PFD report

Rose Jean COLES · Prevention of Future Deaths report

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Issued 27 Sep 2013•Avon

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
13

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. Inadequate communication between the neonatal intensive care and cardiac units
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unreliable inter-specialty communication for complex patient care
  2. Failure of the cardiac unit to provide care suited to premature babies
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.4

  1. Action

    Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  2. Action

    Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  3. Action

    Provide premature-infant feeding guidance and train appropriate staff on the paediatric cardiac ward.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.

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 communication between the neonatal intensive care and cardiac units

Wider context from the report

“Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable communication of patient-care information between clinical staff; Unreliable inter-specialty communication for complex patient care.

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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

Failure of the cardiac unit to provide care suited to premature babies

Wider context from the report

“Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. ”

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

Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.

Verbatim wording from the response

“Improve formal communication between NICU and Cardiac Unit. | RIC | Develop Structured Cardiac Transfer Pack for use between two units. | ████████ | 30th November 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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

Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.

Verbatim wording from the response

“| RIC | Confirm NICU/BCH link consultant through regular circulation of rota to cardiac ward. | ████████ | 28th October 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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

Provide premature-infant feeding guidance and train appropriate staff on the paediatric cardiac ward.

Verbatim wording from the response

“Facilitate care of premature infant on cardiac ward if appropriate for baby to be there. | RIC | Provide feeding guideline for premature infants and appropriate staff training to paediatric cardiac ward. | ████████ | 30th November 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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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

Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.

Verbatim wording from the response

“| RIC | Confirm NICU nurse in charge available 24 hours per day for telephone advice if requested to all cardiac ward staff. | ████████ | 28th October 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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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.9

  1. 1

    Develop and deliver joint education on common NICU and midwifery newborn issues for relevant staff groups.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  2. 2

    Monitor the action plan through Trust governance procedures to ensure full implementation.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  3. 3

    Update, govern, disseminate and provide required training on clinical guidelines for newborn infants at risk of hypoglycaemia.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  4. 4

    Provide dedicated training to improve midwives’ use of SBAR when communicating with neonatologists and paediatricians.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  5. 5

    Plot every newborn infant’s birth weight on a specified centile chart to identify hypoglycaemia risk.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  6. 6

    Update the newborn observation chart to prompt blood-sugar testing for poorly feeding newborn infants.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  7. 7

    Review the postnatal ward workload implications of changing to a centile-specific risk pathway.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  8. 8

    Review the implications of different centile charts and identify newborn infants at risk of hypoglycaemia.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.
  9. 9

    Add competencies for recognising unwell postnatal-ward newborn infants to annual midwife training and education.

    Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2013.

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 deliver joint education on common NICU and midwifery newborn issues for relevant staff groups.

Verbatim wording from the response

“| JWM | Develop and deliver joint education of common NICU & midwifery newborn issues across relevant staff groups. | ████████ | 31st January 2014”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 3 · response
Published 27 September 2013

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 the action plan through Trust governance procedures to ensure full implementation.

Verbatim wording from the response

“Further to the recent inquests, into the deaths of Jared McDowall and Rose Coles, please find attached a composite action plan addressing the matters of concern addressed within the two Regulation 28 Reports issued to the Trust on the 1st October 2013. The Trust is confident that the actions described, many of which are already in hand, will address the concerns expressed and mitigate the risk identified of future deaths attributable to these factors. The action plan will be monitored through the Trust’s governance procedures to ensure its full implementation.”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 1 · response
Published 27 September 2013

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, govern, disseminate and provide required training on clinical guidelines for newborn infants at risk of hypoglycaemia.

Verbatim wording from the response

“| JWM | Update clinical guidelines for at risk new-born infants, secure sign off through appropriate governance channels and disseminate with training as required. | ████████ | 31st January 2014”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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

Provide dedicated training to improve midwives’ use of SBAR when communicating with neonatologists and paediatricians.

Verbatim wording from the response

“Improve joint working between NICU and Postnatal wards. | JWM | Improve the use of SBAR communication tool by midwifery staff to neonatologists and paediatricians, through dedicated training. | ████████ | 31st December 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 3 · response
Published 27 September 2013

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

Plot every newborn infant’s birth weight on a specified centile chart to identify hypoglycaemia risk.

Verbatim wording from the response

“Improve identification of new-born infants at risk of hypoglycaemia. | JWM | Implement the plotting of birth weight for every new-born infant on specific centile chart to identify those at risk of hypoglycaemia. | ████████ | 31st December 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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 newborn observation chart to prompt blood-sugar testing for poorly feeding newborn infants.

Verbatim wording from the response

“| JWM | Update newborn observation chart to request blood sugar on poorly feeding new-born infants. | ████████ | 30th November 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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 the postnatal ward workload implications of changing to a centile-specific risk pathway.

Verbatim wording from the response

“| JWM | Review of implications of change to centile specific risk pathway on workload for postnatal ward. | ████████ | 30th November 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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 the implications of different centile charts and identify newborn infants at risk of hypoglycaemia.

Verbatim wording from the response

“| JWM | Review of implications of different centile charts and identify those at risk of hypoglycaemia. | ████████ | 31st December 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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

Add competencies for recognising unwell postnatal-ward newborn infants to annual midwife training and education.

Verbatim wording from the response

“| JWM | Include specific competencies for recognition of the unwell postnatal ward new-born infant in the current annual midwife training and education update. | ████████ | 31st December 2013”

Source location

2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013

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