PFD report

Kyra Ali Aslam · Prevention of Future Deaths report

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Issued 5 Dec 2023•South Yorkshire (Western)

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
21

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 raised2

  1. Culture preventing medics from taking account of parents' or nursing staff's views in assessing patients' overall presentation
    Part of recurring concern: Failure to incorporate relevant collateral and professional views into clinical assessment
  2. Failure to adequately explain learning to junior doctors after consultant overruling
    Part of recurring concern: Failure to provide feedback and learning to clinicians after safety-relevant clinical errors
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.8

  1. Action

    Implement the Parent and Carer Escalation process across all inpatient areas, with prominent posters and continuing promotion and monitoring.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  2. Action

    Launch the Quality Promise quality strategy across the Trust to embed safe, kind and outstanding care.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  3. Action

    Update nurse escalation policies and support them with training.

    Stated by Sheffield Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.

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

Culture preventing medics from taking account of parents' or nursing staff's views in assessing patients' overall presentation

Wider context from the report

“1. Whether there is a culture which prevents medics from taking account of the views of parents or nursing staff when considering the overall presentation of the patients ”

Is this part of a recurring concern?

Yes — Failure to incorporate relevant collateral and professional views into clinical assessment.

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 adequately explain learning to junior doctors after consultant overruling

Wider context from the report

“2. Where a junior doctor is over ruled by a Consultant, is that learning adequately explained to that junior doctor to learn for next time? ”

Is this part of a recurring concern?

Yes — Failure to provide feedback and learning to clinicians after safety-relevant clinical errors.

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

Implement the Parent and Carer Escalation process across all inpatient areas, with prominent posters and continuing promotion and monitoring.

Verbatim wording from the response

“The Trust has implemented a new process to enable parents and carers to escalate concerns about their child’s clinical condition if they feel they are not being listened to. This new process is called PaCE (Parent and Carer Escalation). It is acknowledged by Sheffield Children’s NHS FT that failure to recognise and treat patients whose condition is deteriorating is a cause of significant harm in healthcare environments. One resource in the early detection of deterioration is the contribution that patients and carers can make.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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 the Quality Promise quality strategy across the Trust to embed safe, kind and outstanding care.

Verbatim wording from the response

“The continued work we are doing with our Quality Strategy, known as the Quality Promise, which has just been launched across the Trust, will assist in embedding our culture to provide safe, kind and outstanding care to everyone. In implementing human factors, engagement with leaders and everyone across the Trust highlighting the importance of listening to parents/ carers and other colleagues across the Trust, along with the learning culture that is being implemented through PSIRF (Patient Safety Incident Response Framework).”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 3 · response
Published 8 December 2023

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

Update nurse escalation policies and support them with training.

Verbatim wording from the response

“The Trust has processes and policies in place for escalation by nurses should they feel that their concerns are not being heard, these policies are being updated and will be supported by training. The new Quality Matron post will play a significant part in enabling this culture change at ward level. All clinical colleagues also have access to the Freedom to Speak Up Guardian who will take concerns and raise these directly with the Executive Team.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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 the In It Together culture framework within the People Plan through leadership events and line-management training.

Verbatim wording from the response

“• Embedding the Trusts ‘In it Together’ culture framework within our People Plan and supporting this with leadership events and line management training.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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 improved supervision training for all supervisors to make clinical contacts learning opportunities.

Verbatim wording from the response

“As a Trust we have introduced a new way for consultants to evidence their upskilling as a Clinical and Educational Supervisor. This is now linked to their appraisal process within their Scope of Work and gives very clear suggestions on how to meet the seven domains required by the GMC. We believe that this will maintain high standards amongst our trainers, increase their accountability and ensure they receive regular training to improve their approach to teaching and give them confidence to challenge colleagues who are not meeting the same standards. Acute medicine can at times require fast decision making by the most senior colleague present which can be appropriate in emergency situations, however embedding improved supervision training for all supervisors will work towards ensuring that all clinical contacts are viewed as learning opportunities.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 3 · response
Published 8 December 2023

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

Provide additional time for specialty clinical tutor posts supporting educational faculty and trainee development.

Verbatim wording from the response

“We have invested in additional time for speciality clinical tutor posts which support the development of educational faculty for doctors in training and as a local support for trainees to discuss their training and training needs. Any trainee placed at Sheffield Children’s has a personal clinical supervisor assigned to them, their role is to provide learning through case-based discussions and review of their experiences (and address unmet learning needs or concerns).”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 3 · response
Published 8 December 2023

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

Implement processes for clinical Care Groups to review complaints and Freedom to Speak Up themes involving unheard families or colleagues.

Verbatim wording from the response

“The Trust has recognised that the views of parents and nursing staff have not always been listened to, through feedback we triangulate from inquests, serious incidents and complaints. As a result of this, we have undertaken a significant amount of work to consider and improve areas within our culture and the processes that underpin our ways of working. This includes:”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 1 · response
Published 8 December 2023

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

Introduce appraisal-linked requirements for consultants to evidence Clinical and Educational Supervisor upskilling.

Verbatim wording from the response

“As a Trust we have introduced a new way for consultants to evidence their upskilling as a Clinical and Educational Supervisor. This is now linked to their appraisal process within their Scope of Work and gives very clear suggestions on how to meet the seven domains required by the GMC. We believe that this will maintain high standards amongst our trainers, increase their accountability and ensure they receive regular training to improve their approach to teaching and give them confidence to challenge colleagues who are not meeting the same standards. Acute medicine can at times require fast decision making by the most senior colleague present which can be appropriate in emergency situations, however embedding improved supervision training for all supervisors will work towards ensuring that all clinical contacts are viewed as learning opportunities.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 3 · response
Published 8 December 2023

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.13

  1. 1

    Fund new Trust-wide Quality Matron, Patient Experience Lead and sepsis Lead Nurse roles.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  2. 2

    Operate Safety Wednesday reviews of incidents and complaints, escalating concerns to patient-safety and executive forums for timely action.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  3. 3

    Roll out the In It Together culture framework, Lead with Care approach and Education and Learning Strategy across the Trust.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  4. 4

    Roll out human factors training across the Trust.

    Stated by Sheffield Children'S NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2023.
  5. 5

    Develop the doctors’ Team Leader role, refresh its job description and review allocated time.

    Stated by Sheffield Children'S NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2023.
  6. 6

    Complete a bereavement-care review with family input and develop future proposals from incident and complaint themes.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  7. 7

    Hold scheduled consultant engagement meetings to share specific learning with the consultant body.

    Stated by Sheffield Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2023.
  8. 8

    Establish a monthly Safety, Quality, Risk and Learning Committee for organisation-wide learning.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  9. 9

    Refresh the Care Experience Group with stronger attendance, feedback and co-production involving the Youth Forum and Healthwatch.

    Stated by Sheffield Children'S NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2023.
  10. 10

    Implement the national Patient Safety Incident Response Framework with training and new Learning Response Learning Leads.

    Stated by Sheffield Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
  11. 11

    Continue reviewing postgraduate training quality and developing learning across all posts.

    Stated by Sheffield Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
  12. 12

    Submit an educational action plan to address training deficiencies identified by Health Education England.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
  13. 13

    Invite external groups to present engagement feedback to the Executive Team and Trust Board.

    Stated by Sheffield Children'S NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.

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

Fund new Trust-wide Quality Matron, Patient Experience Lead and sepsis Lead Nurse roles.

Verbatim wording from the response

“• Funding new Trust wide roles including Quality Matron; Patient Experience Leads and a sepsis Lead Nurse.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Operate Safety Wednesday reviews of incidents and complaints, escalating concerns to patient-safety and executive forums for timely action.

Verbatim wording from the response

“• Implementation of ‘Safety Wednesday’ led by the Medical Director and Chief Nurse to review all incidents and complaints through the week. Areas of concern are escalated to Patient Safety Incident Triage Panel for further consideration and fed into the weekly Executive Team meeting on a Thursday to enable timely action.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 1 · response
Published 8 December 2023

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

Roll out the In It Together culture framework, Lead with Care approach and Education and Learning Strategy across the Trust.

Verbatim wording from the response

“The Trust’s ‘In this Together’ culture and behaviour framework, Lead with Care approach and the Education and Learning Strategy that have been rolled out across the Trust will ensure that our culture develops and that learning is embedded across all areas including surgery.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 4 · response
Published 8 December 2023

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

Roll out human factors training across the Trust.

Verbatim wording from the response

“• Roll out of human factors training across the Trust.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Develop the doctors’ Team Leader role, refresh its job description and review allocated time.

Verbatim wording from the response

“• Development of the Team Leader role for doctors with a refreshed job role and review of time allocated for the role.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Complete a bereavement-care review with family input and develop future proposals from incident and complaint themes.

Verbatim wording from the response

“• Thorough review of bereavement care following themes identified from incidents and complaints with input from families and the development of future proposals.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Hold scheduled consultant engagement meetings to share specific learning with the consultant body.

Verbatim wording from the response

“• Scheduled Consultant engagement meetings for 2024, where feedback from specific learning can be shared with the Consultant body in the Trust.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Establish a monthly Safety, Quality, Risk and Learning Committee for organisation-wide learning.

Verbatim wording from the response

“• A new monthly Safety, Quality, Risk and Learning Committee provides a forum for organisation wide learning.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Refresh the Care Experience Group with stronger attendance, feedback and co-production involving the Youth Forum and Healthwatch.

Verbatim wording from the response

“• Refresh of our Care Experience Group including stronger attendance, feedback and coproduction of action from The Trust’s Youth Forum and Healthwatch.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Implement the national Patient Safety Incident Response Framework with training and new Learning Response Learning Leads.

Verbatim wording from the response

“• Implementing the new national Patient Safety Incident Response Framework with significant training and appointment of new Learning Response Learning Leads.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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

Continue reviewing postgraduate training quality and developing learning across all posts.

Verbatim wording from the response

“We believe that Sheffield Children’s is a positive learning environment and this is evidenced in many areas by the GMC national trainee survey and by positive HEe quality assurance visits. We have however submitted an educational action plan to HEE to address areas where training is not at the level we expect, and our Director of Postgraduate Medical Education continues to review the quality and develop learning across all posts.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 3 · response
Published 8 December 2023

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

Submit an educational action plan to address training deficiencies identified by Health Education England.

Verbatim wording from the response

“We believe that Sheffield Children’s is a positive learning environment and this is evidenced in many areas by the GMC national trainee survey and by positive HEe quality assurance visits. We have however submitted an educational action plan to HEE to address areas where training is not at the level we expect, and our Director of Postgraduate Medical Education continues to review the quality and develop learning across all posts.”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 3 · response
Published 8 December 2023

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

Invite external groups to present engagement feedback to the Executive Team and Trust Board.

Verbatim wording from the response

“• Invitation of external groups to talk to Executive Team and Trust Board for example the Sheffield parent / carer forum came to present feedback from their engagement work Implementation of Patient and Carer Escalation”

Source location

Response from Sheffield Children's NHS Foundation Trust
Page 2 · response
Published 8 December 2023

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