PFD report

Name not published · Prevention of Future Deaths report

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Issued 21 Jun 2021•Plymouth, Torbay and South Devon

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
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised6

  1. Failure to perform a sip test to exclude aspiration
    Part of recurring concern: Unreliable aspiration assessment and prevention
  2. Failure to properly transfer records
  3. Failure to keep appropriate records
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.2

  1. Action

    Move toward procedure-specific consent information and engage external providers to support standardised information for each procedure.

    Stated by University Hospitals Plymouth NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
  2. Action

    Use the revised SIRI process to address similar record-keeping issues immediately when they arise.

    Stated by University Hospitals Plymouth NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Responsibility for documenting clinical records to the required standard lies with individual practitioners, under professional and Trust requirements.

    Stated by University Hospitals Plymouth NHS 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 perform a sip test to exclude aspiration

Wider context from the report

“(2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust. ”

Is this part of a recurring concern?

Yes — Unreliable aspiration assessment and prevention.

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 properly transfer records

Wider context from the report

“(4) Appropriate records were not kept, or were not properly transferred, by senior staff. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 keep appropriate records

Wider context from the report

“(4) Appropriate records were not kept, or were not properly transferred, by senior staff. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 identify or remedy the absent aspiration-exclusion test

Wider context from the report

“(2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust. ”

Is this part of a recurring concern?

Yes — Unreliable aspiration assessment and prevention.

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

Inconsistent consenting procedures for identical endoscopy treatment

Wider context from the report

“(1) There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy. ”

Is this part of a recurring concern?

Yes — Inadequate informed-consent processes for medical treatment.

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 act on an endoscopy report indicating a possible dangerous complication

Wider context from the report

“(3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication. ”

Is this part of a recurring concern?

Yes — Failure to recognise and manage post-endoscopy complications.

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

Move toward procedure-specific consent information and engage external providers to support standardised information for each procedure.

Verbatim wording from the response

“Currently the plan of the organisation is to move to procedure specific consent where possible and appropriate. We are looking to engage with external providers who produce consent and procedural information that are specific to particular procedures. In that way, rather than individual clinicians using their clinical discretion as to what to discuss with patients, standardised information is given each time a patient consents, ensuring all material information is given. For those undergoing elective surgery, it also allows more time for patients to read at their leisure the information provided, so they have time to digest and absorb the relevant information before signing to say they would wish to proceed.”

Source location

2021-0211-University-Hospitals-Plymouth_Published
Page 2 · response
Published 28 June 2021

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

Use the revised SIRI process to address similar record-keeping issues immediately when they arise.

Verbatim wording from the response

“The Trust accepts that poor record keeping should have been discussed with the individuals at the time of the event to ensure reflective learning. The revised SIRI process will ensure that any similar issues that may arise in the future would be addressed immediately.”

Source location

2021-0211-University-Hospitals-Plymouth_Published
Page 4 · response
Published 28 June 2021

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

Responsibility for documenting clinical records to the required standard lies with individual practitioners, under professional and Trust requirements.

Verbatim wording from the response

“The Trust accepts that elements of the record keeping were poor in this case. All professional bodies have an expectation that individual practitioners will document in the clinical records to an accepted standard. The Trust also has a policy that reflects this expectation. This highlights that responsibility lies with the individual professional and the Trust expects that each individual documents in the health records in accordance with the Trust’s policy and in line with codes of practice set by professional standards. Nevertheless, the Trust recognises that documentation may suffer during intense working periods and therefore we regularly remind staff at induction and through mandatory training the importance of proper documentation.”

Source location

2021-0211-University-Hospitals-Plymouth_Published
Page 3 · response
Published 28 June 2021

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

Sip checking is basic post-recovery care, not a diagnostic test for perforation, and its small fluid volume would not cause mediastinitis.

Verbatim wording from the response

“The use of ‘sip’ checking, i.e. ‘drinking a small amount of water post-oesophago-gastro-duodenoscopy (OGD) is to indicate that patients are able to swallow and do not aspirate liquid into the lungs before being allowed to eat. This is part of basic care and doesn’t constitute a diagnostic procedure, merely an aid to support post recovery after an OGD. The sip check is not a test to exclude perforation and the small volume of fluid would not result in mediastinitis.”

Source location

2021-0211-University-Hospitals-Plymouth_Published
Page 3 · response
Published 28 June 2021

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.1

  1. 1

    Amend endoscopy-specific consent forms to explain that rare complications may result in death.

    Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.

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

Amend endoscopy-specific consent forms to explain that rare complications may result in death.

Verbatim wording from the response

“The current consent guideline at UHP is in line with the British Society of Gastroenterologists (BSG) 2016 and does not expressly mention mortality¹. However after consultation with the Endoscopy stakeholders and learning from other incidents, University Hospitals Plymouth has amended the procedure specific consent forms to include:”

Source location

2021-0211-University-Hospitals-Plymouth_Published
Page 2 · response
Published 28 June 2021

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