PFD report

Margaret Lilian SALES · Prevention of Future Deaths report

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Issued 11 Nov 2020•Norfolk

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
3

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 raised3

  1. Lack of completion of required records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure of on-call medical staff to respond reliably to requests to attend patients
    Part of recurring concern: Failure to provide requested on-call clinical review
  3. Failure to communicate required follow-up arrangements to GPs at discharge
    Part of recurring concern: Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPsPart 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.7

  1. Action

    Redesign the clinical escalation pathway to provide a compliant seven-day service and increase medical cover.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.
  2. Action

    Facilitate transfer to electronic patient records through the Multidisciplinary Documentation Forum.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 December 2020.
  3. Action

    Audit escalation through NEWS and incident reporting, provide feedback on failures, and empower nurses to contact consultants when local escalation fails.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.

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

  1. Position

    The system remains robust, so no further action is proposed regarding home blood glucose monitoring advice.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation 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

Lack of completion of required records

Wider context from the report

“1. Evidence was heard that Records were not always completed as required. It is understood clinical teams have been notified of this and the records are being audited. There was no evidence as to the outcome of those audits and any further action taken. ”

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

Failure of on-call medical staff to respond reliably to requests to attend patients

Wider context from the report

“2. Nurses had difficulty in contacting front line on call medical staff on two occasions. Several members were contacted before anyone attended. Bleeps are now to be provided to all on call medical staff. However, some of the team had bleeps and still did not respond to the requests to attend the patient. ”

Is this part of a recurring concern?

Yes — Failure to provide requested on-call clinical review.

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 communicate required follow-up arrangements to GPs at discharge

Wider context from the report

“3. On a previous discharge from hospital, it was noted Mrs Sales had been referred to the Home Enteral Nutrition service for monitoring and follow up and that in situations such as this, requests will be placed with the GP. However, no such request had been placed with the GP. The Discharge Letter in fact stated: "Actions for the GP: No recommendations". As a result, the GP did not monitor Mrs Sales’ capillary blood glucose following discharge. ”

Is this part of a recurring concern?

Yes — Failure of hospital discharge-summary processes to provide accurate, complete and timely information to GPs; Unreliable hospital discharge processes.

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

Redesign the clinical escalation pathway to provide a compliant seven-day service and increase medical cover.

Verbatim wording from the response

“Firstly we have redesigned the clinical escalation pathway with providing a compliant 7-day standard service. This has increased the medical workforce required to improve cover for the patients. Access to medical personnel has improved through this. This is set to improve further with the Urgent and Emergency Pathway Reset program led by the Chief Operating Officer that encompasses system-wide changes to improve early access for patients and facilitate timely treatment. A dedicated Project Management team is set up to expedite this process looking at our medical workforce.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 2 · response
Published 23 December 2020

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

Facilitate transfer to electronic patient records through the Multidisciplinary Documentation Forum.

Verbatim wording from the response

“The Multidisciplinary Documentation Forum oversees all the documentation aspects of Health Records that not only capture medical documentation but all multidisciplinary input into patient records. Equally this forum is planning to facilitate a seamless transfer to Electronic Patient Records that will improve quality of care for patients. Through this forum, improvements in documentation of clinical care that includes, medicines, fluids, feeds, monitoring of vital signs are planned and where deteriorations occur, improved focus to address deterioration is identified and facilitated through examples described above. The Trust is fully committed to identifying issues which may occur regarding all aspects of our documentation and responding accordingly when identified.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 2 · response
Published 23 December 2020

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 escalation through NEWS and incident reporting, provide feedback on failures, and empower nurses to contact consultants when local escalation fails.

Verbatim wording from the response

“The bleep tracking system and the use of smart phones with video calling facilities is in place to enable tracking and access to our medical work force. Inability to access doctors to escalate problems is captured through our incident reporting system (Datix) and actions are enabled through this. Feedback to defaulters for not accessing properly is part of this and if there are avoidable lapses identified then they are put through an internal process. In this way the system is strengthened significantly.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 2 · response
Published 23 December 2020

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

Improve multidisciplinary documentation of medicines, fluids, feeds, vital-sign monitoring and deterioration.

Verbatim wording from the response

“The Multidisciplinary Documentation Forum oversees all the documentation aspects of Health Records that not only capture medical documentation but all multidisciplinary input into patient records. Equally this forum is planning to facilitate a seamless transfer to Electronic Patient Records that will improve quality of care for patients. Through this forum, improvements in documentation of clinical care that includes, medicines, fluids, feeds, monitoring of vital signs are planned and where deteriorations occur, improved focus to address deterioration is identified and facilitated through examples described above. The Trust is fully committed to identifying issues which may occur regarding all aspects of our documentation and responding accordingly when identified.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 2 · response
Published 23 December 2020

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 medical-record completion and route findings through governance forums for oversight and improvement.

Verbatim wording from the response

“1. Evidence was heard that Records were not always completed as required. It is understood clinical teams have been notified of this and the records are being audited. There was no evidence as to the outcome of those audits and any further action taken.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 1 · response
Published 23 December 2020

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 the Urgent and Emergency Pathway Reset programme and use a dedicated project team to improve timely medical access and workforce capacity.

Verbatim wording from the response

“Firstly we have redesigned the clinical escalation pathway with providing a compliant 7-day standard service. This has increased the medical workforce required to improve cover for the patients. Access to medical personnel has improved through this. This is set to improve further with the Urgent and Emergency Pathway Reset program led by the Chief Operating Officer that encompasses system-wide changes to improve early access for patients and facilitate timely treatment. A dedicated Project Management team is set up to expedite this process looking at our medical workforce.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 2 · response
Published 23 December 2020

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 bleep tracking and smartphone video calling to track and improve access to on-call medical staff.

Verbatim wording from the response

“2. Nurses had difficulty in contacting front line on call medical staff on two occasions. Several members were contacted before anyone attended. Bleeps are now to be provided to all on call medical staff. However, some of the team had bleeps and still did not respond to the requests to attend the patient.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 2 · response
Published 23 December 2020

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 system remains robust, so no further action is proposed regarding home blood glucose monitoring advice.

Verbatim wording from the response

“I have heard from our consultant ████████ and also Legal Services Manager that we had not expected this issue to be raised at the inquest, if so we would have taken the opportunity to supply evidence on this point for you at the time from one of our Dietetics or Diabetes team members who deal regularly with referrals to Fresnius and the General Practitioners in Norfolk, Cambridgeshire and Lincolnshire. With hindsight, perhaps our RCA could have gone into more detail on that point; but presently we think that the system remains robust and with no discourtesy intended do not propose to take any further action on this point at the present time.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 3 · response
Published 23 December 2020

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

Current practice and guidelines did not indicate that the Trust should recommend home blood glucose monitoring to the GP.

Verbatim wording from the response

“At this Trust our Diabetic Specialist Nurses would ensure that the GP was made aware that they had to ensure blood glucose monitoring was done at home if a patient had been put on either Gliclazide or Insulin during an admission. It is true to say that if Mrs Sales had had her blood glucose monitored at home between 6th November and 13 December 2019 her subsequent illness would have become apparent sooner, but in terms of current practice and guidelines there was no indication for us to make such a recommendation to the GP.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 3 · response
Published 23 December 2020

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.2

  1. 1

    Run quality-improvement work to improve dementia screening and reduce insulin and anticoagulant prescribing and administration errors.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 December 2020.
  2. 2

    Complete the VTE quality-improvement project by revising pathways, delivering training and induction content, and improving harm capture and screening rates.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 December 2020.

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

Run quality-improvement work to improve dementia screening and reduce insulin and anticoagulant prescribing and administration errors.

Verbatim wording from the response

“The quality improvement project (QIP) led by the Medical Director reviewed and revised the existing pathways, improved awareness through training and inclusion in the induction programs, increasing capture of the harms caused through the patient safety teams (Audit and Effectiveness Group) and over 3 months of this effort the VTE screening rates improved back to above the nationally recommended target levels. A similar project is now in place with regard to improving Dementia screening rates, reduction in prescribing and administration errors”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 1 · response
Published 23 December 2020

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 the VTE quality-improvement project by revising pathways, delivering training and induction content, and improving harm capture and screening rates.

Verbatim wording from the response

“The findings from the documentation audit are taken through appropriate governance channels such as the Harm Free Care Group, Learning from Deaths Forum, Hospital Thrombosis Committee, Divisional Governance Boards to feed into Clinical Governance Executive Group (Executive level) to Quality Committee (sub-committee) and finally to the Trust Board. Assurances provided this way help with enabling visibility and also focus on areas of improvement. Whilst this is a framework and continuing process, we are aware of the areas requiring improvements and have created dedicated quality improvement projects which also report to the Trust Board to track the progress on the work undertaken. For example, there was a decline in the Venous Thrombo-embolism (VTE) screening uptake since January 2020 until April 2020.”

Source location

2020-0233-Response-from-Queen-Elizabeth-Hospital-Kings-Lynn-Redacted.pdf
Page 1 · response
Published 23 December 2020

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