PFD report

Mrs Christine Withers · Prevention of Future Deaths report

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Issued 1 May 2018•Black Country

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised2

  1. Inadequate nursing communication with families expressing concerns about patient deterioration
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and families
  2. Failure to perform recommended repeat blood tests for potassium-level monitoring
    Part of recurring concern: Failure to obtain clinically indicated repeat investigations
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

    Complete in-house palliative care competencies for Ward C4 staff, including communication with patients, families and carers.

    Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 July 2018.
  2. Action

    Present the revised hypokalaemia guideline at the scheduled July Medicine Audit and Governance Meeting.

    Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 July 2018.
  3. Action

    Circulate the revised hypokalaemia guideline to all Trust medical staff.

    Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 July 2018.

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

  1. Position

    Records documented multiple family conversations, and staff considered communication effective, despite the family appearing dissatisfied with some answers.

    Stated by the Dudley Group NHS Foundation TrustDisputes 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

Inadequate nursing communication with families expressing concerns about patient deterioration

Wider context from the report

“2. There was inadequate communication by nursing staff with the family who expressed concerns about the decline in Mrs Withers. ”

Is this part of a recurring concern?

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

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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 perform recommended repeat blood tests for potassium-level monitoring

Wider context from the report

“1. Evidence emerged during the inquest that no repeat blood tests were performed to measure the potassium levels despite this being recommended by the Consultant at the ward round in the morning. ”

Is this part of a recurring concern?

Yes — Failure to obtain clinically indicated repeat investigations.

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

Complete in-house palliative care competencies for Ward C4 staff, including communication with patients, families and carers.

Verbatim wording from the response

“In response to this sad event all the staff within Ward C4 are working with our palliative care champion to complete the in-house palliative care competencies which comprehensively covers communication with patients, families and carers.”

Source location

2018-0127-Response-by-Dudley-Group-NHS-Trust
Page 2 · response
Published 1 July 2018

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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

Present the revised hypokalaemia guideline at the scheduled July Medicine Audit and Governance Meeting.

Verbatim wording from the response

“The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.”

Source location

2018-0127-Response-by-Dudley-Group-NHS-Trust
Page 1 · response
Published 1 July 2018

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

Circulate the revised hypokalaemia guideline to all Trust medical staff.

Verbatim wording from the response

“The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.”

Source location

2018-0127-Response-by-Dudley-Group-NHS-Trust
Page 1 · response
Published 1 July 2018

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

Publicise the revised hypokalaemia guideline on the Trust intranet.

Verbatim wording from the response

“The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.”

Source location

2018-0127-Response-by-Dudley-Group-NHS-Trust
Page 1 · response
Published 1 July 2018

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

Revise and approve the adult hypokalaemia management guideline as a consistent clinical tool.

Verbatim wording from the response

“The important issues you raise have been taken very seriously and following the inquest into the sad death of Mrs Withers, the Chief of Medicine and Integrated Care has reviewed the guidelines relating to the management of hypokalaemia in adults. Appendix 1 details the revised document which has been approved by the Chair of the Clinical guidelines group. This revised guideline has considered the most recent medical evidence and provides clinical staff with a consistent tool to treat and advise patients on the clinical management of low potassium levels. This guideline will be publicised on the Trusts intranet site and has been circulated to all medics in the Trust. A further presentation of these guidelines is scheduled in July at the Medicine Audit / Governance Meeting.”

Source location

2018-0127-Response-by-Dudley-Group-NHS-Trust
Page 1 · response
Published 1 July 2018

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

Records documented multiple family conversations, and staff considered communication effective, despite the family appearing dissatisfied with some answers.

Verbatim wording from the response

“2. There was inadequate communication by nursing staff with the family who expressed concerns about the decline in Mrs Withers.”

Source location

2018-0127-Response-by-Dudley-Group-NHS-Trust
Page 1 · response
Published 1 July 2018

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