PFD report

Michael Edward Giles · Prevention of Future Deaths report

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Issued 30 Oct 2017•Worcestershire

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
9

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 assign responsibility for carrying out and following up tests and investigations during crisis periods
  2. Failure to assign responsibility for complete and thorough handover
    Part of recurring concern: Unreliable shift handover processes
  3. Inadequate case notes and medical records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care 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.5

  1. Action

    Reorganize consultant working practices to increase the proportion of patients receiving review at least every 24 hours.

    Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
  2. Action

    Develop a clinical record-keeping video with the communications team to improve documentation standards.

    Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2017.
  3. Action

    Complete an audit establishing baseline clinical record-keeping performance and assessing improvement interventions.

    Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The existing SBAR handover structure and ward board rounds are considered robust arrangements for transferring clinical information.

    Stated by Worcestershire Acute Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 assign responsibility for carrying out and following up tests and investigations during crisis periods

Wider context from the report

“(3) There was an acknowledgement within the Trusts investigation that, during the crisis period of this patient's admission there was a lack of leadership from both clinicians and nurses with no one taking responsibility to ensure that tests and investigations were in fact carried out and followed up. ”

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 assign responsibility for complete and thorough handover

Wider context from the report

“(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared. It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion. The highlighting of the needs of particular patients who were the subject of the handover was inadequate. ”

Is this part of a recurring concern?

Yes — Unreliable shift handover processes.

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

Inadequate case notes and medical records

Wider context from the report

“4 The case notes and medical records were (again) inadequate. I have been told on many occasions that the importance of good record-keeping is emphasised to clinicians - sadly in this case yet again the lessons do not appear to be being learned. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Inadequate highlighting of particular patients' needs during handover

Wider context from the report

“(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared. It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion. The highlighting of the needs of particular patients who were the subject of the handover was inadequate. ”

Is this part of a recurring concern?

Yes — Unreliable handover of care information and responsibility; Unreliable shift handover processes.

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 handover processes failing to ensure adequate information sharing

Wider context from the report

“(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared. It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion. The highlighting of the needs of particular patients who were the subject of the handover was inadequate. ”

Is this part of a recurring concern?

Yes — Unreliable shift handover processes.

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

Absence of senior review of patients over weekends

Wider context from the report

“(2) The absence of a senior review of patients over the weekend was a factor in the suboptimal care given to this patient. ”

Is this part of a recurring concern?

Yes — Failure to provide effective senior clinical oversight of patient care; Insufficient safe staffing and senior cover out of hours.

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

Reorganize consultant working practices to increase the proportion of patients receiving review at least every 24 hours.

Verbatim wording from the response

“There is already an expectation that all patients need to be reviewed 7 days per week. For those patients with high dependency needs the expectation is that they are seen and reviewed by a consultant twice daily (including acutely ill patients directly transferred and other who deteriorate). An audit of our practice from March 2017 shows that we were able to meet this requirement 93% of occasions. The overall proportion of patients who required a daily consultant review and were reviewed by a consultant was 68%. In order to improve this further working practice by consultants has been reorganised to facilitate a higher proportion of patients being seen at least once every 24 hours. In order to keep the risks to a minimum for patients undergoing invasive procedures we are already reviewing where these can be done, i.e.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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

Develop a clinical record-keeping video with the communications team to improve documentation standards.

Verbatim wording from the response

“We recognise the importance of good clinical record note keeping. As part of this, we have undertaken an audit to assess our baseline and thereby assess the impact of interventions to improve this. I have attached the audit which demonstrates areas of good practice as well as areas in need of improvement. We’re also working with the communications team to develop a clinical records keeping video to drive up standards. I anticipate that this will be available in February. I’ve also attached a leaflet that will be forwarded to all in the Trust that utilise patient’s notes. The attached has yet to be finalised and is merely to provide an indication of the direction of travel. I anticipate that this will be available in February 2018.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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

Complete an audit establishing baseline clinical record-keeping performance and assessing improvement interventions.

Verbatim wording from the response

“We recognise the importance of good clinical record note keeping. As part of this, we have undertaken an audit to assess our baseline and thereby assess the impact of interventions to improve this. I have attached the audit which demonstrates areas of good practice as well as areas in need of improvement. We’re also working with the communications team to develop a clinical records keeping video to drive up standards. I anticipate that this will be available in February. I’ve also attached a leaflet that will be forwarded to all in the Trust that utilise patient’s notes. The attached has yet to be finalised and is merely to provide an indication of the direction of travel. I anticipate that this will be available in February 2018.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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

Finalize and distribute a clinical record-keeping leaflet to Trust staff who use patient notes.

Verbatim wording from the response

“We recognise the importance of good clinical record note keeping. As part of this, we have undertaken an audit to assess our baseline and thereby assess the impact of interventions to improve this. I have attached the audit which demonstrates areas of good practice as well as areas in need of improvement. We’re also working with the communications team to develop a clinical records keeping video to drive up standards. I anticipate that this will be available in February. I’ve also attached a leaflet that will be forwarded to all in the Trust that utilise patient’s notes. The attached has yet to be finalised and is merely to provide an indication of the direction of travel. I anticipate that this will be available in February 2018.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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 a standardized SBAR structure for clinical handovers across the hospital.

Verbatim wording from the response

“1. You’ve invited the Trust to consider standardising the handover process across the hospital and to put in place a protocol whereby the identity of the person responsible for ensuring the handover takes place is clearly recognised.”

Source location

2017-0309-Response
Page 1 · response
Published 28 November 2017

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 existing SBAR handover structure and ward board rounds are considered robust arrangements for transferring clinical information.

Verbatim wording from the response

“The events surrounding this tragic case and your regulation 28 letter was discussed with the trainees in early November 2017. The conclusion from the trainees was that they were confident that the processes now in place were robust and they had not experienced any near misses as a consequence of inadequate handover. There is a standardised structure for handover which follows SBAR. This is an acronym for Situation, Background, Assessment, Recommendation. With reference to identifying a responsible person is a little more fraught. Handover takes place at multiple levels whilst the patient remains an inpatient.”

Source location

2017-0309-Response
Page 1 · response
Published 28 November 2017

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.4

  1. 1

    Review locations for invasive procedures to limit procedures to areas with appropriate post-procedure expertise.

    Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2017.
  2. 2

    Discuss handover safety and processes with medical trainees through the Director for Medical Education.

    Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
  3. 3

    Introduce human factors training for relevant clinical staff.

    Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2017.
  4. 4

    Audit unexpected intensive-care admissions and daytime emergency-team calls for care adequacy and timely escalation.

    Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A protocol nominating a single lead during clinical deterioration cannot be implemented because leadership requirements vary with the patient's condition and care setting.

    Stated by Worcestershire Acute Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 locations for invasive procedures to limit procedures to areas with appropriate post-procedure expertise.

Verbatim wording from the response

“There is already an expectation that all patients need to be reviewed 7 days per week. For those patients with high dependency needs the expectation is that they are seen and reviewed by a consultant twice daily (including acutely ill patients directly transferred and other who deteriorate). An audit of our practice from March 2017 shows that we were able to meet this requirement 93% of occasions. The overall proportion of patients who required a daily consultant review and were reviewed by a consultant was 68%. In order to improve this further working practice by consultants has been reorganised to facilitate a higher proportion of patients being seen at least once every 24 hours. In order to keep the risks to a minimum for patients undergoing invasive procedures we are already reviewing where these can be done, i.e.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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

Discuss handover safety and processes with medical trainees through the Director for Medical Education.

Verbatim wording from the response

“The events surrounding this tragic case and your regulation 28 letter was discussed with the trainees in early November 2017. The conclusion from the trainees was that they were confident that the processes now in place were robust and they had not experienced any near misses as a consequence of inadequate handover. There is a standardised structure for handover which follows SBAR. This is an acronym for Situation, Background, Assessment, Recommendation. With reference to identifying a responsible person is a little more fraught. Handover takes place at multiple levels whilst the patient remains an inpatient.”

Source location

2017-0309-Response
Page 1 · response
Published 28 November 2017

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

Introduce human factors training for relevant clinical staff.

Verbatim wording from the response

“In all cases when patients take a turn for the worse the most senior Doctor is responsible for taking the lead in ensuring optimum care is given. It is not possible to have a protocol to identify a nominated individual because the required leadership depends on the underlying condition. Thus what is required in Emergency Department and who should take the lead might be very different to the needs surrounding a post-operative event or indeed during a period of convalescence whilst on the ward. The key to such events is identifying changes to the patient’s condition in a timely manner before any event occurs. To this end, we audit all patients brought to intensive care unexpectedly or patients requiring the emergency team during the day time. We assess for the adequacy of care and the appropriateness of timely escalation prior to this. We have also started human factors training.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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

Audit unexpected intensive-care admissions and daytime emergency-team calls for care adequacy and timely escalation.

Verbatim wording from the response

“In all cases when patients take a turn for the worse the most senior Doctor is responsible for taking the lead in ensuring optimum care is given. It is not possible to have a protocol to identify a nominated individual because the required leadership depends on the underlying condition. Thus what is required in Emergency Department and who should take the lead might be very different to the needs surrounding a post-operative event or indeed during a period of convalescence whilst on the ward. The key to such events is identifying changes to the patient’s condition in a timely manner before any event occurs. To this end, we audit all patients brought to intensive care unexpectedly or patients requiring the emergency team during the day time. We assess for the adequacy of care and the appropriateness of timely escalation prior to this. We have also started human factors training.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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

A protocol nominating a single lead during clinical deterioration cannot be implemented because leadership requirements vary with the patient's condition and care setting.

Verbatim wording from the response

“In all cases when patients take a turn for the worse the most senior Doctor is responsible for taking the lead in ensuring optimum care is given. It is not possible to have a protocol to identify a nominated individual because the required leadership depends on the underlying condition. Thus what is required in Emergency Department and who should take the lead might be very different to the needs surrounding a post-operative event or indeed during a period of convalescence whilst on the ward. The key to such events is identifying changes to the patient’s condition in a timely manner before any event occurs. To this end, we audit all patients brought to intensive care unexpectedly or patients requiring the emergency team during the day time. We assess for the adequacy of care and the appropriateness of timely escalation prior to this. We have also started human factors training.”

Source location

2017-0309-Response
Page 2 · response
Published 28 November 2017

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