Inadequate Pre-Operative Risk Assessment
133 items
2 sources
Insufficient pre-operative assessments and specialist reviews for patients with significant comorbidities, risking complications.
Cross-Source Insight
Inadequate Pre-Operative Risk Assessment has been flagged across 2 independent accountability sources:
4 inquiry recs
129 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (4)
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
4 — Reflection period for consent
Recommendation: We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. The GMC should monitor this as part of …
Gov response: Accepted in principle. GMC guidance on consent (updated 2020) already emphasises patients should have time to consider information before making decisions. The guidance states patients should not be placed under pressure to make decisions quickly. …
Accepted in Part
No update 2+ yrs
IBI-7a(i) — Transfusion Committees and Tranexamic Acid - England
Recommendation: In England, Hospital Transfusion Committees and transfusion practitioners take steps to ensure that consideration of tranexamic acid be on every hospital surgical checklist; that hospital medical directors be required to report to their boards and the chief executive of their …
Gov response: UK’s governments Recommendation 7 includes an especially complex set of sub recommendations. To ensure a joined up approach across the four nations, experts from across the four nations NHS bodies, blood services and external bodies …
Accepted in Part
In progress
IBI-7a(ii) — Tranexamic Acid - Scotland, Wales and NI
Recommendation: In Scotland, Wales and Northern Ireland offering the use of tranexamic acid should be considered a treatment of preference in respect of all eligible surgery.
Gov response: Scottish Government The Scottish Government’s Oversight and Assurance Group (OAG) Chair and Deputy Chair wrote to Health Boards in November 2024 asking them to review practice within their Board and confirm that they are offering …
Accepted
In progress
PFD Reports (129) — showing 100 most recent
Dominic Hurley
Concerns: The system for renewing diving licenses relies too heavily on self-declaration, failing to verify previous medical history or diving incidents, which risks diver safety.
Response: The Sub Aqua Association states that its dive medical screening forms were updated in May 2020 (and May 2024) to specifically include 'immersion induced pulmonary oedema' and are used for …
Responded
Barry Loxston
Concerns: Serious failures pre-surgery included not recognising unfitness for transplant. Post-operatively, critically low potassium was untreated due to workload, and nursing care lacked proper manual handling and timely response to basic needs, causing distress.
Overdue
Judith Hughes
Concerns: The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Response: The Trust's 'Enhanced Care Risk Assessment Form' was revised in 2022 to clarify the distinction between 'previous falls in the last 12 months' and 'inpatient fall during this admission'. Nursing …
Responded
Vivian Nolan
Concerns: Clinicians lack sufficient knowledge and guidance on the increased risks associated with diagnostic colonoscopies for patients aged 80 and over.
Response: The British Society of Gastroenterology clarifies that current UK guidance emphasizes individualised patient consent, balancing risks and benefits for colonoscopy, including for those over 80. They dispute the suggestion of …
Responded
Amy Cross
Concerns: There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.
Response: NHS England plans to commence a 'proof of concept' trial around February/March 2026 in specific regions, enabling healthcare providers to access the Digital Person Escort Record (DPER) system to improve …
Overdue
Tony Duncan
Concerns: A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication review or escalation.
Response: The Trust has strengthened its psychiatric liaison service at King's College Hospital ED by extending hours to 24/7, introducing comprehensive training, increasing staff, and launching a new ED Low Intensity …
Responded
Amanda Wood
Concerns: No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Overdue
Honoria Culshaw (2)
Concerns: A lack of information sharing regarding positive bacterial swab results from a pacemaker wound potentially delayed necessary extraction, contributing to prolonged infection.
Responded
Linda Sharp
Concerns: Relying solely on a low Wells score is a fundamentally flawed approach to exclude deep vein thrombosis or pulmonary embolus, potentially leading to missed diagnoses.
Responded
Peter Thomas
Concerns: The CIWA protocol is too blunt and lacks nuance for elderly or delirious patients, leading to risks of over-sedation due to clinicians applying it without adequate guidance.
Responded
Gemma Poterajko
Concerns: The absence of formal risk stratification and a written Standard Operating Procedure for lead extraction led to unclear planning and inadequate timely cardiac surgical team support during procedures.
Responded
Jake Lawler
Concerns: Clinicians frequently misinterpret ECGs and lack clear national guidance for paediatric exercise-induced syncope. The national asthma scoring system is insufficient, leading to misdiagnosis and missed cardiac conditions in children.
Responded
Lorraine Parker
Concerns: A lack of guidance means surgeons don't always consider CT scans for post-abdominal surgery patients with persistently high CRP. Over-reliance on clinical judgment alone risks overlooking critical objective indicators.
Responded
Marina Raisbeck
Concerns: No systems exist for prioritizing or monitoring the clinical parameters of urgent surgical patients awaiting transfer between emergency departments and receiving hospitals.
Responded
Joanna Kowalczyk
Concerns: A paramedic lacked crucial stroke symptom training, and chiropractors do not routinely obtain medical records before assessment, particularly after recent hospital visits, creating significant risks for patients.
Responded
Alfie Hinton
Concerns: Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a time-critical spinal anaesthetic procedure also caused significant delays.
Responded
Anne Taylor
Concerns: A patient left hospital unassessed due to waiting times, with no capacity assessment despite a suspected head injury. Secondary investigations were not considered while waiting.
Responded
Susan Shipley
Concerns: An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic failures in patient assessment and incident learning.
Responded
Kasey Beech
Concerns: The current STREAMing guidance's focus on chest pain in emergency assessments may delay recognition of other life-threatening conditions, risking sudden patient deterioration.
Responded
Alan Kinsbury
Concerns: Inadequate guidelines for managing anti-thrombotic medication in frail patients undergoing skin surgery, coupled with a lack of preoperative assessment and advanced consent, led to an inappropriate surgical technique.
Responded
Chloe Hunt
Concerns: The patient's complex trauma was not considered in her treatment plan, and there was inadequate assessment of complex foreign body removal. A lack of urgency and failure to recognise her deteriorating clinical condition contributed to critical delays.
Responded
Harry Vass
Concerns: Inadequate observations were performed due to agitation, and mental health staff lacked awareness that Acute Behavioural Disturbance is a medical emergency, leading to missed physical health assessments.
Responded
Jordan Howarth
Concerns: Hospital care suffered from a lack of multidisciplinary collaboration, undocumented clinical decisions regarding antibiotics and ICU admission, and failure to follow established NEWS2 score protocols.
Responded
Ellen Mercer
Concerns: Hospital policy for VTE risk assessment is dangerously unclear, not requiring assessment in emergency departments and starting the 24-hour period only upon ward admission, despite long patient waits.
Responded
Derek Hand
Concerns: Current dental guidance for patients on Clopidogrel lacks requirements for pre-procedure clotting function checks, posing a risk of excessive post-dental procedure bleeding for these individuals.
Responded
Nuliyati Businje
Concerns: DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed diagnoses and increased VTE risk.
Responded
James Baxter
Concerns: Commercial medical exams for licence renewal bypass GP knowledge, and the system lacks proactive screening for asymptomatic cardiovascular disease or use of risk-based stratification, omitting vital health indicators.
Responded
Terence Sullivan
Concerns: Current NICE and British Society of Gastroenterology guidance on anticoagulation for patients with coronary stents undergoing therapeutic endoscopy does not reflect best practice, specifically regarding single anticoagulant use.
Responded
Gillian Baumgardt
Concerns: There is no system requiring radiographers to use pre-exposure markers or for radiologists to investigate inconsistencies in injury site between x-ray images, risking wrong-site surgery.
Responded
Georgia Dehaney-Perkins
Concerns: A patient with a self-harm history was placed in a room with a faulty anti-ligature mechanism without risk assessment, and medication risks with alcohol were not communicated. Inconsistent recording of alcohol consumption and ignored family concerns compromised patient safety.
Responded
James Atkinson
Concerns: A lack of systematic allergy awareness, regular patient reviews, and proper management structures for anaphylaxis risk leaves diagnosed individuals vulnerable to future deaths.
Overdue
Karena Wicking
Concerns: The surgical mortality review overlooked the role of anticoagulation, and discharge planning lacks a prompt to consider ongoing anticoagulant prophylaxis for patients with reduced mobility.
Responded
David Moore
Concerns: A patient's tracheostomy tube became dislodged, leading to delayed replacement and subsequent hypoxic cardiac arrest, indicating a critical failure in medical management.
Overdue
James Holgate
Concerns: An anomaly in the Human Tissue Act prevents body donation for medical research/training when an inquest is held, even if a post-mortem isn't needed, impeding scientific progress.
Responded
Samantha Shillito
Concerns: A deteriorating patient with a high NEWS score was not reviewed by specialist consultants. Risks of the ascitic tap procedure were unquantified and potential for death was not disclosed during consent.
Responded
Ann Pearce
Concerns: The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.
Responded
Adam Stuyvesant
Concerns: The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.
Overdue
Melissa Kerr
Concerns: Patients traveling abroad for Brazilian Buttock Lift surgery are unaware of high mortality risks and lack of safety controls, including inadequate pre-operative assessment and surgeon consultation.
Responded
Christine Nakafeero
Concerns: A patient fatally slipped out of a care pathway, not receiving critical surgery for three years, and VTE risk assessment criteria inadequately accounted for key risk factors.
Responded
David Wilson
Concerns: The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk ratings, didn't tailor risks to his medical history, omitted the risk of death, and was signed while sedated.
Responded
Elizabeth Hutchins
Concerns: Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received no medical review for four days, indicating a severe failure in monitoring and timely clinical intervention.
Responded
Keith Hodson
Concerns: Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical priority. Delays in incident reporting and family communication were also noted.
Responded
Michael Allen
Concerns: An inexperienced FY1 doctor was left unsupervised to manage a critically ill patient, leading to failures in initiating sepsis protocol, inadequate monitoring, and delayed senior review, which significantly contributed to the patient's deterioration.
Overdue
Mary Nwanonyiri
Concerns: Senior nursing staff failed to implement comprehensive care plans, including capacity assessments for refusing observations, and critically, did not recognize or urgently respond to a patient's acutely deteriorating clinical condition.
Responded
John Lawler
Concerns: The chiropractor failed to take pre-treatment spinal images and mobilised the patient after loss of sensation, highlighting concerns about inadequate pre-treatment assessment and the need for mandatory First Aid training for chiropractors.
Overdue
Ghulam Mohammad
Concerns: There was a four-day delay in conducting a crucial CT head scan after an elderly patient's fall and suspected head injury. Additionally, the patient was inappropriately prescribed an anticoagulant before the scan.
Overdue
Freda Lennox
Concerns: Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.
Responded
Raymond Griffiths
Concerns: The inquest was prompted by a review identifying that failures in care probably contributed to the patient's death following cardiac surgery.
Responded
Sheila Steggles
Concerns: Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Responded
Surekha Shivalkar
Concerns: A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's early departure contributed to a failure to identify a critically ill patient.
Overdue
Margaret Toye
Concerns: Failure to assess malnutrition risk using the MUST score and erroneous documentation meant necessary nutritional interventions were not implemented, despite known widespread non-compliance on the ward.
Overdue
William Doleman, Anita Burkey, Peter Sellars and Carol Cole
Concerns: There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.
Responded
Diana Reay
Concerns: Multiple doctors misread scans, mistaking a fluid-filled cyst for a full bladder, which resulted in unnecessary and repeated catheterisations of the patient.
Overdue
Glenda Logsdail
Concerns: A lack of awareness of capnography guidance, failure to confirm ETT placement, diagnostic fixation, and an inhibitory hierarchy led to chaotic team malfunction during a critical emergency.
Responded
Harold Blackshaw
Concerns: The rehabilitation ward lacks an effective admission process to assess patient needs and implement necessary fall prevention measures for high-risk elderly patients.
Overdue
Jonathan Kingsman
Concerns: The risk assessment tool is flawed as it only considers mobility after an initial step, disregarding other crucial VTE risk factors and lacking clear completion guidance.
Responded
Leslie Horsfield
Concerns: The admissions assessment tool lacks prompts to inquire about previous choking incidents, creating a risk that crucial patient information will be overlooked.
Responded
Gary Day
Concerns: Surgical consent forms failed to disclose death risk from air embolus. No post-operative check for embolus was done, and the patient was discharged too quickly without adequate monitoring.
Responded
Lisa Grant
Concerns: The DVT risk assessment was inadequate, failing to recognise significant risk factors like obesity, inactivity, and a known medication side effect for a patient with reduced mobility.
Overdue
Betty Tadman
Concerns: Hospital staff failed to investigate a potential fracture after a fall in an elderly patient with dementia, neglecting imaging and over-relying on lack of pain, which led to unaddressed severe injuries and no post-death investigation.
Responded
Brandon-Robert Collins-Hayward
Concerns: Absence of national guidance for postnatal home visits to include basic newborn observations and for medical assessment of babies when mothers are admitted with potential sepsis creates future death risks.
Responded
Stanley Babbs
Concerns: Contrast media, a prescription-only medicine, was administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients.
Responded
Allison Bird
Concerns: Concerns include inadequate patient consent processes, with explanations given minutes before major surgery, and nursing staff failing to consistently escalate monitoring or seek clinical review after non-reassuring vital signs.
Overdue
Peter Smith
Concerns: Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery impossible and contributed to the patient's death.
Responded
Richard Ridout
Concerns: A trauma call was not initiated despite clear indicators like a high-speed roll-over collision and high-force injury, leading to a failure to carry out a trauma series CT scan or c-spine imaging.
Responded
Amy Allan
Concerns: Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.
Responded
John Shrosbree
Concerns: Persistent daily staff shortages in the Emergency Department are putting patients' lives at risk and require urgent attention.
Responded
Maureen Jarvis
Concerns: A psychiatric patient lacked a proper medical examination due to consent issues, highlighting the need for a clear, disseminated policy on physical health examinations for admitted psychiatric patients.
Responded
Shahida Begum
Concerns: Clinical streamers at Newham University Hospital triage patients based on visual assessment and brief history before vital clinical observations are taken, which is deemed a less safe system.
Overdue
Alice Dixon
Concerns: A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.
Overdue
Colin Bailey
Concerns: National guidelines on head injury assessment do not universally recommend CT scans for patients on non-warfarin anticoagulants, despite clinical consensus for their necessity.
Overdue
Kenneth Whittington
Concerns: Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after surgery.
Responded
Mary Johnson
Concerns: Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.
Responded
Marian Hoskins
Concerns: An unclear system for obtaining full and informed consent, particularly lacking sufficient outpatient discussion prior to admission, led to insufficient patient information on investigatory options.
Responded
Karen Moran
Overdue
Alba Pemberton
Concerns: Protocols for meconium classification and equipment use are inadequate, and there's insufficient obstetric review and multidisciplinary collaboration in birthing centres and low-risk maternity cases.
Responded
Bernard Fagg
Concerns: Concerns exist over whether patients undergoing CT scans with contrast and subsequent nil-by-mouth procedures should receive intravenous fluids, due to potential dehydration risks.
Overdue
Abdul-Jamal Ottun
Concerns: Critically inadequate risk assessment, supervision, and swimming education for school open-water activities failed to prepare students for cold natural waters, highlighting a systemic risk of drowning without curriculum changes.
Responded
Edwin Hooper
Concerns: Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.
Responded
Shaun Berryman
Concerns: A patient's clinical assessment was conducted in a waiting area without a physical examination, and no clinical record was made of the encounter.
Responded
Rafe Angelo
Concerns: Antenatal checks were insufficient for detecting growth restriction, lacked clear guidance for post-bradycardic episodes, and birthing centers lacked CTG. Transfer policies were unclear, and communication protocols between staff and ambulance services were inconsistent.
Overdue
Patrick Clifford
Concerns: Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.
Overdue
Robert Dymond
Concerns: Hospital DVT protocol did not align with NICE guidelines, and critical DVT history was not communicated to surgical teams, leading to a lack of awareness during subsequent assessments.
Responded
Sheila Hynes
Concerns: A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
Overdue
Lily Townsend
Concerns: Failures in preoperative assessment, including incomplete medical history and inadequate use of care bundles, led to a high-risk patient undergoing surgery without proper risk discussion or informed consent.
Responded
Kevin Mann
Concerns: A medical procedure was inappropriately performed despite clear radiological contraindications and continued after complications, compounded by the radiologist's failure to check prior imaging and an inadequate, unreviewed procedural policy.
Responded
Dennis Teesdale
Concerns: The hospital lacked specialist facilities and clinicians for complex procedures like PEG insertion. Written guidance was not followed, and no risk assessment was conducted for the procedure or alternative feeding methods.
Overdue
Kenneth Evans
Concerns: Thromboprophylaxis was not arranged, and an effective risk assessment for developing blood clots was not undertaken for the patient.
Responded
Maxim Karpovich
Concerns: Midwives and junior obstetricians demonstrated a critical lack of skill in interpreting abnormal cardiotocograph (CTG) traces. This highlights a systemic failure in CTG training and a need for mandatory competency testing for intrapartum care.
Responded
Frances Cappuccini
Concerns: Multiple failures included not checking for retained placenta, ignoring haemorrhage protocols, inadequate anaesthetist supervision, delays in emergency help, and poor note-keeping, all impacting patient safety.
Responded
Albie Marlow
Concerns: A mother's repeated requests for a Caesarean Section were not granted, leading to the baby's death and raising concerns about respecting maternal wishes in delivery.
Responded
Marjorie Bassendine
Concerns: Failure to recognise the cardiac risks of multiple psychotropic medications led to a lack of pre-treatment and regular ECGs to monitor for potential QT interval prolongation.
Overdue
George Watson
Concerns: Concerns include an unsatisfactory discharge process with unclear medication protocols, inefficient staffing allocation, inadequate monitoring of night shift staff, and insufficient clarity on investigatory process improvements.
Overdue
Diana Ritchie
Responded
Harry Glibbery
Responded
Jean Stockley
Responded
Michael Blow
Overdue
Joshua Knox-Hooke
Responded
Kirsty Childs
Concerns: The provided concerns text is incomplete and does not clearly articulate specific safety issues or systemic failures regarding Kirsty Childs' death.
Overdue
Rhianne Barton
Concerns: Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis and care. National guidelines on bariatric surgery in pregnancy are also lacking.
Overdue