 13 August 2024

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

Embed twice-daily operational team or matron touch bases with each ward during industrial action to address concerns and escalations.

Verbatim wording from the response

“2. Operational Teams/Matrons to embed twice daily touch bases with each ward area, during periods of industrial action, to support and address any areas of concern/escalation.”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 6 · response
Published 13 August 2024

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

Issue a Trust-wide fluid-balance safety alert requiring specified adult inpatients to have charts completed, reviewed and acted upon, with compliance monitored.

Verbatim wording from the response

“During the inquest, you commended the excellent work the Trust had undertaken in improving fluid balance management and were reassured that you duly issued a Regulation 28 Report in this regard was not triggered. The Trust remains committed to ensuring that staff understand that the assessment and management of patients’ fluid and electrolyte needs is absolutely fundamental to providing good patient care. Healthcare professionals need to consider this as part of every review to reduce the potential serious impact of inadequate fluid balance on all our patients. An urgent patient safety alert was therefore issued to all Trust staff on 30/08/2024 that as a minimum requirement, the following group of adult patients all have a Fluid Balance Chart completed, reviewed and acted upon as needed:”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 1 · response
Published 13 August 2024

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

Embed twice-daily extraordinary safety huddles for ward multidisciplinary teams during industrial action.

Verbatim wording from the response

“1. The Ward Teams to embed extraordinary safety huddles twice daily during periods of industrial action to allow MDT members to attend and discuss concerns/escalations.”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 6 · response
Published 13 August 2024

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

Maintain the existing industrial-action planning process and staffing plans for safe levels of medical cover during future industrial action.

Verbatim wording from the response

“The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures safe levels of cover during periods of industrial action to meet need, and that this does not give rise to a risk of future deaths. The process and plans will therefore be maintained during any future periods of industrial action. However, despite the Trust’s robust framework in ensuring appropriate medical cover during periods of industrial action, the Trust has identified areas of learning which could contribute to the Trust’s resilience:”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 5 · response
Published 13 August 2024

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 industrial-action staffing processes and plans are considered sufficient to provide safe cover and will be maintained during future industrial action.

Verbatim wording from the response

“The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures safe levels of cover during periods of industrial action to meet need, and that this does not give rise to a risk of future deaths. The process and plans will therefore be maintained during any future periods of industrial action. However, despite the Trust’s robust framework in ensuring appropriate medical cover during periods of industrial action, the Trust has identified areas of learning which could contribute to the Trust’s resilience:”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 5 · response
Published 13 August 2024

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 Trust considers that staffing levels during industrial action did not cause or contribute to missed opportunities in the patient’s care.

Verbatim wording from the response

“In view of the Trust’s assurance that there is safe levels of cover during periods of industrial action to meet patient needs, the Trust is satisfied that this did not cause or contribute to any missed opportunities within Ms Austin’s care. However, the Trust unreservedly acknowledges that there is a need to establish what the causal and/or contributory factors were in Ms Austin not receiving medical input and basic, fundamental observations and interventions during her hospital admission. The Trust will therefore carry out a review into this to identify any learning and take immediate action to embed the learning to prevent recurrence and ensure that the care we provide is safe, effective, and of a high quality.”

Source location

Response from North Cumbria Integrated Care NHS Trust
Page 6 · response
Published 13 August 2024

Open published response
Back to top

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