PFD report

Mary Fenton · Prevention of Future Deaths report

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Issued 13 Oct 2014•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.

View original report
Concerns
12

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
18

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 raised12

  1. Failure to assess patients’ mental capacity
    Part of recurring concern: Unreliable assessment and recording of patients’ mental capacity
  2. Failure to document unavailable consent or self-consenting rationale
    Part of recurring concern: Failure to reliably document the rationale for consequential decisionsPart of recurring concern: Inadequate informed-consent processes for medical treatment
  3. Unavailability of specialist cardiology advice outside normal hours
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.15

  1. Action

    Work with European and North American countries to resolve pharmaceutical supply issues.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 13 October 2014.
  2. Action

    Ask the NHS UK Medicines Information service to produce a shortage memorandum on isoprenaline availability and alternative supply sources.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 13 October 2014.
  3. Action

    Review and update the DNACPR policy to require discussion, clear communication and checking of understanding.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Some medicine supply problems are inevitable and unavoidable because of manufacturing, regulatory and raw-material difficulties.

    Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 assess patients’ mental capacity

Wider context from the report

“4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital) ”

Is this part of a recurring concern?

Yes — Unreliable assessment and recording of patients’ mental capacity.

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 document unavailable consent or self-consenting rationale

Wider context from the report

“5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting”. (For Tameside Hospital) ”

Is this part of a recurring concern?

Yes — Failure to reliably document the rationale for consequential decisions; 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

Unavailability of specialist cardiology advice outside normal hours

Wider context from the report

“1. Although Tameside Hospital holds itself out as performing pacemaker insertions, both temporary and permanent, no Cardiology Consultant is on call after 5.00pm or at week-ends. There is therefore no-one available to the junior staff having the requisite levels of skill and expertise to advise. (For Tameside Hospital) ”

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

Fragility of the national pharmaceutical supply chain

Wider context from the report

“9. The National pharmaceutical supply chain was described in evidence by a Chief Pharmacist as being “very fragile” (For Secretary of State) ”

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

Lack of adequate facilities to manage complications of pacing placement

Wider context from the report

“8. It was demonstrated by the evidence that if there should be a situation where the placing of the pacing causes unforeseen problems (e.g. by causing bleeding within the pericardium leading to cardiac tamponade) there is a lack of adequate facilities to address that situation. (For Tameside Hospital) ”

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

Unavailability of skilled and qualified staff to fit pacing wires

Wider context from the report

“6. Despite this being a major District General Hospital providing cardiology cover for a large proportion of the population of Greater Manchester, there is no-one with the skill or qualification to fit “temporary/permanent” pacing wires. (For Tameside Hospital) ”

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

Delays in inserting pacing wires

Wider context from the report

“7. There were inexcusably and potentially catastrophic delays in inserting the pacing wires (For Tameside Hospital) ”

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 obtain consent to treatment

Wider context from the report

“5. There was a failure of the medical staff to obtain “consent” to treatment or to document why such consent was unavailable and why they were “self-consenting”. (For Tameside Hospital) ”

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 document patients’ mental capacity

Wider context from the report

“4. There was a failure of the medical staff to assess and/or document the mental “capacity” of the patient (For Tameside Hospital) ”

Is this part of a recurring concern?

Yes — Unreliable assessment and recording of patients’ mental capacity.

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

Severe shortages of Isoprenaline

Wider context from the report

“3. This patient was being kept alive by the use of Isoprenaline. It transpires that there were severe shortages of this drug in the hospital but also nationally. I was told that this drug is produced as an unlicensed drug by NHS Pharmaceutical Productions. If so why do they not ensure sufficient supply? (For Tameside Hospital and for The Secretary of State) ”

Is this part of a recurring concern?

Yes — Unreliable access to clinically required medication during supply shortages.

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

Unavailability of echocardiography facilities after 5.00pm

Wider context from the report

“2. After 5.00pm there is no facility for an echocardiogram to be performed at the hospital. (For Tameside Hospital) ”

Is this part of a recurring concern?

Yes — Failure of echocardiography services to provide timely diagnostic assessment and follow-up.

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 of communication between staff, patients and families

Wider context from the report

“10. There was very poor communication between staff and other staff, and between staff and the family of the deceased and the patient herself (e.g. in relation to DNAR notice, “consent” forms etc.) (Tameside Hospital). ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families.

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

Work with European and North American countries to resolve pharmaceutical supply issues.

Verbatim wording from the response

“Supply issues are complex and most have to be dealt with on a case by case basis but in recognising the main problems it is possible to take action to mitigate them. Our Government is currently working with other countries in Europe and with North America to resolve some of these supply issues.”

Source location

2014-0443-Response-by-Department-of-Health
Page 2 · response
Published 13 October 2014

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

Ask the NHS UK Medicines Information service to produce a shortage memorandum on isoprenaline availability and alternative supply sources.

Verbatim wording from the response

“The Department of Health is aware that there have been problems with the availability of isoprenaline and that earlier this year the NHS PMUs experienced problems obtaining the active pharmaceutical ingredient. The Department of Health therefore asked the NHS UK Medicines Information service (UKMI) to produce a “Shortage Memo” which summarises the situation and advises on alternative sources of supply. This was sent out to hospitals and uploaded to the UKMI website, at the following address, on 24 April 2014:-”

Source location

2014-0443-Response-by-Department-of-Health
Page 2 · response
Published 13 October 2014

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

Review and update the DNACPR policy to require discussion, clear communication and checking of understanding.

Verbatim wording from the response

“In May 2014 the DNACPR policy was reviewed in line with R (on the application of David Tracey) v Cambridge University Hospitals NHS Foundation Trust [2014] to involve discussion with patients/their families. A DVD was created and is available on the Trust's intranet. The review of the policy was promoted through screensavers, to inform staff of the new policy.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 5 · response
Published 13 October 2014

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

Relocate and equip a cardiac pacing room in theatre 4 for in-hours and out-of-hours cardiac procedures.

Verbatim wording from the response

“There is also now a cardiac pacing room in theatre 4 and all equipment therein is operational. Relocation took place in September 2014 and this facility provides an in-hours and out of hours provision for all cardiac procedures, revisions and repairs and all Cardiologists are capable of carrying out emergency cardiac ultrasound to deal with very rare complications. Also, the old pacing room that the Trust was making use of is no longer required for pacing and the Trust is currently considering whether this could be used to expand the CCU area.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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 24-hour Consultant Cardiologist cover for emergency temporary pacing through an operational on-call rota.

Verbatim wording from the response

“Following the Inquest into Mrs Fenton’s death a review was undertaken by the Trust into the provision of pacing procedures out of hours. The Lead of the Cardiology Department was charged with organising an on call rota for pacing wires. The rota became operational on the 10 November 2014 and provides for a Consultant Cardiologist on-call to cover all emergency temporary pacing and pathway. The service is available 24 hours per day, every day of the year. The on-call rota for temporary pacing wires is shared with the hospital switchboard and CCU. The rota provides for out of hours cover by the following Consultant Cardiologists – ████████ ████████. This is currently being provided with nursing support via the Night Nurse Practitioner and Level 2 / CCU nursing staff on shift.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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

Maintain safe Critical Care medication storage, regular staff checks and pharmacist audits.

Verbatim wording from the response

“The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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

Create a Temporary Pacing Wire Pathway.

Verbatim wording from the response

“As a result of the review a Temporary Pacing Wire Pathway has also been created, a copy of which is attached.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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

Review existing Pharmacy Department pathways for managing medicines shortages.

Verbatim wording from the response

“Please be assured that the Trust finds any shortage of drugs unacceptable and we are doing everything within our power to ensure such shortages do not impact upon the care our patients receive. The Trust does have a strong contingency plan in place and in the case of Mrs Fenton this was evidenced by the incident itself where the Trust utilised local networks to ensure continuity of supply. Following the inquest into the death of Mrs Fenton, the Trust has reviewed all existing pathways to the Pharmacy Department and we cannot identify a case where the Trust has not been able either a medicine experiencing a shortage or a clinically appropriate and suitable agreed alternative for a patient.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 4 · response
Published 13 October 2014

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

Review out-of-hours CRI provision and explore procurement of a portable echocardiogram machine.

Verbatim wording from the response

“Currently, the provision of echocardiogram services is undertaken as a day case service between the hours of 9.00am and 5.00pm and this existing service is provided by the specialist CRI technicians. Due to the existing capacity and demand for the service, the existing provision can only currently provide an in hours service. Echocardiograms are and have been undertaken by qualified Consultants and Staff Grade Doctors as and when required. Going forward, the recent external cardiology service review and your concerns following the inquest into the death of Mrs Fenton have formed the basis for a service review specifically around the provision of CRI services. As part of this review, the procurement of a portable echocardiogram machine and out of hour provision is being explored as part of the wider service developments.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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

Create and provide a bedside patient-safety booklet for patients and relatives.

Verbatim wording from the response

“The Trust is striving to improve communication between clinicians, patients and family members. The Trust has created a bedside booklet, available for patients and relatives – “Patient Safety – Keeping you safe during your stay in hospital”. This empowers patients and their families to ask questions.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 4 · response
Published 13 October 2014

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

Employ a specialist nurse in adult safeguarding, mental capacity and deprivation of liberty safeguards.

Verbatim wording from the response

“The Trust has employed a specialist nurse in safeguarding adults, MCA and DOLS to support medical and nursing staff and to ensure that a thorough and correct assessment relating to mental capacity is completed and that any decisions made are in the best interests of the patient. During 2013/14 the Trust has seen a significant increase in activity (146%) and profile of adult safeguarding. Therefore, an assertive training programme has been put in place and we have seen over 828 staff trained to date. The Trust’s solicitor, Weightmans have also been utilised in providing training and they have provided an extensive training course throughout the year titled “The Legal Principles of the Mental Health Act; Mental Capacity Act and Deprivation of Liberty”.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 4 · response
Published 13 October 2014

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

Reiterate the medicines-shortage protocol to the Pharmacy Department.

Verbatim wording from the response

“Also, the Trust does have a protocol in place which is followed when any shortage arises. This involves conducting a risk assessment to evaluate the potential effect of the shortage and the assessment takes account of the estimated duration of the shortage; usage figures; the availability of suitable alternative products; and the potential risk to patients. As you will appreciate, not all shortages will need further action but where the risk assessment supports further work on a long term critical shortage, the Trust’s Pharmacy Department makes an estimate of the stock in hand within the entire organisation and of the time period this will cover. Where limited stock might lead to a restriction being placed on the use of a medicine, then this restriction will be discussed and agreed with the most relevant and appropriate Senior Doctor within the Trust.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 3 · response
Published 13 October 2014

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

Roll out refresher training on mental-capacity, consent and communication policies.

Verbatim wording from the response

“As to the actions of the particular staff involved in the care of Mrs Fenton, and with particular reference to the assessment and documentation of mental capacity, consent and communication, we have reminded the clinicians of the relevant policies and advised them that we will be rolling out refresher training. All Cardiology staff have also been informed by the Lead Consultant Cardiologist that no usage of Isoprenaline should be permitted in the CCU / Ward 31 without the consent of a Consultant Cardiologist / the on-call Cardiologist for pacing out of hours.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 5 · response
Published 13 October 2014

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

Replenish the Trust’s Isoprenaline stock following the national shortage.

Verbatim wording from the response

“The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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 an assertive adult safeguarding and mental-capacity training programme to Trust staff.

Verbatim wording from the response

“The Trust has employed a specialist nurse in safeguarding adults, MCA and DOLS to support medical and nursing staff and to ensure that a thorough and correct assessment relating to mental capacity is completed and that any decisions made are in the best interests of the patient. During 2013/14 the Trust has seen a significant increase in activity (146%) and profile of adult safeguarding. Therefore, an assertive training programme has been put in place and we have seen over 828 staff trained to date. The Trust’s solicitor, Weightmans have also been utilised in providing training and they have provided an extensive training course throughout the year titled “The Legal Principles of the Mental Health Act; Mental Capacity Act and Deprivation of Liberty”.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 4 · response
Published 13 October 2014

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

Some medicine supply problems are inevitable and unavoidable because of manufacturing, regulatory and raw-material difficulties.

Verbatim wording from the response

“Medicines shortages are not new, nor are they confined to the UK. There are a number of reasons why such shortages do arise but the two main reasons are commonly referred to as ‘upstream’ and ‘downstream’:-”

Source location

2014-0443-Response-by-Department-of-Health
Page 2 · response
Published 13 October 2014

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 stocks, contingency arrangements and local networks are considered sufficient to maintain medicines or suitable alternatives during shortages.

Verbatim wording from the response

“The Trust currently keeps a supply of 200 ampoules of Isoprenaline supplies in stock. This would last a patient approximately 17 calendar days if prescribed in the same dosage as that provided to Mrs Fenton. The Trust has replenished its stocks following the end of the national alert on the Isoprenaline shortage due to manufacturing difficulties in August/September 2014. Actions have also been taken to ensure that within Critical Care there is safe storage”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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 capacity and demand mean echocardiography can currently be provided only during daytime hours, while out-of-hours provision is being explored.

Verbatim wording from the response

“Currently, the provision of echocardiogram services is undertaken as a day case service between the hours of 9.00am and 5.00pm and this existing service is provided by the specialist CRI technicians. Due to the existing capacity and demand for the service, the existing provision can only currently provide an in hours service. Echocardiograms are and have been undertaken by qualified Consultants and Staff Grade Doctors as and when required. Going forward, the recent external cardiology service review and your concerns following the inquest into the death of Mrs Fenton have formed the basis for a service review specifically around the provision of CRI services. As part of this review, the procurement of a portable echocardiogram machine and out of hour provision is being explored as part of the wider service developments.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 2 · response
Published 13 October 2014

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.3

  1. 1

    Inform Cardiology staff that Isoprenaline use requires Consultant Cardiologist or on-call pacing Cardiologist consent.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2014.
  2. 2

    Create and disseminate DNACPR information through a patient leaflet, staff intranet DVD and screensaver promotion.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2014.
  3. 3

    Issue a warning to all medical staff about duties to report matters to the coroner.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2014.

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

Inform Cardiology staff that Isoprenaline use requires Consultant Cardiologist or on-call pacing Cardiologist consent.

Verbatim wording from the response

“As to the actions of the particular staff involved in the care of Mrs Fenton, and with particular reference to the assessment and documentation of mental capacity, consent and communication, we have reminded the clinicians of the relevant policies and advised them that we will be rolling out refresher training. All Cardiology staff have also been informed by the Lead Consultant Cardiologist that no usage of Isoprenaline should be permitted in the CCU / Ward 31 without the consent of a Consultant Cardiologist / the on-call Cardiologist for pacing out of hours.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 5 · response
Published 13 October 2014

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

Create and disseminate DNACPR information through a patient leaflet, staff intranet DVD and screensaver promotion.

Verbatim wording from the response

“In May 2014 the DNACPR policy was reviewed in line with R (on the application of David Tracey) v Cambridge University Hospitals NHS Foundation Trust [2014] to involve discussion with patients/their families. A DVD was created and is available on the Trust's intranet. The review of the policy was promoted through screensavers, to inform staff of the new policy.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 5 · response
Published 13 October 2014

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

Issue a warning to all medical staff about duties to report matters to the coroner.

Verbatim wording from the response

“You also requested that the Trust issue a warning to all medical staff as to their duties to report matters to Her Majesty’s Coroner and the circumstances in which this duty arises. I have attached a copy of the warning that has been issued to all medical staff as a result of your request.”

Source location

2014-0443-Response-by-Tameside-Hospital
Page 5 · response
Published 13 October 2014

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