PFD report

Anne Patricia Leake · Prevention of Future Deaths report

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Issued 16 Dec 2024•Staffordshire and Stoke-on-Trent

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 shared accessible medical notes across hospital teams
    Part of recurring concern: Unsafe coordination of shared care
  2. Reliance on manual transcription of treatment decisions between medical notes
    Part of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unsafe coordination of shared care
  3. Failure to access and act on MDT treatment decisions
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
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.4

  1. Action

    Develop a digital vision and strategy including a goal for a new electronic patient record across the Integrated Care System.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
  2. Action

    Introduce resident doctor induction teaching requiring clinicians to check the ICD decision before discharge.

    Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 27 December 2024.
  3. Action

    Draft a business case with the Integrated Care System to apply for NHS funding for an interoperable electronic patient record.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.

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

  1. Position

    A single Trust-wide EPR cannot currently be implemented because it requires substantial investment, development and deployment time, and existing infrastructure is limited.

    Stated by University Hospitals of North Midlands NHS TrustUnable 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

Lack of shared accessible medical notes across hospital teams

Wider context from the report

“(1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked. (2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system. (3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another, with the continuing potential for human error and important decisions about treatment being overlooked. ”

Is this part of a recurring concern?

Yes — Unsafe coordination of shared 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

Reliance on manual transcription of treatment decisions between medical notes

Wider context from the report

“(1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked. (2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system. (3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another, with the continuing potential for human error and important decisions about treatment being overlooked. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff; Unsafe coordination of shared 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 access and act on MDT treatment decisions

Wider context from the report

“(1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked. (2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system. (3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another, with the continuing potential for human error and important decisions about treatment being overlooked. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

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

Develop a digital vision and strategy including a goal for a new electronic patient record across the Integrated Care System.

Verbatim wording from the response

“Whilst the Trust aspires to acquire a new, highly sophisticated, purpose-built single EPR system, this will necessitate securing significant capital investment, development and time to ensure safe deployment. To support this ambition, the trust is currently engaged in setting out a new digital vision and strategy, which includes the goal for a new EPR across the whole Integrated Care System (ICS).”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 27 December 2024

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 resident doctor induction teaching requiring clinicians to check the ICD decision before discharge.

Verbatim wording from the response

“As an immediate action, the development of a new alert within iPortal will be implemented – this will be populated by the multidisciplinary team to inform clinicians that an ICD is required prior to discharge. The team are going to introduce teaching into the resident doctor induction to ensure this is checked prior to discharge.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 2 · response
Published 27 December 2024

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

Draft a business case with the Integrated Care System to apply for NHS funding for an interoperable electronic patient record.

Verbatim wording from the response

“The UНNM digital team together with the ICS, are drafting a business case to apply for NHS funding for an EPR that will meet our growing needs and provide the functionality and interoperability required to prevent the events that contributed to Mrs Leake’s death.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 27 December 2024

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 a new iPortal alert, populated by the multidisciplinary team, to notify clinicians that an ICD is required before discharge.

Verbatim wording from the response

“As an immediate action, the development of a new alert within iPortal will be implemented – this will be populated by the multidisciplinary team to inform clinicians that an ICD is required prior to discharge. The team are going to introduce teaching into the resident doctor induction to ensure this is checked prior to discharge.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 2 · response
Published 27 December 2024

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 single Trust-wide EPR cannot currently be implemented because it requires substantial investment, development and deployment time, and existing infrastructure is limited.

Verbatim wording from the response

“Whilst the Trust aspires to acquire a new, highly sophisticated, purpose-built single EPR system, this will necessitate securing significant capital investment, development and time to ensure safe deployment. To support this ambition, the trust is currently engaged in setting out a new digital vision and strategy, which includes the goal for a new EPR across the whole Integrated Care System (ICS).”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 27 December 2024

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

    Continue optimising digital systems in line with the highest clinical risks.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
  2. 2

    Continue assessing patient-safety risks across current digital systems and develop mitigating actions.

    Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.

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

Continue optimising digital systems in line with the highest clinical risks.

Verbatim wording from the response

“Ongoing work to optimise the digital systems aligned to the highest clinical risks will continue within UНNM. This will be undertaken alongside continued work to understand the patient safety risks across all of our current digital systems in order to develop mitigating actions. As you are aware, those specific to Mrs Leake’s case have already been outlined in an after action review (AAR) following an investigation of the case.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 27 December 2024

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

Continue assessing patient-safety risks across current digital systems and develop mitigating actions.

Verbatim wording from the response

“Ongoing work to optimise the digital systems aligned to the highest clinical risks will continue within UНNM. This will be undertaken alongside continued work to understand the patient safety risks across all of our current digital systems in order to develop mitigating actions. As you are aware, those specific to Mrs Leake’s case have already been outlined in an after action review (AAR) following an investigation of the case.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 27 December 2024

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