PFD report

Margaret Elizabeth GRIMSLEY · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 15 Jan 2026•Shropshire, Telford and Wrekin

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

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 raised4

  1. Failure to establish routine practice of setting upper alarms on bedside oxygen meters
    Part of recurring concern: Unreliable alarm controls for oxygen therapy
  2. Uncertainty over whether bedside oxygen meters can be set with an upper alarm
    Part of recurring concern: Unreliable alarm controls for oxygen therapy
  3. Failure to reflect relevant written responses in consultant evidence
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Upper oxygen alarms are not used because lower alarms with regular monitoring better address the greater risk of low oxygen levels.

    Stated by the Shrewsbury and Telford Hospital NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 routine practice of setting upper alarms on bedside oxygen meters

Wider context from the report

“(3) It is not clear whether an upper alarm can be set and/or whether it is practice to do so. ”

Is this part of a recurring concern?

Yes — Unreliable alarm controls for oxygen therapy.

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

Uncertainty over whether bedside oxygen meters can be set with an upper alarm

Wider context from the report

“(3) It is not clear whether an upper alarm can be set and/or whether it is practice to do so. ”

Is this part of a recurring concern?

Yes — Unreliable alarm controls for oxygen therapy.

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 reflect relevant written responses in consultant evidence

Wider context from the report

“(2) The evidence of a Consultant Respiratory Physician did not reflect the response from SaTH in a letter to the deceased daughter of the 30 May 2024 at page 10. ”

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 set an upper alarm on bedside oxygen meters

Wider context from the report

“(1) The apparent absence of or use of an upper alarm setting on a bedside oxygen meter. The evidence indicated that a lower scale alarm was set, but not an upper alarm which required manual observations and when a nurse or healthcare assistant was carrying out observations. The risk is that over-oxygenation could take place without medical attention being sought. ”

Is this part of a recurring concern?

Yes — Unreliable alarm controls for oxygen therapy.

Open source report

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

Upper oxygen alarms are not used because lower alarms with regular monitoring better address the greater risk of low oxygen levels.

Verbatim wording from the response

“The upper alarm is not used as the greatest risk to the patient is low blood oxygen levels. Using the lower alarm in patients with severe lung disease to keep oxygen levels within the required tight range is extremely challenging, and will often require frequent adjustment by the nursing staff to keep the oxygen levels high enough. When considering the poor correlation between oxygen saturations and actual blood levels as well as the higher risk of low oxygen levels, the focus on the ward is the lower alarms with regular monitoring to minimise higher results.”

Source location

Response from Shewsbury and Telford Hospital Trust
Page 2 · response
Published 21 January 2026

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