PFD report

Linda Ann PHILLIPSON · Prevention of Future Deaths report

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Issued 8 Sep 2020•Brighton and Hove

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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. Failure to mobilize the patient
  2. Delay in applying the external fixator
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.2

  1. Action

    Include spanning external fixation, elevation and early physiotherapist-led mobilisation for peri-articular complex fractures in the transfer protocol.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2020.
  2. Action

    Implement a ratified inter-hospital transfer policy and protocol for complex trauma patients requiring specialist surgery, including interim management while awaiting transfer.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2020.

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 mobilize the patient

Wider context from the report

“(1) The delay in applying the external fixator (2) The apparent failure to mobilize the patient ”

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

Delay in applying the external fixator

Wider context from the report

“(1) The delay in applying the external fixator (2) The apparent failure to mobilize the patient ”

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

Include spanning external fixation, elevation and early physiotherapist-led mobilisation for peri-articular complex fractures in the transfer protocol.

Verbatim wording from the response

“We can confirm that a Trust Surgical Board ratified Transfer Policy has been put in place between Brighton & Sussex University Hospitals and Western Sussex Hospitals NHS Foundation Trust hospitals for the management of complex trauma patients who need specialist surgery at the Major Trauma Centre. The immediate management of major trauma in Western Sussex Hospitals whilst awaiting transfer is included within the transfer protocol. The application of spanning external fixator for all Peri-articular complex fractures, elevation and early mobilisation with physiotherapists has been also included within the protocol to prevent any further similar occurrence.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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 a ratified inter-hospital transfer policy and protocol for complex trauma patients requiring specialist surgery, including interim management while awaiting transfer.

Verbatim wording from the response

“We can confirm that a Trust Surgical Board ratified Transfer Policy has been put in place between Brighton & Sussex University Hospitals and Western Sussex Hospitals NHS Foundation Trust hospitals for the management of complex trauma patients who need specialist surgery at the Major Trauma Centre. The immediate management of major trauma in Western Sussex Hospitals whilst awaiting transfer is included within the transfer protocol. The application of spanning external fixator for all Peri-articular complex fractures, elevation and early mobilisation with physiotherapists has been also included within the protocol to prevent any further similar occurrence.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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.6

  1. 1

    Share the further root-cause analysis with the deceased’s family and Sussex Trauma Network consultants.

    Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 November 2020.
  2. 2

    Discuss radiology learning from the CT findings at Radiology Events and Learning meetings and share it with departmental radiologists.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2020.
  3. 3

    Discuss the PFD report at the Trust Trauma and Orthopaedic Clinical Governance meeting.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2020.
  4. 4

    Conduct a further thorough root-cause analysis of trauma care.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2020.
  5. 5

    Hold regular cross-Trust educational and clinical governance meetings on complex trauma management.

    Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 November 2020.
  6. 6

    Share the PFD report with trauma and orthopaedic consultants, radiologists, physiotherapists, ward nurses and junior doctors through teaching.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2020.

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

Share the further root-cause analysis with the deceased’s family and Sussex Trauma Network consultants.

Verbatim wording from the response

“The Trust welcomes the opportunity to review the way that patients who sustain trauma are managed. As part of this process, the PFD report has been shared with the Trauma and Orthopaedic Consultants, Radiologists, Physiotherapists, ward nurses and through teaching with the junior doctors on both sites of the Trust. It has also been discussed at the Trust Trauma and Orthopaedic Clinical Governance meeting and a further thorough RCA been conducted which will be shared with Mrs Linda Phillipson’s family and Sussex Trauma Network Consultants.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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

Discuss radiology learning from the CT findings at Radiology Events and Learning meetings and share it with departmental radiologists.

Verbatim wording from the response

“Mrs Phillipson’s CT scan findings were also discussed at Radiology Events and Learning meetings (REALM, formerly discrepancy meeting) to all radiologists in the department and the learning from this shared.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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

Discuss the PFD report at the Trust Trauma and Orthopaedic Clinical Governance meeting.

Verbatim wording from the response

“The Trust welcomes the opportunity to review the way that patients who sustain trauma are managed. As part of this process, the PFD report has been shared with the Trauma and Orthopaedic Consultants, Radiologists, Physiotherapists, ward nurses and through teaching with the junior doctors on both sites of the Trust. It has also been discussed at the Trust Trauma and Orthopaedic Clinical Governance meeting and a further thorough RCA been conducted which will be shared with Mrs Linda Phillipson’s family and Sussex Trauma Network Consultants.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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 a further thorough root-cause analysis of trauma care.

Verbatim wording from the response

“The Trust welcomes the opportunity to review the way that patients who sustain trauma are managed. As part of this process, the PFD report has been shared with the Trauma and Orthopaedic Consultants, Radiologists, Physiotherapists, ward nurses and through teaching with the junior doctors on both sites of the Trust. It has also been discussed at the Trust Trauma and Orthopaedic Clinical Governance meeting and a further thorough RCA been conducted which will be shared with Mrs Linda Phillipson’s family and Sussex Trauma Network Consultants.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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 regular cross-Trust educational and clinical governance meetings on complex trauma management.

Verbatim wording from the response

“Further to this, there are also plans for regular Educational and Clinical Governance meetings between Brighton & Sussex University Hospitals, Eastern Sussex Hospitals NHS Trust and Western Sussex Hospitals for complex trauma management beginning from January 2021.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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

Share the PFD report with trauma and orthopaedic consultants, radiologists, physiotherapists, ward nurses and junior doctors through teaching.

Verbatim wording from the response

“The Trust welcomes the opportunity to review the way that patients who sustain trauma are managed. As part of this process, the PFD report has been shared with the Trauma and Orthopaedic Consultants, Radiologists, Physiotherapists, ward nurses and through teaching with the junior doctors on both sites of the Trust. It has also been discussed at the Trust Trauma and Orthopaedic Clinical Governance meeting and a further thorough RCA been conducted which will be shared with Mrs Linda Phillipson’s family and Sussex Trauma Network Consultants.”

Source location

2020-0172-Response-from-Western-Sussex-Hospital-Trust_Redacted.pdf
Page 1 · response
Published 10 November 2020

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