Recurring concern

Clinical layouts failing to support full patient oversight

First to latest report 5 Mar 2014 — 30 Sep 2022

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
8

What this concern includes

Includes deficiencies in the physical layout or distribution of clinical care areas that materially impede staff visibility, oversight, supervision or timely coordination of patients, including multi-floor arrangements that separate assessment, treatment or observation areas.

What is not included
  • Excludes generic hospital or maternity capacity, staffing and leadership deficiencies where layout-related loss of oversight is not the unsafe condition.
  • Excludes ordinary building, accessibility or privacy deficiencies that do not impair clinical oversight of patients.
  • Excludes split-site service, transfer and cross-hospital coordination failures where the concern is the operation of separate sites rather than layout within a clinical care environment.
  • Excludes isolated ward or room hazards, such as ligature points, unsafe surfaces or inadequate barriers, unless the layout specifically impairs patient oversight.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Liverpool and the Wirral

    AI-generated summary

    Katharine Mary TYRER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Katharine Mary TYRER died at the scene on 12 April 2018 after being found unresponsive with a ligature in a bathroom on the Lakefield Ward. The report identified concerns about the ward layout limiting observation, inadequate risk assessment, missed opportunities to respond to increased short-term risk, and the absence of a clear protocol for escalation and enhanced monitoring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Ward layout failing to support easy observation of vulnerable patients

    Wider context from the report

    “1. The ward layout did not lend itself to easy observation of patients. The Court’s expert considered it ‘wholly inadequate’. The jury felt that this contributed more than minimally to Katharine’s death. A number of rooms (including Katharine’s room, 23) were remote from the nursing station and largely out of sight unless visited for a specific purpose. Whilst I am aware that some changes have been made since 2018, I am concerned that the current layout continues to place vulnerable patients, who might take their own lives, at risk. It is appreciated that the Trust might not be in a position to create a ward which eliminates all of the layout issues. However, mitigation measures might be appropriate if the present facilities are to be used on an ongoing basis in an unmodified form. I am concerned that the limitations presented by the current layout may mean that staffing levels need to be adjusted to allow for greater levels of informal observation, oversight and monitoring. ”

    Source location

    Katharine Mary TYRER · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Reconfigure the ward as a 20-bed facility to improve patient observation and oversight.

    Verbatim wording from the response

    “In response to the above I can confirm that the ward was reconfigured in October 2021 when it has become a 20-bed facility. As a result, the new ward layout assists with observation and oversight. The layout of the ward is in line with the existing estate available. For any new build developments or full refurbishments, the Trust is aware of and would plan the specifications in accordance with the Health Building Note 03-01 (Adult Acute Mental Health Units). This best practice guidance concurs with the Care Quality Commission (CQC) regulatory framework (regulation 15).”

    Source location

    Response from Cheshire and Wirral Partnership NHS Foundation Trust
    Page 2 · response
    Published 10 October 2022

    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

    Relocate the ligature knife and position nurse stations within ward corridor areas to support appropriate observations.

    Verbatim wording from the response

    “At the time of the incident the ward was a 24-bed facility and was appropriately staffed according to the number of beds. Immediately post incident several improvement actions were taken in respect of the location of the ligature knife and nurse stations situated within the ward (including corridor areas) to support appropriate observations.”

    Source location

    Response from Cheshire and Wirral Partnership NHS Foundation Trust
    Page 2 · response
    Published 10 October 2022

    Open published response

  2. Greater Manchester South

    AI-generated summary

    Jos Tarse-Joy · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jos Tarse-Joy was born by emergency caesarean section at 41 weeks after his high-risk pregnancy was not explicitly identified to his parents or care team, no induction had been arranged, and CTG monitoring was not used on admission. He was born in very poor condition, sustained severe brain damage following hypoxia, and died at Royal Oldham Hospital on 15 December 2020. The principal concerns included communication and documentation failures, lack of appropriate monitoring and induction planning, unclear escalation processes, and wider issues concerning maternity-service layout and national guidance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Maternity service layout impeding full patient oversight

    Wider context from the report

    “3. The evidence before the inquest was that the layout of maternity services at the trust meant that triage and delivery were on different floors. The trust did have steps in place to alleviate the challenges of this but evidence was that it made it more difficult for full oversight of patients. The inquest was told that this was not unusual across the NHS estate. ”

    Source location

    Jos Tarse-Joy · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. London (West)

    AI-generated summary

    Neil James Carter · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Neil James Carter took his own life on 20 November 2012 by jumping in front of a train while he was an inpatient at Priory Hospital Roehampton. The report identified repeated failures to perform basic nursing observations, inadequate staffing and skill mix, poor ward layout and discipline, management failures, and deliberate falsification of the nursing record. The inquest concluded that these failures led to missed opportunities to realise he was missing, search for him early, and offer life-saving interventions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inappropriate ward layout over two floors

    Wider context from the report

    “(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act. ”

    Source location

    Neil James Carter · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Conduct an unannounced joint compliance inspection of The Priory Hospital Roehampton and require remedial action for identified non-compliance.

    Verbatim wording from the response

    “Since June 2013 the Commission have carried out the following compliance inspections of The Priory Hospital Roehampton:”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 4 · response
    Published 5 March 2014

    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 an unannounced follow-up inspection assessing emergency procedures, observation policies, staff training and completion of earlier compliance actions.

    Verbatim wording from the response

    “2. 24 October 2013: The Commission undertook a joint unannounced inspection in direct response to information that was received following a death of a patient at the hospital in September 2013. The inspection was conducted by compliance inspectors and a Mental Health Act Commissioner. The inspection focussed on outcome areas that related to some of the concerns raised including emergency procedures, observation policies and staff training and also assessed whether the actions required to achieve compliance with Outcomes 1 and 10, following the inspection on 25 June and 3 July 2013, had been completed. The Priory Hospital Roehampton was found to be compliant with all outcomes that were assessed. We set out a summary of those findings below:”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 5 · response
    Published 5 March 2014

    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

    Include ward layout and its impact on patient care in planning and execution of the next hospital inspection.

    Verbatim wording from the response

    “• The appropriateness of the ward layout over two floors and its impact on patient care has not been specifically looked at by the Commission to date in its inspections since the death of Mr Carter. Within the Commission’s regulatory methodology this concern relates to outcome 10 dealing with the safety and suitability of premises. Outcome 10 corresponds to regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We are grateful that this concern has been brought to our attention and we intend to incorporate the outcome specifically into the planning and execution of our next inspection of the hospital.”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 8 · response
    Published 5 March 2014

    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

    Undertake an unannounced inspection within four months covering reported concerns, additional regulatory concerns and new intelligence, coordinated with Mental Health Act monitoring.

    Verbatim wording from the response

    “The Commission plans to undertake the next inspection visit of The Priory Hospital Roehampton within the next four months. The precise date of the inspection has not been set and it is to be unannounced. It is also intended that that visit would consider not only the specific areas of concern highlighted in this report but also those highlighted in a separate Regulation 28 report that was addressed to the Commission following the inquest into the death of another service user at The Priory Hospital Roehampton. That visit would also take account of any further intelligence that is gathered or brought to the Commission’s attention before that inspection. The planning of that inspection is also being coordinated with the Mental Health Act Commissioners’ monitoring of the provider for the same purposes.”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 8 · response
    Published 5 March 2014

    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 weekly four-week-cycle Quality Walk Rounds, including checks of patient observations and care plans, with results reviewed through clinical governance.

    Verbatim wording from the response

    “To support compliance, standards across Roehampton Hospital are also monitored internally through the use of Healthcare Division ‘Quality Walk Rounds’ which are undertaken on a weekly basis and operate to a set four-week rolling programme of monitoring. For example, week one involves an assessment of the environment and week two involves an assessment of patient care which includes a review of the completion of patient observations and care plans.”

    Source location

    2014-0103-Response-by-Priory-Group
    Page 2 · response
    Published 5 March 2014

    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

    Separate Garden Wing into two wards with dedicated managers, nursing teams, therapists and activity coordinators.

    Verbatim wording from the response

    “I am informed that following Mr Carter's death, Garden Wing was separated into two distinct wards. Each ward has its own ward manager and nursing team together with therapists and activity co-ordinators. I am informed by the hospital that the two smaller wards are sufficiently staffed and that the managers and nursing staff of the wards are sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital Director and additional clinical support is provided by the Clinical Services Manager. They will continue to monitor staffing levels and skill mixes to ensure they are appropriate.”

    Source location

    2014-0103-Response-by-Priory-Group
    Page 2 · response
    Published 5 March 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026