PFD report

Lady Lola Kay Crouch · Prevention of Future Deaths report

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Issued 21 Feb 2025•Essex

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 trigger a Medical Emergency call when elevated NEWS scores require medical review
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants itPart of recurring concern: Unreliable activation of emergency medical response teamsPart of recurring concern: Unreliable clinical Early Warning Score systems for deterioration
  2. Delays in medical review due to doctor staffing levels
    Part of recurring concern: Failure to provide timely medical review of admitted patientsPart of recurring concern: Insufficient medical staffing capacity for timely patient care
  3. Failure to follow up potential malignancy findings
    Part of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted upon
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.5

  1. Action

    Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  2. Action

    Reiterate NEWS and local clinical escalation processes to new surgical residents during standard induction.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
  3. Action

    Provide patients with copies of their radiology reports through the NHS App, including summaries of clinical findings.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The referring clinician is responsible for delivering requested radiology results and communicating significant findings to patients.

    Stated by Mid and South Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 trigger a Medical Emergency call when elevated NEWS scores require medical review

Wider context from the report

“(2) Staffing levels – A Medical Emergency call was not triggered overnight on the surgical ward when elevated NEWS scores required medical review that was escalated but delayed due to doctor staffing levels. ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it; Unreliable activation of emergency medical response teams; Unreliable clinical Early Warning Score systems for deterioration.

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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

Delays in medical review due to doctor staffing levels

Wider context from the report

“(2) Staffing levels – A Medical Emergency call was not triggered overnight on the surgical ward when elevated NEWS scores required medical review that was escalated but delayed due to doctor staffing levels. ”

Is this part of a recurring concern?

Yes — Failure to provide timely medical review of admitted patients; Insufficient medical staffing capacity for timely patient care.

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 follow up potential malignancy findings

Wider context from the report

“(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023. ”

Is this part of a recurring concern?

Yes — Failure to ensure clinical investigation results are reliably available, interpreted and acted upon.

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 include relevant diagnostic findings in the patient history

Wider context from the report

“(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically significant diagnostic findings to patients and care providers.

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 inform patients of potential malignancy findings

Wider context from the report

“(1) Lady Lola was not informed of the findings of potential malignancy from a CT scan in December 2022. This was not followed up and was then not given as part of the history when Lady Lola attended hospital in February 2023. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically significant diagnostic findings to patients and care providers.

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

Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.

Verbatim wording from the response

“Since Lady Lola’s case we have established the hospital out of hours service in the surgical department to provide a more robust response to the surgical wards. This process has been in place for other specialties previously and we know it works very well.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 25 February 2025

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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

Reiterate NEWS and local clinical escalation processes to new surgical residents during standard induction.

Verbatim wording from the response

“Along with the hospital wide trigger response team and hospital out of hours service, this provides the surgical team, with senior nursing support who can provide the more junior surgical resident with clinical support, vascular access, resuscitative support, and escalation prompting. We have further reiterated the NEWS and local clinical escalation process to the new residents as part of our standard induction process.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 25 February 2025

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 patients with copies of their radiology reports through the NHS App, including summaries of clinical findings.

Verbatim wording from the response

“As part of our digital improvement innovation project, we have signed up to the ‘NHS App’ radiology reporting service whereby patients now receive a copy of their own imaging reports to their personal NHS App. The reports include a summary of clinical findings that can be read by patients to improve communication and understanding of their own health record.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 25 February 2025

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 learning from the case and reinforce NEWS2 escalation, trigger-response-team and local escalation requirements with surgical staff.

Verbatim wording from the response

“Our ‘NEWS2’ escalation policy was in place at the time of Lady Lola’s attendances. The outcome of Lady Lola’s case was communicated at both our July 2024 and August 2024 general surgical audit meetings to share learning. During the meetings we highlighted the importance of compliance with the NEWS2 escalation policy again and reminded the surgical staff about the role of the trigger response team, and our local departmental escalation process. The trigger response and hospital out of hours team are automatically notified by the electronic observation system, NEWS escalations and attend the unwell patient.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 25 February 2025

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 changes and processes to ensure patients are properly informed of their imaging results.

Verbatim wording from the response

“We have implemented the necessary changes to ensure that patients are properly informed of their imaging results, and embedded new processes within our surgical teams to make sure surgical colleagues are well supported overnight for urgent cases and when required the Consultants act down as per policy.”

Source location

Response from Mid & South Essex NHS Trust
Page 3 · response
Published 25 February 2025

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 referring clinician is responsible for delivering requested radiology results and communicating significant findings to patients.

Verbatim wording from the response

“Our policy ‘Communication of time critical or unexpected significant findings during diagnostic reporting’ MSEPO-21240’ makes clear that the referring clinician is responsible for delivery of any radiology they request. Where radiological imaging reports detect an unexpected, significant or time sensitive finding, our policy provides that a radiology alert is sent to the responsible consultant with the full report so that prompt action can be taken, including communication with the patient.”

Source location

Response from Mid & South Essex NHS Trust
Page 1 · response
Published 25 February 2025

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

NEWS2 escalation, trigger response, out-of-hours support and consultant acting-down arrangements provide sufficient staffing safeguards for urgent surgical cases.

Verbatim wording from the response

“Our ‘NEWS2’ escalation policy was in place at the time of Lady Lola’s attendances. The outcome of Lady Lola’s case was communicated at both our July 2024 and August 2024 general surgical audit meetings to share learning. During the meetings we highlighted the importance of compliance with the NEWS2 escalation policy again and reminded the surgical staff about the role of the trigger response team, and our local departmental escalation process. The trigger response and hospital out of hours team are automatically notified by the electronic observation system, NEWS escalations and attend the unwell patient.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 25 February 2025

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 radiology alerts, communication procedures and annual audits provide sufficient arrangements for timely review and patient communication of significant findings.

Verbatim wording from the response

“Our policy ‘Communication of time critical or unexpected significant findings during diagnostic reporting’ MSEPO-21240’ makes clear that the referring clinician is responsible for delivery of any radiology they request. Where radiological imaging reports detect an unexpected, significant or time sensitive finding, our policy provides that a radiology alert is sent to the responsible consultant with the full report so that prompt action can be taken, including communication with the patient.”

Source location

Response from Mid & South Essex NHS Trust
Page 1 · response
Published 25 February 2025

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 presentation and symptom resolution were more consistent with adhesive than malignant small bowel obstruction, making malignancy an unexpected outcome.

Verbatim wording from the response

“I am advised by my surgical colleagues that presentations to the Emergency Department (ED) with signs and symptoms of bowel obstruction, particularly small bowel obstruction, have a variety of differential diagnoses. As in Lady Lola’s case, with a background of multiple previous complex open operations, adhesions are the leading cause of small bowel obstruction.”

Source location

Response from Mid & South Essex NHS Trust
Page 2 · response
Published 25 February 2025

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