PFD report

Amanda Jane Ellams · Prevention of Future Deaths report

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Issued 8 Jul 2015•Manchester South

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
2

Named on the report

Responses found
1

Of 2 recipients

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 maintain complete and accessible medical and nursing records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure of the out-of-hours District Nursing telephone system to answer calls
  3. Failure to ensure safe oxygen saturation levels before discharge
    Part of recurring concern: Unreliable hospital discharge processes
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

    Maintain and use a hospital-wide documentation standards audit, recording variances and sharing results through peer review.

    Stated by BMI The Alexandra HospitalStated completedThe respondent said that this action was complete when they made their response on 7 August 2015.
  2. Action

    Notify relevant nursing staff that notes must record observations taken after patients are removed from oxygen.

    Stated by BMI The Alexandra HospitalStated plannedThe respondent said that this action was planned when they made their response on 7 August 2015.
  3. Action

    Deliver Royal College of Nursing presentations to nursing staff on documentation standards.

    Stated by BMI The Alexandra HospitalStated plannedThe respondent said that this action was planned when they made their response on 7 August 2015.

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

  1. Position

    Oxygen saturation readings of 90–92% were generally considered adequate for a patient who smoked, although the 89% reading was not adequately documented.

    Stated by BMI The Alexandra HospitalDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 maintain complete and accessible medical and nursing records

Wider context from the report

“1. During the course of the inquest it was apparent that the standard of note keeping at the Alexandra Hospital (both medical and nursing) was well below that which would be generally regarded as satisfactory. There was even one attendance on the patient by the consultant surgeon in February (according to the surgeon’s evidence to me) for which there was no written record whatsoever. The surgeon conceded that he did not have a full medical history available to him pre-operatively and he was not aware of all the prescribed drugs which she was taking. (BMI Healthcare) ”

Is this part of a recurring concern?

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

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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 out-of-hours District Nursing telephone system to answer calls

Wider context from the report

“3. The out-of-hours telephone system for the District Nursing team in Tameside area was operated by Good HealthCare (which also provides the out-of-hours GP service in that area). It was apparent that during the night of her death, Mrs Ellams had made three separate calls to the telephone number she had been given to contact the District Nurses and none of those calls was answered. The duration of the unanswered calls was 2 minutes, 1 minute 50 seconds and 1 minute 14 seconds respectively. In giving his evidence, the Chief Executive of GTD conceded that “it is a flawed system”. (GTD Healthcare) ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 to ensure safe oxygen saturation levels before discharge

Wider context from the report

“2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare) ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge 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

Failure to adequately record and monitor blood oxygen levels

Wider context from the report

“2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare) ”

Is this part of a recurring concern?

Yes — Unreliable monitoring of oxygen saturation during clinical 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 prevent unsafe disconnection of oxygen supply and departure from the ward

Wider context from the report

“2. The Alexandra Hospital Staff Nurse conceded that Mrs Ellams was discharged from hospital even though it is now clear that her oxygen saturations were still too low for such discharge to take place. There was what appeared to be a very lax attitude to recording and monitoring the Blood/Oxygen levels and the patient was allowed to disconnect her oxygen supply and walk out of the ward to go for a cigarette. (BMI Healthcare) ”

Is this part of a recurring concern?

Yes — Failure to safely supervise patients receiving oxygen therapy; Unsafe provision of oxygen therapy.

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

Maintain and use a hospital-wide documentation standards audit, recording variances and sharing results through peer review.

Verbatim wording from the response

“1. From June 2015 a new documentation standards audit has been established. The audit is completed by nursing staff and any variances, omissions or errors are recorded and the results shared through a peer review to ensure learning is shared and improvements made, where identified.”

Source location

2015-0312-Response-Alexandra-Hospital
Page 2 · response
Published 7 August 2015

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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

Notify relevant nursing staff that notes must record observations taken after patients are removed from oxygen.

Verbatim wording from the response

“1. During September 2015 all relevant nursing staff will be notified that nursing notes should always include a record of observations taken after patients have been taken off oxygen.”

Source location

2015-0312-Response-Alexandra-Hospital
Page 3 · response
Published 7 August 2015

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

Deliver Royal College of Nursing presentations to nursing staff on documentation standards.

Verbatim wording from the response

“3. The Royal College of Nursing have been invited to attend the hospital to deliver presentations to nursing staff on the importance of documentation standards. This training is expected to be complete by December 2015.”

Source location

2015-0312-Response-Alexandra-Hospital
Page 2 · response
Published 7 August 2015

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

Deliver education sessions to clinical staff on completing patient care pathways.

Verbatim wording from the response

“2. The company lead for care pathway development has been asked to attend the hospital to deliver education sessions on the completion of patient care pathways to all clinical staff. The delivery of this training is expected to be complete by the end of October 2015.”

Source location

2015-0312-Response-Alexandra-Hospital
Page 2 · response
Published 7 August 2015

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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

Complete hospital-wide training on documentation and the legal aspects of patient records.

Verbatim wording from the response

“The hospital expects and works to uphold, the highest standards of record keeping. At the time of this response, hospital-wide completion of training on documentation and legal aspects for patient records was 95%. Further documentation training has been scheduled to be delivered by the Royal College of Nursing and we continue to work with all staff and consultants to maintain and improve the standard of record keeping.”

Source location

2015-0312-Response-Alexandra-Hospital
Page 1 · response
Published 7 August 2015

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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

Oxygen saturation readings of 90–92% were generally considered adequate for a patient who smoked, although the 89% reading was not adequately documented.

Verbatim wording from the response

“The consultant confirmed during the hearing that the patient’s oxygen saturation readings of 90-92% would generally be adequate in view of her cigarette smoking and the recorded oxygen saturation level was 89% on the morning of discharge when the nurse decided to commence oxygen. It is unsatisfactory that information regarding the patient’s oxygen saturation level prior to discharge was not recorded. The consultant and the nurse accept that all actions and decisions taken must be clearly documented in the patient record.”

Source location

2015-0312-Response-Alexandra-Hospital
Page 2 · response
Published 7 August 2015

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