PFD report

Anne Elizabeth Sandever · Prevention of Future Deaths report

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Issued 9 Sep 2014•South and West Cambridgeshire

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised5

  1. Failure to identify and manage patients' diabetic control
    Part of recurring concern: Unreliable diabetes care and management
  2. Poor communication and handover of patient information
    Part of recurring concern: Unreliable clinical handover processes
  3. Failure to investigate serious incidents and prevent recurrence
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management processes
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.6

  1. Action

    Present the anonymised case and learning on safe handover and deteriorating-patient recognition at a Clinical Governance Day.

    Stated by North West Anglia NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 September 2014.
  2. Action

    Revise the Trust’s Serious Incident process within the wider quality-improvement programme.

    Stated by North West Anglia NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2014.
  3. Action

    Implement revised ward-transfer and SBAR requirements, including documented face-to-face handover, transfer risk assessment and nurse transfer for patients with MEWS of at least 3.

    Stated by North West Anglia NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2014.

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 identify and manage patients' diabetic control

Wider context from the report

“(2) Communication and handover was poor, no one on the ward knew Mrs Sandever was diabetic or took appropriate care of her diabetic control. ”

Is this part of a recurring concern?

Yes — Unreliable diabetes care and management.

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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 and handover of patient information

Wider context from the report

“(2) Communication and handover was poor, no one on the ward knew Mrs Sandever was diabetic or took appropriate care of her diabetic control. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes.

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 investigate serious incidents and prevent recurrence

Wider context from the report

“(4) There has been no SUI inquiry and the hospital has not investigated this sufficiently to ensure that this does not recur and has not taken the necessary steps to assure me of this. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management processes.

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 provide intravenous fluids to patients with renal failure

Wider context from the report

“(3) She was left without intravenous fluids for many hours despite having renal failure. ”

Is this part of a recurring concern?

Yes — Failure to provide clinically required fluids.

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 nursing observation and care

Wider context from the report

“(1) There was a lack on nursing care afforded to Mrs. Sandever, She was not seen by any nurse or medical staff from until 1030 until 1610 whilst on Walnut ward. ”

Is this part of a recurring concern?

Yes — Inadequate physical nursing care for vulnerable patients.

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

Present the anonymised case and learning on safe handover and deteriorating-patient recognition at a Clinical Governance Day.

Verbatim wording from the response

“Finally, we have presented this case, in an anonymised form, as part of the lessons learned section of a Clinical Governance Day, to make more staff aware of the issues identified and, especially, the core learning around safe handover and the recognition of, and response to, deteriorating patients.”

Source location

2014-0393-Response_Redacted
Page 3 · response
Published 4 September 2014

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

Revise the Trust’s Serious Incident process within the wider quality-improvement programme.

Verbatim wording from the response

“The Trust’s Serious Incident process is also being revised as part of a wider quality improvement programme.”

Source location

2014-0393-Response_Redacted
Page 3 · response
Published 4 September 2014

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 revised ward-transfer and SBAR requirements, including documented face-to-face handover, transfer risk assessment and nurse transfer for patients with MEWS of at least 3.

Verbatim wording from the response

“The recommendations coming from our internal investigation on this issue were that the ward transfer policy and the SBAR chart [which documents the key information at transfer] should be reviewed and updated and that this update would specifically include a requirement to ensure and document that a face to face handover has occurred at the point of transfer from one clinical area to another. All patient transfers would also be risk assessed and any patients who have a MEWS score of ≥3 will be transferred by a nurse who knows the patient.”

Source location

2014-0393-Response_Redacted
Page 2 · response
Published 4 September 2014

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

Recirculate NICE guidance and the ALERT on acute kidney injury to nursing and medical staff.

Verbatim wording from the response

“Please see the response to concern 1 above, as the actions incorporate this issue. In addition, the investigating team recommended specific work around raising awareness of Acute Kidney Injury (AKI) in chronic renal patients. We have, therefore, re-circulated NICE guidance and a subsequent ALERT around AKI to all nursing and medical staff, through which we are raising awareness of the significance of a lack of urine output and fluid replacement in patients with Chronic Renal Failure in an acute episode. Minutes of Critical Care meetings have confirmed circulation and we will include AKIs in our review of incidents.”

Source location

2014-0393-Response_Redacted
Page 2 · response
Published 4 September 2014

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

Monitor revised transfer and handover arrangements through internal audit.

Verbatim wording from the response

“This work is already under way, with the revised policy implemented, and we have a target date of the end of December 2014 for all related actions to have been put in place. This will then be monitored for effectiveness via internal audit.”

Source location

2014-0393-Response_Redacted
Page 2 · response
Published 4 September 2014

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 ward spot checks of patient interactions, call-bell response times and required risk assessments.

Verbatim wording from the response

“We have taken action as a result of this issue, developing and implementing a Trust-wide action plan to address the deficits highlighted in this case. In relation to this specific issue, actions have included the introduction of spot checks undertaken on wards, which include a review of the number of patient interactions, call bell response times and completion of required risk assessments, as well as the delivery of a specific training programme for all staff, in the recognition of a deteriorating patient, the importance of Modified Early Warning Scores (MEWS) and the importance of monitoring urine output as part of the MEWS system. This includes clear triggers and routes for escalation, including input from the Critical Care Outreach team.”

Source location

2014-0393-Response_Redacted
Page 1 · response
Published 4 September 2014

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

    Develop and make Service Excellence training available to staff.

    Stated by North West Anglia NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 September 2014.
  2. 2

    Deliver staff training on deteriorating patients, MEWS, urine-output monitoring and escalation to Critical Care Outreach.

    Stated by North West Anglia NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2014.
  3. 3

    Monitor communication issues through complaints and specifically sought communication feedback.

    Stated by North West Anglia NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2014.
  4. 4

    Identify a means to cascade Service Excellence training more widely.

    Stated by North West Anglia NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2014.
  5. 5

    Include acute kidney injuries in incident reviews.

    Stated by North West Anglia NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 September 2014.
  6. 6

    Audit completion of the deteriorating-patient training and review incident data for failures to treat.

    Stated by North West Anglia NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 September 2014.

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 and make Service Excellence training available to staff.

Verbatim wording from the response

“communication techniques in those interactions. Service excellence training has been developed and is available for staff but the Trust is also identifying a means of wider cascade. We will monitor communications issues via complaints received, and feedback specifically sought on communication.”

Source location

2014-0393-Response_Redacted
Page 3 · response
Published 4 September 2014

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

Deliver staff training on deteriorating patients, MEWS, urine-output monitoring and escalation to Critical Care Outreach.

Verbatim wording from the response

“We have taken action as a result of this issue, developing and implementing a Trust-wide action plan to address the deficits highlighted in this case. In relation to this specific issue, actions have included the introduction of spot checks undertaken on wards, which include a review of the number of patient interactions, call bell response times and completion of required risk assessments, as well as the delivery of a specific training programme for all staff, in the recognition of a deteriorating patient, the importance of Modified Early Warning Scores (MEWS) and the importance of monitoring urine output as part of the MEWS system. This includes clear triggers and routes for escalation, including input from the Critical Care Outreach team.”

Source location

2014-0393-Response_Redacted
Page 1 · response
Published 4 September 2014

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

Monitor communication issues through complaints and specifically sought communication feedback.

Verbatim wording from the response

“communication techniques in those interactions. Service excellence training has been developed and is available for staff but the Trust is also identifying a means of wider cascade. We will monitor communications issues via complaints received, and feedback specifically sought on communication.”

Source location

2014-0393-Response_Redacted
Page 3 · response
Published 4 September 2014

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

Identify a means to cascade Service Excellence training more widely.

Verbatim wording from the response

“communication techniques in those interactions. Service excellence training has been developed and is available for staff but the Trust is also identifying a means of wider cascade. We will monitor communications issues via complaints received, and feedback specifically sought on communication.”

Source location

2014-0393-Response_Redacted
Page 3 · response
Published 4 September 2014

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 acute kidney injuries in incident reviews.

Verbatim wording from the response

“Please see the response to concern 1 above, as the actions incorporate this issue. In addition, the investigating team recommended specific work around raising awareness of Acute Kidney Injury (AKI) in chronic renal patients. We have, therefore, re-circulated NICE guidance and a subsequent ALERT around AKI to all nursing and medical staff, through which we are raising awareness of the significance of a lack of urine output and fluid replacement in patients with Chronic Renal Failure in an acute episode. Minutes of Critical Care meetings have confirmed circulation and we will include AKIs in our review of incidents.”

Source location

2014-0393-Response_Redacted
Page 2 · response
Published 4 September 2014

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 completion of the deteriorating-patient training and review incident data for failures to treat.

Verbatim wording from the response

“This training programme has commenced and is due to be completed by 31 March 2015. We will also conduct a Trust wide audit to ensure completion of the course, alongside a review of”

Source location

2014-0393-Response_Redacted
Page 1 · response
Published 4 September 2014

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