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

28 results

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.

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.