PFD report

Roger Edward Humphrey Ballard · Prevention of Future Deaths report

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Issued 24 May 2021•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
2

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 raised2

  1. Failure to document clinical decisions and rationale, including decisions contrary to neurosurgical advice
    Part of recurring concern: Failure to reliably document the rationale for consequential decisions
  2. Failure to clearly report and record scan findings
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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

    Complete the Trust-wide rollout of the Results Governance Tracker requiring timely PACS acknowledgement of imaging results.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
  2. Action

    Conduct the documentation standards audit.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
  3. Action

    Conduct the commissioned serious incident investigation and present its findings to the Executive Scrutiny Panel.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.

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

  1. Position

    Existing GMC documentation standards and junior doctor induction sufficiently require recording clinical decisions, specialist advice, deviations and reasons in medical records.

    Stated by Tameside and Glossop Integrated Care 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

Failure to document clinical decisions and rationale, including decisions contrary to neurosurgical advice

Wider context from the report

“2. The documentation regarding clinical decisions taken including the decision to not follow the advice of the neurosurgeons was not documented in the notes. It was unclear if there was an expectation that where clinicians took a decision contrary to such advice how and in what detail the rationale should be recorded within the notes. ”

Is this part of a recurring concern?

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

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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 clearly report and record scan findings

Wider context from the report

“1. The inquest heard evidence that the way in which the scan was reported and then recorded was not clear and contributed to the treating clinician not appreciating the scan findings. ”

Is this part of a recurring concern?

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

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 the Trust-wide rollout of the Results Governance Tracker requiring timely PACS acknowledgement of imaging results.

Verbatim wording from the response

“In addition, I wish to give you wider assurances around how imaging is reported and reviewed by clinicians at the Trust. The Trust has been developing a Results Governance Tracker, which has already been implemented in one major area of the Trust. It is anticipated that this roll-out will continue, although it did undoubtably experience some delays due to the pandemic. Once this Tracker is Trust-wide, it will ensure that all Pathology and Radiology results will have to be acknowledged as read on the PACS system within a specified timeframe. This will assist our clinicians in complying with the existing expectations on their practice and ensure safer care for patients.”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 May 2021

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

Conduct the documentation standards audit.

Verbatim wording from the response

“The clinician involved in this matter has reflected on this point and learning has also been included in the 7 Minute Briefing, shared across the Trust. Further, a documentation standards audit has also been commenced and dependent on the”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 May 2021

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

Conduct the commissioned serious incident investigation and present its findings to the Executive Scrutiny Panel.

Verbatim wording from the response

“To ensure that all learning has been identified in relation to this issue, an investigation has also been commissioned as part of our serious incident framework and the findings of this will be presented to our Executive Scrutiny Panel which I and the Executive Director of Nursing and Integrated Governance attend.”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 May 2021

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

Develop an action plan addressing issues identified by the documentation standards audit.

Verbatim wording from the response

“The clinician involved in this matter has reflected on this point and learning has also been included in the 7 Minute Briefing, shared across the Trust. Further, a documentation standards audit has also been commenced and dependent on the”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 May 2021

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 GMC documentation standards and junior doctor induction sufficiently require recording clinical decisions, specialist advice, deviations and reasons in medical records.

Verbatim wording from the response

“It is an expected standard that any decisions made relating to a patient’s care and management plan are to be documented within the medical records. This includes discussions with tertiary centre colleagues, the advice they provide, and any decisions made to deviate from this advice and the reasons why. As I am sure you are aware, this requirement is within the GMC standards and guidance relating to documentation, and is absolutely expected from all medical staff. In addition, as part of junior doctor induction, clinicians are sign-posted to resources to assist them in managing their professional responsibilities and obligations regarding documentation in medical records.”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 May 2021

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 radiology policy sufficiently requires clinicians to review CT scan reports directly on PACS rather than rely on transcribed medical records.

Verbatim wording from the response

“When an investigation is undertaken such as a CT scan, it is expected that the treating clinicians should be logging onto the PACS system and reviewing the scan report instead of relying on what has been transcribed in the medical records. This is to avoid any misinterpretation or the omission of any detail, which may be vital when making a clinical decision about a patient’s management plan and on-going treatment. This expectation is clearly documented in the Trust’s Radiology Requesting and Reporting Policy, which all clinicians are required to be familiar with as part of their post at the Trust.”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 24 May 2021

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

    Share the learning at the Trust Grand Round and Clinical Advisory Group.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
  2. 2

    Disseminate the case learning across the Trust through a 7 Minute Briefing.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.

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

Share the learning at the Trust Grand Round and Clinical Advisory Group.

Verbatim wording from the response

“To reiterate the standards we expect of our clinicians, Mr Ballard’s story is being shared across the Trust by way of a 7 Minute Briefing (enclosed for your information). The learning from this story has been put on the agenda for the Trust’s Grand Round meeting, a regular forum attended by clinicians of all specialties and experience. It will be shared by Dr ████████, Clinical Director of Urgent Care. In addition to this, Ms ████████, Associate Medical Director, will share the learning from this case at the Clinical Advisory Group, which includes Clinical Directors and Medical Leads from all areas of the Trust and which is chaired by me as Medical Director.”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 May 2021

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

Disseminate the case learning across the Trust through a 7 Minute Briefing.

Verbatim wording from the response

“To reiterate the standards we expect of our clinicians, Mr Ballard’s story is being shared across the Trust by way of a 7 Minute Briefing (enclosed for your information). The learning from this story has been put on the agenda for the Trust’s Grand Round meeting, a regular forum attended by clinicians of all specialties and experience. It will be shared by Dr ████████, Clinical Director of Urgent Care. In addition to this, Ms ████████, Associate Medical Director, will share the learning from this case at the Clinical Advisory Group, which includes Clinical Directors and Medical Leads from all areas of the Trust and which is chaired by me as Medical Director.”

Source location

2021-0168-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 24 May 2021

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