Recurring concern

Failure to provide fundamental personal care and welfare

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First reported 24 Sep 2014•Latest report 22 Jul 2024

Definition

What this concern includes

Includes failures in the bounded delivery of fundamental personal care and general welfare to people receiving care, including meeting basic needs for warmth, hygiene, grooming, clean and adequate clothing, safe assistance with meals, comfort and comparable essential daily care needs.

Not included

  • Excludes failures confined to a specific named care process, such as continence care, nutrition and hydration management, pressure-ulcer care or moving and handling, when that process supplies the more specific supported concern.
  • Excludes generic staffing, training, documentation or management deficiencies unless they directly result in failure to provide fundamental personal care or welfare.
  • Excludes clinical assessment, diagnosis, treatment, referral or escalation failures where basic personal care and welfare are not the unsafe condition.
  • Excludes ordinary dissatisfaction or preferences about care where no failure to meet an essential personal-care or welfare need is identified.
Reports
15

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
21

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

University Hospitals Sussex NHS Foundation Trust3
East London NHS Foundation Trust2
NHS England2
Barts Health NHS Trust1
Berrycroft Manor1
Betsi Cadwaladr University LHB1
Care Quality Commission1
Care UK1
Care UK Community Partnerships Ltd1
CSC Computer Sciences Limited1
Department of Health and Social Care1
East Sussex Healthcare NHS Trust1
Essex Partnership University NHS Foundation Trust1
Guy'S and St Thomas' NHS Foundation Trust1
HM Prison and Probation Service1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. East London

    AI-generated summary

    Omar Abdi Ahmed · 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

    Omar Abdi Ahmed, who had significant comorbidity and bilateral lower-limb amputations, was found unresponsive and severely hypothermic at home on 15 November 2023 after receiving domiciliary and district nursing care. He died in hospital on 20 November 2023; the inquest concluded that hypothermia, with pneumonia and ischaemic heart disease contributing, was the medical cause of death. Concerns included poor communication between care organisations, shortcomings in district nursing oversight, and domiciliary care arrangements that did not adequately address his personal care, nutrition, cleaning, and heating needs.

    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

    Failure of domiciliary care to provide essential cleaning, personal care and meal support

    Wider context from the report

    “3. Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death. Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café. ”

    Source location

    Omar Abdi Ahmed · Prevention of Future Deaths report
    Page 3 · 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

    Meet with Sunlight Care to address and mitigate risks to residents receiving its care and support.

    Verbatim wording from the response

    “2. Action: A meeting with the Sunlight Care to ensure that any risks to residents they provide care and support to is mitigated. This will be achieved by the following actions By who: Strategic Safeguarding and Quality Assurance and By when: Meeting held on 17/07/24 although the QIP is ongoing”

    Source location

    Response from London Borough of Newham
    Page 1 · response
    Published 31 July 2024

    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

    Implement and continue the quality improvement plan for Sunlight Care.

    Verbatim wording from the response

    “2. Action: A meeting with the Sunlight Care to ensure that any risks to residents they provide care and support to is mitigated. This will be achieved by the following actions By who: Strategic Safeguarding and Quality Assurance and By when: Meeting held on 17/07/24 although the QIP is ongoing”

    Source location

    Response from London Borough of Newham
    Page 1 · response
    Published 31 July 2024

    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

    Provide enhanced monitoring of all residents receiving care and support from Sunlight Care.

    Verbatim wording from the response

    “• Enhanced monitoring of all residents Sunlight Care provide care and support to is in place”

    Source location

    Response from London Borough of Newham
    Page 2 · response
    Published 31 July 2024

    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 welfare checks for Sunlight Care residents who live alone.

    Verbatim wording from the response

    “• Welfare checks of all residents Sunlight Care provide care and support to who live alone has taken place By who: Commissioning Team”

    Source location

    Response from London Borough of Newham
    Page 2 · response
    Published 31 July 2024

    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 escalation procedure for partners to flag high unmitigated risk or differing risk assessments, including reviews of no-reply and refusal-of-care protocols.

    Verbatim wording from the response

    “4. Adult Social Care will lead on the development of an escalation procedure which will enable partners to flag cases where there is concern about a high level of unmitigated risk or differences of opinion about level of risk. This procedure will involve reviews of the following protocols:”

    Source location

    Response from London Borough of Newham
    Page 2 · response
    Published 31 July 2024

    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

    Update safeguarding, notification, response and monitoring policies, including 24-hour reporting, 48-hour response expectations and proactive follow-up.

    Verbatim wording from the response

    “In addition to updating and, where necessary amending our policies, we commenced an eight-week implementation programme on 5 August 2024. A summary of this programme setting out the topics of training, appears in Appendix A.”

    Source location

    Response from Sunlight Care Group
    Page 1 · response
    Published 31 July 2024

    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

    Implement an eight-week programme of revised-policy communication and staff training covering self-neglect, safety, nutrition, risk, capacity, safeguarding and multidisciplinary collaboration.

    Verbatim wording from the response

    “We are committed to providing the highest standards of safety and care and wish to ensure that any lessons to be learnt from the circumstances of Mr Ahmed’s tragic death are identified and implemented as necessary within our agency. Alongside our engagement with the coroner’s investigation, we have conducted our own internal review process, updated our policies, commenced the implementation of a full programme of updated communication, consultation and training, and proactively liaised with the East London Foundation NHS Trust (‘the Trust’) and the London Borough of Newham (‘the Local Authority’).”

    Source location

    Response from Sunlight Care Group
    Page 1 · response
    Published 31 July 2024

    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

    Implement new inter-agency communication and escalation strategies for timely safeguarding escalation across teams.

    Verbatim wording from the response

    “In addition, we attended a multi-agency discussion with the Local Authority and NHS Trust to discuss lessons learnt on 23 July 2024 and arranged a follow up on 4 September 2024. At the second meeting, the following actions were agreed to be undertaken within a twelve week time frame:”

    Source location

    Response from Sunlight Care Group
    Page 3 · response
    Published 31 July 2024

    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

    Introduce regular multidisciplinary reviews for cases involving self-neglect, incorporating physical, mental and social wellbeing in decision-making.

    Verbatim wording from the response

    “3. We are introducing regular multidisciplinary reviews for cases involving self-neglect, allowing for a more holistic approach to care that includes input from a range of professionals. This will help ensure that all aspects of the client's well-being—physical, mental, and social—are considered in decision-making processes;”

    Source location

    Response from Sunlight Care Group
    Page 5 · response
    Published 31 July 2024

    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

    Publish the first part of the Care Workforce Pathway for adult social care.

    Verbatim wording from the response

    “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 July 2024

    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 the Care Workforce Pathway to work alongside existing standards and competency frameworks.

    Verbatim wording from the response

    “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 July 2024

    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

    Formal interventions for capacitous clients depend on statutory agencies rather than the care provider.

    Verbatim wording from the response

    “An element of Mr Ahmed’s Care and Support Plan was to facilitate community engagement and social interaction, which was important to Mr Ahmed. In circumstances where there is evidence of self-neglect and a client may not be making appropriate decisions concerning eating, cleaning, hearing and personal care, it is clear that this must be addressed by those involved in the client’s care. As the coroner is aware, Mr Ahmed had capacity and was therefore able to make his own decisions. This creates significant challenges for care providers, which are reliant upon working alongside the statutory agencies to make any formal interventions necessary.”

    Source location

    Response from Sunlight Care Group
    Page 4 · response
    Published 31 July 2024

    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 DoLS safeguards do not apply to people living at home, and the proposed LPS framework will not be implemented.

    Verbatim wording from the response

    “The Local Authority has informed us that the LPS framework will no longer be implemented. As a result, they will continue to rely on the existing DoLS framework, which does not apply to individuals living at home. We understand that the new LPS framework would have provided those involved in Mr Ahmed’s care with the opportunity for assessment of his ability to make appropriate decisions in his own best interests. This is a challenge we trust will be remedied within new legislation.”

    Source location

    Response from Sunlight Care Group
    Page 5 · response
    Published 31 July 2024

    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

    The Trust cannot comment on behalf of the local authority or domiciliary care company regarding their communication and care arrangements.

    Verbatim wording from the response

    “4. The Trust is unable to comment on behalf of London Borough of Newham (‘LBN’) or the domiciliary care company. However, it can confirm that LBN and the Trust have systems in place which facilitate joint working to improve care for service users under both services.”

    Source location

    Response from ELFT
    Page 2 · response
    Published 31 July 2024

    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

    The commissioner and General Practitioner are expected to manage concerns about domiciliary care and the service user’s poor decision-making.

    Verbatim wording from the response

    “The local authority, not the Trust commissioned the domiciliary care providers. Consequently, it is expected that the commissioner and the General Practitioner would manage concerns. However, as outlined in paragraph 8, Trust staff should be proactive when they witness concerns and arrange professionals’ meetings between agencies. This will be reviewed with staff over the next two months.”

    Source location

    Response from ELFT
    Page 4 · response
    Published 31 July 2024

    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

    Employers have ultimate responsibility for ensuring health and care staff possess the necessary skills and competence.

    Verbatim wording from the response

    “While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 July 2024

    Open published response
  2. East Sussex

    AI-generated summary

    Carol Ann DIVALL · 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

    Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.

    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

    Failure to provide basic nursing oral care

    Wider context from the report

    “A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case. ”

    Source location

    Carol Ann DIVALL · 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

    Maintain electronic MUST and mouthcare assessments to record and monitor patient care.

    Verbatim wording from the response

    “We recognise that the mouthcare received by Mrs Divall was not of a standard we expect. Since 2022 the Malnutrition Universal Screening Tool (MUST) and Mouthcare assessment have been a central element of basic documentation. At the end of last year both documents were transferred to an electronic system, to enable staff to record and monitor the care provided to patients, with a decreased risk of losing manual recording.”

    Source location

    Response from East Sussex Healthcare
    Page 1 · response
    Published 15 May 2024

    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

    Provide risk-based scheduled mouthcare reviews with electronic prompts and escalation of missed reviews.

    Verbatim wording from the response

    “High risk patients now receive daily mouthcare reviews, medium risk patients are reviewed every other day, and low risk patients are reviewed every third day ensuring that any oral concerns are picked up in a timely manner and managed until improvement is seen. All reviews are prompted on the electronic system and highlighted if not actioned.”

    Source location

    Response from East Sussex Healthcare
    Page 1 · response
    Published 15 May 2024

    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

    Establish a dedicated Mouth Care Matters Lead role and deliver targeted mouthcare training.

    Verbatim wording from the response

    “The Trust has now established a role (the ‘Mouth Care Matters’ Lead) that is dedicated to the promotion of good standards of mouthcare for patients and targeted training is delivered as per requirements and individual patient need (for example, in the event of a patient who is distressed or failing to comply, additional support and training would be available to staff providing care).”

    Source location

    Response from East Sussex Healthcare
    Page 2 · response
    Published 15 May 2024

    Open published response
  3. East Riding and Hull

    AI-generated summary

    Ethel Doreen Reed · 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

    Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.

    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

    Paucity of personal care on the ward

    Wider context from the report

    “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward. Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff. ”

    Source location

    Ethel Doreen Reed · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Essex

    AI-generated summary

    Ronald Scott Ashdown · 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

    Ronald Scott Ashdown died from aspiration pneumonia on 15 August 2021, following severe disability caused by a hypoxic brain injury after a cardiac arrest in 2013. Concerns included failures in basic personal hygiene while he was dependent on hospital staff, and a flawed investigation that failed to consider photographic evidence and contributed to subsequent safeguarding investigations being undermined.

    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

    Failure to provide basic personal hygiene care to physically dependent patients

    Wider context from the report

    “(b) The evidence confirmed that, despite his clear vulnerability and complete physical dependence on Trust staff providing basic nursing care, including simple personal hygiene, RA did not receive such basic care for an extended period – probably over several days. This does not indicate, as appears to have been suggested at one point by the Trust, a failure in record keeping but, rather, a serious failure in the provision of the most basic of nursing care. Running as it did over several days, the evidence confirmed that this failure to provide basic care likely extended beyond one or two members of staff and, further, was simply not picked up by the more senior nurses on the Ward. ”

    Source location

    Ronald Scott Ashdown · Prevention of Future Deaths report
    Page 3 · 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

    Launch a ward manager supervisory role with linked performance indicators to strengthen supervision and audit of nursing care.

    Verbatim wording from the response

    “The action plan is underpinned by a focus on matron and ward manager leadership. We are planning to launch a ward manager supervisory role with linked key performance indicators later this month which will allow closer supervision and audit of the nursing care provided This will include monitoring the quality of the nursing care we provide. We are passionate about getting the basics right for our patients and this work feeds into an extensive Trust-wide plan to achieve this.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 2 · response
    Published 21 July 2023

    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

    Maintain systems and processes to monitor compliance with patients’ personal care standards.

    Verbatim wording from the response

    “I am confident we are doing all we can to meet the personal care needs of our patients, and that we have systems and processes in place to monitor compliance with this standard. We will continue to strengthen our governance in relation to safeguarding practices and information sharing with external stakeholders; ensuring that all documentation is considered when completing our internal investigations.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 2 · response
    Published 21 July 2023

    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 systems and processes are considered sufficient to monitor compliance with patients’ personal care needs.

    Verbatim wording from the response

    “I am confident we are doing all we can to meet the personal care needs of our patients, and that we have systems and processes in place to monitor compliance with this standard. We will continue to strengthen our governance in relation to safeguarding practices and information sharing with external stakeholders; ensuring that all documentation is considered when completing our internal investigations.”

    Source location

    Response from Mid and South Essex NHS Foundation Trust
    Page 2 · response
    Published 21 July 2023

    Open published response
  5. North Wales (East and Central)

    AI-generated summary

    Philip Hawkins · 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

    Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.

    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

    Insufficient space for nursing care and pressure-area assessment

    Wider context from the report

    “Care Concerns in the ED 4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas. 5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians. 6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician. 7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23. 8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him. ”

    Source location

    Philip Hawkins · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    John Francis GREGORY · 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

    John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.

    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

    Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine

    Wider context from the report

    “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff. On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine. ”

    Source location

    John Francis GREGORY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Inner South London

    AI-generated summary

    Daniel Williams · 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

    Daniel Williams died at St Thomas' Hospital on 26 November 2017 after developing complications of gastrointestinal surgery, including infection and sepsis, against a background of significant medical complexity. Concerns included deficient nursing care on a general gastrointestinal ward and a potential limitation in the investigation of Clostridium difficile cases when a patient had recently been transferred from another ward.

    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

    Failure to deliver the fundamentals of care on a general gastrointestinal ward

    Wider context from the report

    “2) The nursing care which Mr Williams received on this general gastrointestinal (GI) ward was found - by an internal Trust investigation which took place sometime after Mr Williams' death following a request by myself - to be "deficient in delivering the fundamentals of care". ”

    Source location

    Daniel Williams · 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

    Embed Fundamentals of Care standards through staff training, induction education and competency assessments covering core care, hygiene, infection prevention, fluids and nutrition.

    Verbatim wording from the response

    “The Trust launched its Fundamentals of Care standards (‘the standards’) in April 2018. Following its inception, members of staff at the Trust have received training on the standards and I am satisfied that they are now embedded into the nursing practice on both Page Ward and Northumberland Ward. All new members of staff at the Trust receive education and training in relation to the standards as part of the Trust’s specialised induction programme. Staff are also required to complete a competency assessment document which includes assessments around hygiene; infection prevention and control; fluid management and nutrition. All nursing staff on the GI unit, as part of their ongoing development, are required to complete competencies which include getting the basics of the core correct and delivering excellent fundamental care.”

    Source location

    2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
    Page 3 · response
    Published 5 November 2019

    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 quality rounds across Gastro Medicine and Surgical Directorate wards to review patient safety and experience and escalate staff concerns.

    Verbatim wording from the response

    “The Trust’s Directorate Management Team (‘DMT’) is committed to ensuring that fundamental care is the cornerstone of our practice; this is not just within nursing care but also across the wider multi-disciplinary team. Quality rounds take place weekly which are led by the Clinical Director and Head of Nursing; these endeavour to review both patient safety and patient experience on all wards in the Gastro Medicine and Surgical (‘GMS’) Directorate. The Trust has found that engaging with the clinical teams in this way enables its DMT to clearly interact with staff members and offers a forum for staff to voice any concerns they hold. In addition, it allows the Trust’s DMT to support staff with challenging situations (e.g. an operational issue, a staffing issue or a patient with complex needs) that require escalation.”

    Source location

    2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
    Page 3 · response
    Published 5 November 2019

    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

    Increase Page Ward staffing by one whole-time-equivalent senior nursing assistant on both day and night shifts.

    Verbatim wording from the response

    “A Trust wide establishment review takes place twice a year to determine whether the current staffing levels meet the needs of our service. Workforce Key Performance Indicators are considered (such as: vacancies, sickness and statutory and mandatory training) as well as planned staffing numbers against actual staff numbers. The workforce establishment review in 2018 highlighted the need to increase the numbers of senior nursing assistants on Page Ward in order to support the effective delivery of fundamental care. These posts have now been recruited into and the staff are now in place on Page Ward. Staffing has therefore increased by 1 whole time equivalent senior nursing assistant on both the day and the night shift on Page Ward.”

    Source location

    2019-0309-Response-by-Guys-and-St-Thomas-NHS-Trust
    Page 4 · response
    Published 5 November 2019

    Open published response
  8. Essex

    AI-generated summary

    Kelly Marie Campbell · 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

    Kelly Marie Campbell was a 17-year-old girl detained under section 3 of the Mental Health Act at Rochford Hospital. She was found hanging by a ligature made from shoe laces attached to a bathroom light fitting, and the inquest concluded that she killed herself. Concerns included the return of her shoe laces, the need for rigorous policies governing such decisions, and dreary physical surroundings that may have contributed to boredom during the night.

    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

    Lack of stimulating and suitable physical surroundings in patient rooms

    Wider context from the report

    “(2) Kelly’s mother lamented the fact that the physical surroundings in the rooms were so dreary – she cited magnolia paint everywhere, no colourful pictures to brighten up the environment etc. She observed that the lack of mobiles, a clock etc. in the rooms led to boredom in the long night hours. ”

    Source location

    Kelly Marie Campbell · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  9. Brighton and Hove

    AI-generated summary

    Leslie Isaac LERNER · 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

    Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

    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

    Failure to provide appropriate positioning and personal care

    Wider context from the report

    “17th May – 22nd May 2016 There is no evidence of any continuity of care. There is good evidence of “hands off” care and nursing. In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering. No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics. In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing, because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing. ”

    Source location

    Leslie Isaac LERNER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Brighton and Hove

    AI-generated summary

    Jack MOLYNEUX · 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

    Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.

    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

    Failure to provide adequate personal hygiene care

    Wider context from the report

    “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above. Mobility He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month. His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth. His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it. With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged. At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death. I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed. Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death. When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content. Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016. ”

    Source location

    Jack MOLYNEUX · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026