PFD report

Mr Critall · Prevention of Future Deaths report

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Issued 16 May 2016•Surrey

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
23

Raised in this report

Recipients
5

Named on the report

Responses found
2

Of 5 recipients

Stated actions
21

Described in 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.

Report evidence summary

Concerns raised23

  1. Minimal respiratory consultant documentation
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Outdated chest drain management protocol lacking complication actions
    Part of recurring concern: Unreliable chest drain insertion and management
  3. Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence
    Part of recurring concern: Failure to ensure clinical treatment approaches are supported by adequate evidence
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.17

  1. Action

    Incorporate British Thoracic Society diagnostic guidance into the pathway for managing patients with pleural infection.

    Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
  2. Action

    Establish a local SOP requiring critically ill patients to move automatically to the theatre recovery area for comprehensive monitoring and anaesthetic support.

    Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
  3. Action

    Audit and reinforce complete consent documentation, including procedural risks, benefits, complications and radiological indication for chest-drain insertion.

    Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    The proactive chest-drain approach was attributed only to the consultants concerned, with no evidence that other hospital consultants adopted it.

    Stated by Circle Health Group LimitedDisputes 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

Minimal respiratory consultant documentation

Wider context from the report

“11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Outdated chest drain management protocol lacking complication actions

Wider context from the report

“7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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

Use of 6 f gauge pigtail catheters for pleural effusions without supporting evidence

Wider context from the report

“8. The use of a 6 f gauge pig tail catheter in the management of pleural effusions with or without an empyema was against both national guidelines and expert evidence heard at inquest and was unsupported by either international research or any recent local audits undertaken to justify their use in preference for larger small bore chest drains. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical treatment approaches are supported by adequate evidence.

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

Excessive patient caseloads and unclear experience among senior resident medical staff

Wider context from the report

“1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care.

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 document clinical examination

Wider context from the report

“11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 complete consent detailing chest drain complications

Wider context from the report

“7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

Is this part of a recurring concern?

Yes — Inadequate informed-consent processes for medical treatment; Unreliable chest drain insertion and management.

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 request repeat inflammatory markers

Wider context from the report

“11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist. ”

Is this part of a recurring concern?

Yes — Failure to obtain clinically indicated repeat investigations.

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

Poor communication of the post-procedure care plan to ward staff

Wider context from the report

“7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management; Unreliable communication of patient-care information between clinical staff.

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 use a WHO checklist for radiological interventions

Wider context from the report

“7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

Is this part of a recurring concern?

Yes — Unreliable use of the WHO Surgical Safety Checklist.

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

Proactive chest drain insertion without objective clinical evidence

Wider context from the report

“9. The court heard evidence there was a ‘local’ proactive approach for the insertion of chest drains based on no objective evidence other than a belief that the very smallest catheters were safer and more comfortable and reduced referral for surgical management of an empyema. This view was against expert evidence at inquest and concern was raised that this approach inevitably led to an excess of chest drains being inserted unnecessarily particularly when BTS guidelines were not being routinely applied and/or no evidence of a developing or actual empyema. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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

Absence of a documented management plan

Wider context from the report

“11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist. ”

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

Failure to use real-time ultrasound guidance for chest drain insertion

Wider context from the report

“5. Real time ultrasound visualisation was not used to guide the chest drain insertion against ‘best practice’. I was led to believe ‘best practice’ was not commonly practiced at the Royal Surrey County Hospital and in many other hospitals nationally. I also heard evidence real time ultrasound visualisation would have assisted the insertion as the effusion was small and lay in an awkward position close to tethering of the lung to the chest wall (which was not documented in the hospital notes or radiologist’s statement but was clearly present on ultrasound pictures examined by ████████ and acknowledged to be present by the radiologist who undertook the chest drain insertion in oral testimony). ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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 establish clinical necessity for chest drain insertion

Wider context from the report

“3. The insertion of a chest drain on the 4th July was not supported by British Thoracic Society (BTS) guidelines and was attempted on a background of an improving clinical picture without repeat of relevant investigations (e.g. inflammatory markers) or evidence of a developing or actual empyema or a further medical review, by either the radiologist or responsible clinician, to confirm its necessity. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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 Acute or Basic Life Support training for the radiologist

Wider context from the report

“10. The radiologist did not have Acute or Basic Life Support training as would be expected for all clinical hospital staff as part of mandatory training for NHS appointments. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide first aid.

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

Reliance on emergency paramedic attendance to provide hospital care before transfer

Wider context from the report

“2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital. ”

Is this part of a recurring concern?

Yes — Unreliable emergency access to hospital care.

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 nursing competence in resuscitation and chest drain management

Wider context from the report

“1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management; Unsafe assignment of staff without the required qualifications or competence to care work.

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 independent radiological indications for chest drain insertion

Wider context from the report

“7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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

Chest drain insertion decisions influenced by the day of the week

Wider context from the report

“4. I heard evidence that the insertion of a chest drain may pre-empt difficulties that may arise if Mr Critall deteriorated over the approaching weekend. This was contrary to expert evidence that chest drain insertion should only be considered as a necessity and should not be influenced by the day of the week. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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 radiologically confirm the position of a non-draining chest drain

Wider context from the report

“6. The position of the non-draining (second attempt) chest drain was not radiologically confirmed, against expected practice, particularly as it was not draining. I heard exert evidence that this resulted in a delay in the recognition and prompt management of the haemothorax which contributed to Mr Critall’s death. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management.

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 record observations before and after chest drain procedures

Wider context from the report

“7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

Is this part of a recurring concern?

Yes — Unreliable chest drain insertion and management; Unreliable recording of required observations in care and custody.

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

Admission of acutely unwell patients without onsite HDU/ITU facilities

Wider context from the report

“1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions. ”

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

Absence of operational protocols for hospital emergency situations

Wider context from the report

“2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital. ”

Is this part of a recurring concern?

Yes — Unreliable hospital emergency-response protocols.

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

Absence of HDU or ITU capability for hospital emergency situations

Wider context from the report

“2. The absence of operational protocols and a HDU/ITU facility to manage emergency situations and a reliance on a 999 call for paramedics to provide care for a hospital who undertakes such procedures prior to transferring an unwell patient to an NHS hospital. ”

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

Incorporate British Thoracic Society diagnostic guidance into the pathway for managing patients with pleural infection.

Verbatim wording from the response

“5. Following the feedback from the coroner we have further strengthened the process for the management of patients with pleural infection, utilising the diagnostic algorithm for the management of such patients as described in the BTS guidelines 2010.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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 local SOP requiring critically ill patients to move automatically to the theatre recovery area for comprehensive monitoring and anaesthetic support.

Verbatim wording from the response

“2. A local standard operating procedure (SOP) has been agreed at the hospital resuscitation committee to reinforce the management of a critically ill patient whereby a patient is automatically transferred to the recovery area within the hospital’s theatre complex to ensure access to comprehensive monitoring equipment and anaesthetic staff.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 3 · response
Published 16 May 2016

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

Audit and reinforce complete consent documentation, including procedural risks, benefits, complications and radiological indication for chest-drain insertion.

Verbatim wording from the response

“In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 6 · response
Published 16 May 2016

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

Require annual consultant reporting of completed mandatory training through the updated BMI practising privileges policy.

Verbatim wording from the response

“In 2014 the BMI Practicing Privileges policy required confirmation of a completed appraisal whereby a consultant’s Responsible Officer /Clinical Director would confirm that all requirements for the appraisal were met. Since that time an updated practicing privileges policy has been introduced across all BMI hospitals which includes a requirement that details of completed mandatory training are provided by all consultants on an annual basis.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 7 · response
Published 16 May 2016

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

Conduct monthly sample audits of consultant medical-record documentation and refer non-compliance for appropriate action.

Verbatim wording from the response

“2. Consultant input into the medical record is subject to a monthly audit on a sample basis and audit results indicate significant improvement.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 8 · response
Published 16 May 2016

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 and update the Elective and Non-Elective Transfer Policy, agreeing emergency transfer processes with Royal Surrey County Hospital and making them available to relevant staff.

Verbatim wording from the response

“1. The hospital’s Elective and Non-Elective Transfer Policy, has been reviewed and updated to reinforce the registered level of care provided by the hospital. The process for transfer in an emergency situation was agreed with the Medical Director at the Royal Surrey County Hospital NHS Trust and incorporated into the policy. The Policy is available for RMO and senior nursing staff within the RMO induction and bleep holder file.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 3 · response
Published 16 May 2016

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 the chest-drain care protocol to align with British Thoracic Society guidance.

Verbatim wording from the response

“4. The protocol for the care of patients with a chest drain has been updated to align with British Thoracic Society (BTS) guidelines. Training and competencies for all radiology and nursing staff on the understanding of chest drain insertion is currently under review by BMI to be incorporated in the Acute Care Competencies.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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 a patient pathway linking ward and radiology teams, requiring pre- and post-procedure observations and clear handover communication.

Verbatim wording from the response

“2. A patient pathway has been developed for patients undertaking this type of procedure to ensure improved communication between staff on the ward and in radiology. The pathway ensures base line observations are recorded prior to and following the procedure and requires clear communication on handover.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 6 · response
Published 16 May 2016

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

Reinforce contemporaneous consultant documentation of management plans, interventions and clinical examinations.

Verbatim wording from the response

“1. There have been a number of initiatives across the hospital in the last 2 years to reinforce the standard and ensure that all consultants are aware of the requirement to make contemporaneous notes regarding their patients.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 8 · response
Published 16 May 2016

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

Include chest-drain complication management procedures within the patient pathway for ward staff.

Verbatim wording from the response

“3. The pathway includes the protocol for the management of chest drains on the ward which addresses actions to take if complications arise.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 6 · response
Published 16 May 2016

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

Run regular unannounced resuscitation scenarios for staff and RMOs, identifying learning requirements for follow-up.

Verbatim wording from the response

“2. All staff and RMO’s are involved with regular unannounced resuscitation scenarios run at the hospital by an externally appointed resuscitation training company engaged to teach resuscitation skills to all staff. Any learning requirements are identified to staff and to the RMOs and their agency.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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 a consultant pathway presenting the patient’s clinical condition to support decisions about proceeding with interventional procedures.

Verbatim wording from the response

“3. We have developed a pathway which provides consultants with a clear picture of the patient’s clinical condition which will support any decision regarding the progression to an interventional procedure.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 4 · response
Published 16 May 2016

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

Require RMOs to meet hospital-specific experience and competency criteria, selecting familiar RMOs to improve continuity and consultant communication.

Verbatim wording from the response

“1. Any RMO’s offered to the hospital are required to meet specific criteria regarding previous experience and competency and a number of RMOs have been specifically selected who are familiar with the hospital, the consultants and nursing staff with the aim of improving continuity of care and communication with consultants.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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 and incorporate chest-drain insertion training and competencies for radiology and nursing staff into Acute Care Competencies.

Verbatim wording from the response

“4. The protocol for the care of patients with a chest drain has been updated to align with British Thoracic Society (BTS) guidelines. Training and competencies for all radiology and nursing staff on the understanding of chest drain insertion is currently under review by BMI to be incorporated in the Acute Care Competencies.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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

Promote British Thoracic Society guidance specifying larger 10–14 gauge tubes for pleural infection management.

Verbatim wording from the response

“1. As discussed previously in the response to Concern 6, BTS guidance for the management of patients with pleural infection is promoted which includes reference to the use of a larger bore tube size 10 – 14.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 6 · response
Published 16 May 2016

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

Train nursing staff and healthcare assistants in acute illness management and assess competencies for caring for deteriorating patients.

Verbatim wording from the response

“3. All nursing staff and Health Care Assistants have attended AIMS (Acute Illness Management training) and completed competencies in the care of the deteriorating patient.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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

Make Fellows and members aware of the BTS Pleural Disease Guideline 2010 Quick Reference Guide.

Verbatim wording from the response

“In the light of your report, we are taking steps later this month to make our Fellows and members aware once again of these important guidelines.”

Source location

2016-0187-Response-by-Royal-College-of-Radiologists
Page 1 · response
Published 16 May 2016

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 proactive chest-drain approach was attributed only to the consultants concerned, with no evidence that other hospital consultants adopted it.

Verbatim wording from the response

“The ‘local’ proactive approach described was specific to the consultants concerned based on their practice and experience. There is no evidence that any other consultants at the hospital adopted such an approach.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 7 · response
Published 16 May 2016

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

Continuous hospital and radiology staffing, including an on-call radiographer, meant chest-drain decisions need not be influenced by the day of the week.

Verbatim wording from the response

“The decision to insert a chest drain should not be influenced by the day of the week. The hospital is open and staffed 24 hours a day, 7 days a week as is the Radiology department. An on call radiographer is provided to enable procedures to be carried out whenever required. Consultants are not expected to make such clinical decisions based on the day of the week.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 4 · response
Published 16 May 2016

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 RMO met hospital-specific requirements, including GMC registration, life-support certification and relevant clinical experience.

Verbatim wording from the response

“Resident Medical Officer (RMO) - The role of the RMO is to respond to requests from consultants and nursing staff in matters which require medical input and involves the assessment of surgical and medical patients who deviate from the treatment pathway, and deteriorating patients. RMO’s are provided to the hospital by an agency and are provided on the basis that they are able to work within the clinical requirements specific to the hospital, including GMC registration, a current Advanced Life Support certificate and European Paediatric Life Support certificate and experience in cancer care. This was the case for the RMO on duty that day. At the time of Mr Critall’s admission, the hospital was registered for 72 beds.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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 hospital had an emergency transfer policy and facilities to stabilise critically ill patients before transfer.

Verbatim wording from the response

“The hospital has an Elective and Non-Elective Transfer Policy in place which sets out the requirements for transfer of patients in emergency situations. The policy acknowledges that clinical deterioration can occur at any stage of a patient’s pathway. The National Early Warning Score (NEWS) is a tool to support staff to recognise deterioration at an early stage and escalate for medical assessment by the RMO. If following assessment it is deemed necessary, the patient’s consultant or other relevant professional, e.g. consultant anaesthetist should be contacted for advice or asked to attend.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 3 · response
Published 16 May 2016

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

Nursing staff had required resuscitation training, with senior nurses generally holding advanced life-support certification.

Verbatim wording from the response

“Nursing staff - All hospital staff receive either advanced life support (ALS); basic life support (BLS) or immediate life support (ILS) resuscitation council accredited training. All nursing staff are ILS trained as a minimum requirement and the current senior nursing team are ALS trained with the exception of 1 member of the team. The requirement is for renewal every 4 years. In the intervening years between formal ALS training all ALS qualified staff attend an ALS refresher (previously this was an ILS refresher).”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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 radiology department already used the WHO procedural checklist, required comprehensive consent and audited compliance.

Verbatim wording from the response

“In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 6 · response
Published 16 May 2016

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

Consultants were required to maintain basic life-support training through practising-privileges and annual appraisal arrangements.

Verbatim wording from the response

“All consultants are required to have basic life support training as a minimum. As part of the practising privileges that are granted to consultants to allow them to practice at the hospital, annual practice appraisals are conducted, part of which is a requirement for a consultant’s responsible officer to confirm that basic life support training has been completed.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 7 · response
Published 16 May 2016

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

Admission was considered appropriate because the patient required only level 0 care and existing escalation arrangements supported deterioration management.

Verbatim wording from the response

“hospital’s resident medical officer (RMO) as required. Following assessment by the RMO if necessary, the patient’s consultant or other relevant professional, e.g. consultant anaesthetist would be contacted for advice or asked to attend. On admission, Mr Critall’s condition was assessed to be level 0, an appropriate admission to the hospital”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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.4

  1. 1

    Disseminate that critically ill patient management takes priority over elective surgery among consultant anaesthetists.

    Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
  2. 2

    Require consultant radiologists to consider CT imaging after failed sampling of loculated fluid, following British Thoracic Society guidance.

    Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
  3. 3

    Develop a hospital SOP reflecting British Thoracic Society requirements for CT consideration and image-guided aspiration after failed sampling or small loculated effusion.

    Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
  4. 4

    Withdraw the consultant radiologist from interventional radiology practice following notification to the responsible officer and GMC.

    Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Chest-drain management principles were considered applicable to both pneumonic and malignant pleural effusions.

    Stated by Circle Health Group LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Disseminate that critically ill patient management takes priority over elective surgery among consultant anaesthetists.

Verbatim wording from the response

“4. All consultant anaesthetists are aware that whilst in the hospital, the management of a critically ill patient is a priority over elective surgical cases.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 3 · response
Published 16 May 2016

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

Require consultant radiologists to consider CT imaging after failed sampling of loculated fluid, following British Thoracic Society guidance.

Verbatim wording from the response

“2. Where there is a failed sampling of loculated fluid, consultant radiologists are expected to follow the BTS guidance which requests that the consultant consider CT imaging for further image guided aspiration.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 4 · response
Published 16 May 2016

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 a hospital SOP reflecting British Thoracic Society requirements for CT consideration and image-guided aspiration after failed sampling or small loculated effusion.

Verbatim wording from the response

“1. A Standard Operating Procedure, local to the hospital, has been developed. The procedure reflects the requirements of best practice detailed within the BTS guidance in relation to the requirement to consider a CT scan and further image guided aspiration following a failed sampling or presence of a small loculated effusion.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 5 · response
Published 16 May 2016

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

Withdraw the consultant radiologist from interventional radiology practice following notification to the responsible officer and GMC.

Verbatim wording from the response

“1. The consultant radiologist withdrew from interventional radiology following this event having notified his responsible officer and the GMC.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 4 · response
Published 16 May 2016

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

Chest-drain management principles were considered applicable to both pneumonic and malignant pleural effusions.

Verbatim wording from the response

“Understanding of chest drains – While the specifics of chest drain insertion may differ according to the condition being treated, the principles for the management of a chest drain apply both to pneumonic pleural effusions and malignant pleural effusions.”

Source location

2016-0187-Response-by-Mount-Alvernia-Hospital
Page 2 · response
Published 16 May 2016

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

Official responses located
2/5

Data last updated 7 September 2026