PFD report

Michael Chadwick · Prevention of Future Deaths report

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Issued 27 Apr 2026•Nottinghamshire

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.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

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

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Concerns raised1

  1. Failure to provide patients with advice to stop driving and notify the DVLA about cough syncope
    Part of recurring concern: Unreliable DVLA medical fitness notification arrangements
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.9

  1. Action

    Disseminate DVLA fitness-to-drive guidance to clinical governance leaders and clinicians through governance meetings, reports and email, requiring clinicians to familiarise themselves with it.

    Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2026.
  2. Action

    Add a DVLA medical-conditions link, including syncope guidance, to the Cardiology specialist intranet page.

    Stated by Sherwood Forest Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
  3. Action

    Implement the Trust-wide “Fitness to Drive: Ask, Advise, Document” patient safety alert.

    Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.

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 patients with advice to stop driving and notify the DVLA about cough syncope

Wider context from the report

“1. On the multiple occasions that Mr Chadwick was assessed, and his cough syncope brought to the attention of the medical professionals, there was no advice given him to stop driving and to notify the DVLA of his cough syncope, either orally or in writing. I am concerned that clinicians may fail to provide similar guidance to other patients, which may lead to episodes of syncope whilst driving, with potentially fatal consequences. ”

Is this part of a recurring concern?

Yes — Unreliable DVLA medical fitness notification arrangements.

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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

Disseminate DVLA fitness-to-drive guidance to clinical governance leaders and clinicians through governance meetings, reports and email, requiring clinicians to familiarise themselves with it.

Verbatim wording from the response

“Communication to all Heads of Service and Clinical Governance Leads”

Source location

Response from Sherwood Forest Hospitals NHS Trust
Page 1 · response
Published 17 July 2026

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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

Add a DVLA medical-conditions link, including syncope guidance, to the Cardiology specialist intranet page.

Verbatim wording from the response

“The DVLA link regarding medical conditions to be added to Cardiology intranet page.”

Source location

Response from Sherwood Forest Hospitals NHS Trust
Page 2 · response
Published 17 July 2026

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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

Implement the Trust-wide “Fitness to Drive: Ask, Advise, Document” patient safety alert.

Verbatim wording from the response

“Patient Safety Alert – Fitness to Drive: Ask, Advise, Document”

Source location

Response from Sherwood Forest Hospitals NHS Trust
Page 1 · response
Published 17 July 2026

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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

Add DVLA fitness-to-drive guidance to the EOLAS learning area and resources.

Verbatim wording from the response

“Add the DVLA guidance to be added to the learning area on EOLAS, as part of the extended learning and resources.”

Source location

Response from Sherwood Forest Hospitals NHS Trust
Page 1 · response
Published 17 July 2026

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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

Add DVLA fitness-to-drive guidance to the Trust intranet.

Verbatim wording from the response

“Add DVLA guidance to the Trust intranet.”

Source location

Response from Sherwood Forest Hospitals NHS Trust
Page 1 · response
Published 17 July 2026

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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

Advise all clinicians to bookmark DVLA fitness-to-drive standards and guidance for easy access.

Verbatim wording from the response

“that this was a complex case, had multiple speciality input but on balance would and should have resulted in advice regarding fitness to drive. As a Practice this has highlighted the need to refresh our knowledge of the DVLA standards and guidance for medical professionals. All clinicians were advised to keep this guidance as a bookmark for ease of access. We have also identified the importance of accurate documentation, if this advice is given verbally but not documented, even if fitness to drive has been considered but deemed safe, both relevant and need clear documentation. There is also the ability to quick code this advice via our clinical system, SystmOne. This also includes a quick guide and notification responsibilities of the patient and clinicians.”

Source location

Response from Middleton Lodge Practice
Page 2 · response
Published 17 July 2026

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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

Circulate the transient loss of consciousness guidance to all Trust consultants.

Verbatim wording from the response

“1. Review of the NUH guidelines relating to Transient Loss of Consciousness”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 2 · response
Published 17 July 2026

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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

Review the Trust’s transient loss of consciousness guidance.

Verbatim wording from the response

“In response, the following actions are being taken:”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 2 · response
Published 17 July 2026

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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

Circulate Medical Director and DVLA driving-advice guidance to consultants and Care Group Governance teams, and publish it on KOHA.

Verbatim wording from the response

“2. Guidance from the Medical Director and DVLA circulated to all Consultants and Care Group Governance teams within the Trust to confirm the importance of providing this information to patients.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 2 · response
Published 17 July 2026

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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.3

  1. 1

    Continue monitoring completion of the action plan and securely store completion evidence with the relevant Datix action identifiers.

    Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2026.
  2. 2

    Run a six-month system audit of read-code use and identification.

    Stated by Partnership at Middleton Lodge PracticeStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
  3. 3

    Provide Quality and Safety Governance Committee oversight of action delivery and submit progress reports to the Board’s committees.

    Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.

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

Continue monitoring completion of the action plan and securely store completion evidence with the relevant Datix action identifiers.

Verbatim wording from the response

“An action plan has been formulated, and the Trust will continue to monitor the completion of these actions by attaching evidence of their completion that will be securely stored on the Trust’s datix incident system alongside the relevant action ID number to provide assurance of their completion.”

Source location

Response from Sherwood Forest Hospitals NHS Trust
Page 1 · response
Published 17 July 2026

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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

Run a six-month system audit of read-code use and identification.

Verbatim wording from the response

“Following from this I plan to run a system audit in 6 months to audit the use of readcodes/identification.”

Source location

Response from Middleton Lodge Practice
Page 2 · response
Published 17 July 2026

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 Quality and Safety Governance Committee oversight of action delivery and submit progress reports to the Board’s committees.

Verbatim wording from the response

“The actions taken in response to the learning from the inquest are summarised in the attached document. Oversight of the delivery of these actions will be through our Quality and Safety Governance Committees, with Executive oversight and the Committees of our Board will receive a progress report.”

Source location

Response from Nottingham University Hospitals NHS Trust
Page 1 · response
Published 17 July 2026

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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