University Hospitals Birmingham NHS Foundation Trust

PFD Addressee

Reports: 34 Earliest: Oct 2013 Latest: 20 Oct 2025

100% 2-year response rate (above 83% average). 56% of classified responses show concrete action taken.

Action Taken 56%

Action Planned 26%

Noted 19%

Disputed 0%

Based on 43 classified responses

PFD Reports

34 results

Ronald Lowe

2019-0113 3 Apr 2019 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) A hospital's system for ensuring radiographers had read and signed standard operating procedures was not robust, increasing the risk of dangerous practice due to incorrect understanding of duties.

Action Taken (AI summary) The Trust conducted a review of outpatient CTPA studies, created a central register for radiographer training across multiple sites, and reviews staff training during annual appraisals.

Ann Swoffer

2019-0026 22 Jan 2019 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Hospital practices diverged from national guidelines, junior staff failed to escalate issues during weekends due to senior staff absence, and a lack of integrated protocols across trust sites created inconsistent care standards.

Action Taken (AI summary) The Trust found the guidelines are recognized and used at Good Hope Hospital, and a gastroenterology consultant now attends weekend ward rounds. A unified operational structure will be established by May 2019, with alignment of protocols and guidelines across sites as a short-term goal.

Kathleen Allen

2018-0213 4 Jul 2018 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Inconsistent application and understanding of MEWS escalation pathways in the A&E department, with conflicting staff guidance, created a risk of inconsistent patient monitoring and delayed escalation.

Action Taken (AI summary) The Trust has deployed an ED-specific MEWS Observation Chart for use in the BHH and Good Hope EDs, and the Solihull Minor Injuries Unit; the ED directorate has circulated an email to Divisional Directors across HGS sites disseminating the ED MEWS SOP; the nurse responsible for the care of Mrs Allen has received a period of supervised practice and completed targeted objectives.

Alfie Rose

2016-0382 26 Oct 2016 Birmingham and Solihull

Child Death Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on neurological referral protocols.

Action Planned (AI summary) Following meetings between the hospitals involved, a detailed action plan has been developed and commenced to improve communication, including copying the referring doctor from RHH on letters, addressing the visibility of patients on Norse, and considering guidelines for managing patients with hydrocephalus in the emergency setting. An action plan is attached. Following meetings between the hospitals involved, actions have been agreed to improve communication, including copying the referring doctor from RHH on letters, addressing the visibility of patients on Norse, and considering guidelines for managing patients with hydrocephalus in the emergency setting. An action table is attached.

Leslie Carswell

Partially Responded

2016-0147 19 Apr 2016 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.

Action Taken (AI summary) The Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify how images are transmitted, including contingencies for out of hours and documentation requirements. All radiographers are being trained in IEP and Image Link and a weekly data report from the CRIS system has been set up to monitor image transfers performed out of hours.

Joyce Tozer

Historic (No Identified Response)

15 Dec 2015 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.

Hireiti Kuflesion

Historic (No Identified Response)

2015-0414 23 Oct 2015 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Pregnant women with mechanical heart valves received insufficient Clexane dosing and monitoring, combined with clinicians' lack of understanding of thrombosis risks, resulting in delayed diagnosis.

Lottie Reid

2015-0241 25 Jun 2015 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) There were critical medication discrepancies between the discharge letter and the administration chart, with no clear protocol for checking these errors, especially problematic on weekends.

Action Planned (AI summary) Birmingham Heartlands Hospital is piloting new documentation within palliative care for clarity of prescribing. Dissemination of information about the Intermediate Care Procedure to all wards at Good Hope Hospital and staff at the intermediate care facility can check the patient's prescribed medication by telephoning the discharging ward directly.

George Leonard Parkes

Historic (No Identified Response)

2013-0252 4 Oct 2013 Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Concerns summary (AI summary) Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.