Maurice Cowling and 2 others · Prevention of Future Deaths report

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Issued 13 Mar 2015•North Lincolnshire and Grimsby

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

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 raised1

  1. Inadequate resources for managing recognised procedural complications

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. Northern Lincolnshire and Goole NHS Foundation Trust

    Complete a patient safety review of the three cases from anaesthetic and surgical perspectives to determine whether further Trust action was needed.

  2. Northern Lincolnshire and Goole NHS Foundation Trust

    Complete the Serious Untoward Incident action plan to minimise recurrence risk and ensure staff understand the required response to similar cases.

  3. Northern Lincolnshire and Goole NHS Foundation Trust

    Share the Serious Untoward Incident report and action plan with the coroner.

  4. Northern Lincolnshire and Goole NHS Foundation Trust

    Keep the Trust’s arrangements for managing post-operative complications under review.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Northern Lincolnshire and Goole NHS Foundation Trust

    The three patients’ complications were managed appropriately, including appropriate treatment of the haemorrhage, infection and post-operative deterioration.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Northern Lincolnshire and Goole NHS Foundation Trust

    Existing arrangements are considered appropriate for managing post-operative complications, so no further specific actions have been identified, subject to review.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. Northern Lincolnshire and Goole NHS Foundation Trust

    The evidence does not establish with certainty that the acetabular screw caused the pelvic haemorrhage; an underlying vascular abnormality was also possible.

    Disputes 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

Inadequate resources for managing recognised procedural complications

Wider context from the report

“Despite evidence of the rarity of deaths occurring as a consequence of such procedures three cases have received the attention of the Coroner within a short period. Two procedures were carried out within the Trust, the third (Mr. Connon) by St Hugh’s Hospital under an NHS contract. In the latter case the deceased was transferred to a Trust hospital for emergency management. Evidence led in the cases raise concerns that resources within the Trust area may be inadequate to deal with recognised complications occurring either during the procedure or later ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 patient safety review of the three cases from anaesthetic and surgical perspectives to determine whether further Trust action was needed.

Verbatim wording from the response

“Further to your letter of 13 March with enclosed Regulation 28 report, the Trust has now completed the patient safety review of the three cases that you requested.”

Source location

2015-0096-Response-by-Northern-Lincolnshire-Goole-NHS-Trust
Page 1 · response
Published 13 March 2015

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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 the Serious Untoward Incident action plan to minimise recurrence risk and ensure staff understand the required response to similar cases.

Verbatim wording from the response

“The Trust investigated this case as a Serious Untoward Incident (SUI) and, as you are aware, an independent external opinion was obtained from a Consultant Orthopaedic Surgeon, ████████. He confirmed that the injury sustained to the blood vessel is a rare but well recognised complication and that the complication was also managed appropriately.”

Source location

2015-0096-Response-by-Northern-Lincolnshire-Goole-NHS-Trust
Page 2 · response
Published 13 March 2015

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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 Serious Untoward Incident report and action plan with the coroner.

Verbatim wording from the response

“The SUI report made a number of recommendations in relation to minimising the risk of such an incident occurring again and also ensuring staff are aware of what action needs to be taken in a similar case. I am aware that the SUI report and action plan were shared with you ahead of the Inquest which was held. I can also confirm that all actions are now complete.”

Source location

2015-0096-Response-by-Northern-Lincolnshire-Goole-NHS-Trust
Page 2 · response
Published 13 March 2015

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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

Keep the Trust’s arrangements for managing post-operative complications under review.

Verbatim wording from the response

“In conclusion, from the Trust’s review it is felt that the Trust has in place appropriate arrangements to deal with post-operative complications of the nature experienced. Whilst no further specific actions have been identified, this will be kept under review.”

Source location

2015-0096-Response-by-Northern-Lincolnshire-Goole-NHS-Trust
Page 4 · response
Published 13 March 2015

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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 three patients’ complications were managed appropriately, including appropriate treatment of the haemorrhage, infection and post-operative deterioration.

Verbatim wording from the response

“The Trust investigated this case as a Serious Untoward Incident (SUI) and, as you are aware, an independent external opinion was obtained from a Consultant Orthopaedic Surgeon, ████████. He confirmed that the injury sustained to the blood vessel is a rare but well recognised complication and that the complication was also managed appropriately.”

Source location

2015-0096-Response-by-Northern-Lincolnshire-Goole-NHS-Trust
Page 2 · response
Published 13 March 2015

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

Existing arrangements are considered appropriate for managing post-operative complications, so no further specific actions have been identified, subject to review.

Verbatim wording from the response

“In conclusion, from the Trust’s review it is felt that the Trust has in place appropriate arrangements to deal with post-operative complications of the nature experienced. Whilst no further specific actions have been identified, this will be kept under review.”

Source location

2015-0096-Response-by-Northern-Lincolnshire-Goole-NHS-Trust
Page 4 · response
Published 13 March 2015

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 evidence does not establish with certainty that the acetabular screw caused the pelvic haemorrhage; an underlying vascular abnormality was also possible.

Verbatim wording from the response

“From an orthopaedic point of view it is relatively common for the acetabular screw to enter the pelvis during this type of surgery but the haemorrhage which occurred here is not something that the surgeons have previously encountered. The surgery was performed by a very experienced surgeon (a Consultant) and the technique used was a standard one. Precisely why on this occasion there was such a significant haemorrhage is very difficult to establish. The Pathologist has noted that he was unable to identify the blood vessel from which the bleed had originated because the arteries were heavily calcified, difficult to cut and the site was obscured by blood clot. It is therefore difficult to conclude with any degree of certainty why the haemorrhage occurred in this case.”

Source location

2015-0096-Response-by-Northern-Lincolnshire-Goole-NHS-Trust
Page 3 · response
Published 13 March 2015

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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