Recurring concern

Inadequate Enhanced Care Supervision

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First reported 9 Aug 2017•Latest report 13 Mar 2025

Definition

What this concern includes

Includes deficiencies in the named Enhanced Care Supervision or Enhanced Care system that undermine risk-based supervision, including failures in assessment, staffing arrangements, observation delivery, policy compliance or related dedicated controls.

Not included

  • Excludes generic staffing shortages or staff fatigue unless the report explicitly links them to failure of Enhanced Care Supervision.
  • Excludes ordinary handover, record-keeping or training deficiencies that are not specifically dedicated to or explicitly tied to Enhanced Care Supervision.
  • Excludes unrelated observation, welfare-checking or monitoring failures outside the Enhanced Care Supervision system.
  • Excludes failures concerning general patient care where no Enhanced Care Supervision requirement or system is identified.
Reports
8

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2017–2025

First to latest report issue date

Stated actions
14

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.

South Tyneside and Sunderland NHS Foundation Trust2
Aneurin Bevan University LHB1
Bristol NHS Foundation Trust1
Cardiff & Vale University LHB1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Langley Trust1
Royal London Hospital1

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. South Wales Central

    AI-generated summary

    Colin Colley · 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

    Colin Colley, who had dementia, frailty and a high assessed risk of falls, suffered an unwitnessed fall from a hospital bed after being left unsupervised with bed rails in place. He sustained a fatal brain bleed and died after transfer to the University Hospital of Wales. The principal concern was insufficient staff confidence and training in falls risk assessments, enhanced supervision and use of the Enhanced Supervision Document.

    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 confidence among nursing staff and healthcare support workers in the use and importance of enhanced supervision and the Enhanced Supervision Document

    Wider context from the report

    “(1) Evidence was taken from nurses at St David’s that there remains a lack of confidence in both qualified nursing staff, healthcare assistants and healthcare support workers in the use of and implication of risk assessments around falls, and the use of and importance of enhanced supervision and the Enhanced Supervision Document. I am concerned that unless more training is provided and refreshed frequently, there is a risk of future deaths occurring, particularly given the cohort being nursed at that hospital and the turnover of staff. ”

    Source location

    Colin Colley · 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

    Deliver enhanced-supervision education through pilots and the newly registered nurse preceptorship programme.

    Verbatim wording from the response

    “Since autumn 2023, pilots of education programmes have been delivered to over ninety staff across the Health Board, and educational resources have been developed and are currently being delivered as part of the newly registered nurse preceptorship programme.”

    Source location

    Response from Cardiff and Vale University Health Board
    Page 3 · response
    Published 17 March 2025

    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 the enhanced-supervision framework and develop a new governance policy through the task and finish and steering groups.

    Verbatim wording from the response

    “Alongside this, a task and finish group is updating the existing enhanced supervision framework and developing a new policy to provide more robust governance around its use. From May 2025, a steering group has been convened, chaired by the Deputy Executive Nurse Director, to take forward this work.”

    Source location

    Response from Cardiff and Vale University Health Board
    Page 3 · response
    Published 17 March 2025

    Open published response

  2. Sunderland

    AI-generated summary

    Mr Allan Taylor · 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

    Mr Allan Taylor was admitted to Sunderland Royal Hospital after an unwitnessed fall at home and later suffered a further unwitnessed fall in hospital, fracturing his right neck of femur. He died in theatre on 1 June 2024 after becoming hypotensive and suffering cardiac arrest during surgery. The report identified that required Level 2 observations were not provided because the side room was not within sight or sound of the nursing station, and the issue was not escalated; it noted that closer observation might have enabled assistance and possibly prevented the fall.

    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 escalate non-compliance with Level 2 EICO observation requirements

    Wider context from the report

    “1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it. 2. The evidence was that this was not escalated to the Matron or Site Manager, which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations. 3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall. ”

    Source location

    Mr Allan Taylor · 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

    Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.

    Verbatim wording from the response

    “Our internal investigation identified omissions in care regarding the level of observation in place for Mr Taylor and the lack of escalation of concerns. Actions were undertaken to address this issue; an urgent review of the existing Enhanced Interactive Care and Observation (EICO) guideline took place which has now been amended and renamed Enhanced Therapeutic Observation and Care (ETOC) for patients in line with recent national changes in guidance as recommended by NHS England. In addition to exploring best practice nationally, the review of the guideline also took into consideration how other local Trusts manage safe observation and care of patients.”

    Source location

    Response from South Tyneside and Sunderland NHS Foundation Trust
    Page 1 · response
    Published 11 March 2025

    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 the amended Enhanced Therapeutic Observation and Care guideline across the organisation.

    Verbatim wording from the response

    “This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.”

    Source location

    Response from South Tyneside and Sunderland NHS Foundation Trust
    Page 1 · response
    Published 11 March 2025

    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

    Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.

    Verbatim wording from the response

    “This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.”

    Source location

    Response from South Tyneside and Sunderland NHS Foundation Trust
    Page 1 · response
    Published 11 March 2025

    Open published response

  3. Gwent

    AI-generated summary

    Mary Doreen White · 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

    Mary Doreen White was admitted to hospital in April 2021 and suffered three falls while an inpatient, including fractures requiring surgery. Her condition deteriorated while recovering from surgery, and she died from a chest infection, with frailty of old age also recorded. Concerns included staffing shortages, difficulties providing required enhanced observation on the ward, and the absence of a documented and communicated plan for managing patients requiring Level 4 enhanced care in that setting.

    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 continuous in-view observation for Level 4 enhanced care patients

    Wider context from the report

    “2. The ward is L-shaped and the patients on the ward are managed in individual cubicles. Mrs White should have been in view of nursing staff as part of her Level 4 enhanced care (‘observation of cohorted patients’). However, it was not possible to provide the observations that Mrs White required because: a. Patients were inside cubicles and therefore out of sight of staff and, b. The ward itself was L-shaped. 3. The Bargoed ward is a stroke ward and one where it is usual to see patients who have a high risk of falls and mobility difficulties. Prior to Covid-19 it was explained that staff would take patients who required the Enhanced Care to the dayroom so that they could be under the required observation. Since Covid-19, this had not been possible. To counteract the logistical difficulties faced by staff in observation of Enhanced Care patients on the ward it was explained that patients are now moved to their cubicle doorway for periods of the day so that they are in sight of nursing staff. This appeared to be ineffective because: a. The particular care needs/wishes of a patient may mean that is not suitable. b. That only accounts for part of the day. ”

    Source location

    Mary Doreen White · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 day room cannot always be used for patient cohorting during periods of extreme demand.

    Verbatim wording from the response

    “All wards have a day room area for patients, these are utilised to support the use of meaningful activities. Since the reduction in Covid 19 cases this area is often used during daytime hours to support the cohorting of patients who require a higher level of supervision. However, there are instances during extreme demand when the dayroom is unable to be used.”

    Source location

    Response from Aneurin Bevan University Health Board
    Page 3 · response
    Published 20 February 2023

    Open published response

  4. Avon

    AI-generated summary

    Mr Gerwyn John REES · 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

    Mr Gerwyn John REES, who was elderly and frail, was admitted to hospital after experiencing falls and was assessed as requiring low-risk enhanced care observations. He fell twice on 29 November 2020, fracturing his hip, and later died in January 2021 following surgery, as a result of general frailty and the hip injury. The principal concerns were the initial low-risk falls assessment, inadequate steps to prevent the fall, and an apparent lack of learning and investigative rigour following his death.

    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 allocate the appropriate ECO observation level following falls risk assessment

    Wider context from the report

    “• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020 • However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death • The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2 • Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment • When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time) • I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES • The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy • Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question • For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe. ”

    Source location

    Mr Gerwyn John REES · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    ECO Policy not fit for purpose or safe

    Wider context from the report

    “• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020 • However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death • The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2 • Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment • When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time) • I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES • The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy • Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question • For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe. ”

    Source location

    Mr Gerwyn John REES · Prevention of Future Deaths report
    Page 4 · 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

    Implement the revised Enhanced Care Observation and Meaningful Activities Policy with non-numbered observation categories and holistic patient-needs guidance.

    Verbatim wording from the response

    “As a direct result of this case, we have reconsidered our Enhanced Care Observation (ECO) and Meaningful Activities Policy and are in the process of implementing a revised policy to take on board our learning from this case. It is expected that this updated policy will be in place by November 2022. The updated policy removes the levels of 1, 2, 3, and 4 for ECO, which sometimes causes confusion amongst practitioners and replaces the levels for all inpatients requiring observations with:”

    Source location

    Response from University Hospital Bristol and Weston
    Page 2 · response
    Published 30 September 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

    Strengthen the Enhanced Care Observation policy with North Bristol NHS Trust partners.

    Verbatim wording from the response

    “In addition, to provide equitable and consistent care for all our patients, we will look at strengthening the ECO policy along with our partners in North Bristol NHS Trust.”

    Source location

    Response from University Hospital Bristol and Weston
    Page 2 · response
    Published 30 September 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

    Provide affected staff groups with support, education, training, ward signs, meaningful-activities resources and task kits after policy approval.

    Verbatim wording from the response

    “Once the updated policy has been approved, key staff groups affected by the ECO policy will be provided support, education, and training in applying the policy in practice. This will include display signs in ward areas, a meaningful activities list and task kits, and additional training to the ECO team from the dementia, delirium and falls team.”

    Source location

    Response from University Hospital Bristol and Weston
    Page 3 · response
    Published 30 September 2022

    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 patient’s admission presentation did not trigger higher observation because he was calm, oriented, engaged, and able to follow instructions.

    Verbatim wording from the response

    “We have reflected on the Root Cause Analysis carried out in this case with particular regard to the concerns you have raised. When assessing the falls risk for new patients admitted to hospital, we consider many aspects including their past medical history, reason for admission, and the presentation of the patient at that time. In Mr Rees’ case he was assessed on admission and assigned ECO level 2. At the time of presentation Mr Rees was found to be alert, orientated, not agitated, and calm. Mr Rees was able to hold a coherent conversation and was able to understand instructions to sit and wait for help to assist him to mobilise. Mr Rees was not putting himself at risk e.g., he was not attempting to mobilise on his own. We recognised that Mr Rees was an elderly gentleman with a history of previous falls and underlying mental health and medical health issues.”

    Source location

    Response from University Hospital Bristol and Weston
    Page 2 · response
    Published 30 September 2022

    Open published response

  5. East London

    AI-generated summary

    Vijaykumar Girishbhai Gadhavi · 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

    Vijaykumar Girishbhai Gadhavi died from a drug overdose while an in-patient at Whipps Cross Hospital under enhanced one-to-one care. The report raised concerns about breaches of the Enhanced Care Policy, the absence of an alert or risk-management plan, inadequate recording of property and medication, insufficient family involvement, and a lack of evidence that learning from earlier self-harming incidents had been implemented.

    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 consider breaking up the 1:1 carer shift

    Wider context from the report

    “5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer. ”

    Source location

    Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 keep hourly observations by the 1:1 carer

    Wider context from the report

    “5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer. ”

    Source location

    Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 the allocated nurse to complete a risk assessment

    Wider context from the report

    “5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer. ”

    Source location

    Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Gwent

    AI-generated summary

    Alan Jones · 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

    Alan Jones was admitted to Neville Hall Hospital after a fall at home and, during his admission, fell seven times. On 13 November 2019 he fell while he should have been under constant supervision, suffered a fatal head injury, and died the following day. Concerns included inadequate multidisciplinary management of his falls risk, failure to provide the required supervision, and unsafe staffing levels.

    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 required enhanced supervision for high-falls-risk patients

    Wider context from the report

    “1:1 Supervision Throughout Mr Jones’ admission I heard evidence that he required either 1:1 supervision (Enhanced Care Level 5) or to be supervised in a cohorted bay (Enhanced Care Level 4). This level of care was not achieved and as a result within less than 3 weeks of his admission, Mr Jones had fallen on 7 occasions, at times as a direct result of a failure to provide adequate supervision. I am satisfied that the nursing staff were aware of the level of supervision required and regularly requested additional nursing support. These requests were not resourced. It appears that the nursing staff had become used to this situation and tried to do the best they could in the circumstances. It also appeared that a ward which cares for patients who are the most likely to require extra support because they are confused, elderly and at risk of falls, is staffed to a minimum level which does not take account of any fluctuations in acuity. Of concern was that despite hearing evidence that improvements in falls management had been introduced, I also heard evidence that nursing staff on the ward continue to find themselves nursing with unsafe levels of staff. ”

    Source location

    Alan Jones · 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

    Increase the substantive Health Care Support Worker workforce to support enhanced care and continuity.

    Verbatim wording from the response

    “previously identified a need for an increase in Health Care Support Worker’s to support enhanced care by night and as a consequence the substantive HCSW workforce was increased to support this requirement.”

    Source location

    2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 4 · response
    Published 30 March 2021

    Open published response

  7. South Yorkshire (Eastern)

    AI-generated summary

    Alfred William Meek · 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

    Alfred William Meek, an 87-year-old man with dementia and cognitive impairment, suffered falls before and during his hospital admission and died on 13 September 2017. Concerns included missed or delayed Enhanced Care Supervision reviews, failure to provide supervision matching his assessed risk, and no evidence of further action after staff escalated concerns about insufficient resources.

    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 complete Enhanced Care Supervision daily assessments

    Wider context from the report

    “1) There was clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments. There was evidence before the Court of numerous days being missed and when the assessment was made the care was not provided in accordance with the policy or the level of risk identified leaving patient’s vulnerable to falls. 2) There was no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision in accordance with the level of risk identified. The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced Care Supervision and its implications, as ████████ is concerned that this situation could occur again. ”

    Source location

    Alfred William Meek · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 Enhanced Care Supervision in accordance with identified risk

    Wider context from the report

    “1) There was clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments. There was evidence before the Court of numerous days being missed and when the assessment was made the care was not provided in accordance with the policy or the level of risk identified leaving patient’s vulnerable to falls. 2) There was no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision in accordance with the level of risk identified. The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced Care Supervision and its implications, as ████████ is concerned that this situation could occur again. ”

    Source location

    Alfred William Meek · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 act on escalated concerns about insufficient supervision resources

    Wider context from the report

    “1) There was clear evidence of poor compliance with the Enhanced Care Supervision engagement policy and daily assessments. There was evidence before the Court of numerous days being missed and when the assessment was made the care was not provided in accordance with the policy or the level of risk identified leaving patient’s vulnerable to falls. 2) There was no evidence to suggest that any action was taken by the Trust following escalation by ward staff regarding concerns about the lack of resources to provide appropriate supervision in accordance with the level of risk identified. The Secretary of State for Health is asked to consider whether it is appropriate for Trust to review its systems and procedures in place in relation to Enhanced Care Supervision and its implications, as ████████ is concerned that this situation could occur again. ”

    Source location

    Alfred William Meek · 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

    Conduct regular audits of daily reassessment and intervention reliability across wards.

    Verbatim wording from the response

    “The first concern in your letter was regarding gaps in the reliability of daily reassessment and appropriate intervention. In response to this concern, I can confirm that our policies and documentation are designed to achieve an appropriate frequency of reassessment and appropriate interventions. The reliability of daily assessment and appropriate intervention can be seen through monitoring with regular audits. The total results for ward S12 are:”

    Source location

    2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 9 July 2018

    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 Trust-wide falls prevention audits to identify compliance and improvement needs.

    Verbatim wording from the response

    “The Trust Falls Specialist Practitioner has also undertaken audits across the Trust and these can be found appended to this letter. This shows a broadly high level of compliance in respect of assessments being undertaken at the appropriate frequency and action for supervision being taken. There are some areas for improvement on the implementation of the relevant actions to address a patients specific falls risk factors/ and de-escalation interventions, which is supported through the training provided, subsequently described in this letter.”

    Source location

    2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 9 July 2018

    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 falls ward accreditation, including staff training, supervision-assessment sign-off, monthly audits and monitoring for further support.

    Verbatim wording from the response

    “The Trust action plan for Falls & Bone Health Management supports the falls ward accreditation to be implemented this year. This is similar to other accreditation initiatives already in place such as nutrition and infection control. The falls accreditation will provide proactive assurance of the work”

    Source location

    2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust
    Page 2 · response
    Published 9 July 2018

    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 policies, documentation, monitoring and audits are considered sufficient to ensure reliable daily reassessment and appropriate intervention.

    Verbatim wording from the response

    “The first concern in your letter was regarding gaps in the reliability of daily reassessment and appropriate intervention. In response to this concern, I can confirm that our policies and documentation are designed to achieve an appropriate frequency of reassessment and appropriate interventions. The reliability of daily assessment and appropriate intervention can be seen through monitoring with regular audits. The total results for ward S12 are:”

    Source location

    2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 9 July 2018

    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 enhanced supervision systems, staffing assessments and resource-allocation procedures are considered sufficient to manage staffing after escalation.

    Verbatim wording from the response

    “The second concern described in the letter was about the action taken following escalation. The investigation report found that the staff did not escalate any staffing needs, as they had not recognised the need for Mr Meek. This aspect relates to the reliability point above and there are systems in place through the Enhanced Supervision & Engagement Policy. The following steps set out the systematic approach that is in place to manage staffing resources optimisation:”

    Source location

    2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust
    Page 1 · response
    Published 9 July 2018

    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

    Short-notice additional staffing responses remain limited by finite resources, temporary-staff fill rates, sickness and absence.

    Verbatim wording from the response

    “The Trust is resourced with finite financial support, but when there is a clinical need for additional resources, additional resources will be requested from the nursing bank, provided by NHS Professionals. The fill rate for NHS Professionals is at about 80% of the demand for Heath Care Assistants, who are the staff group booked for supervision needs. Staff who already work for the Trust are asked to undertake additional duties, prioritised on part time staff, but would include overtime when other options have not been successful. If there is no-one available despite these attempts, then staff may be redeployed to spread the risk and optimise patient safety and safe staffing levels across the hospital. A limitation remains in achieving short notice responses, exacerbated when there is sickness and absence that creates additional demands for temporary staffing.”

    Source location

    2018-0190-Response-by-Doncaster-and-Bassetlaw-Teaching-Hospital-NHS-Trust
    Page 2 · response
    Published 9 July 2018

    Open published response

  8. Sunderland

    AI-generated summary

    Mr James Trevor Vinson · 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

    Mr James Trevor Vinson, aged 72, was admitted to Sunderland Royal Hospital for rehabilitation after treatment for an acute subdural haematoma. He was found after an unwitnessed fall in his hospital room and later died from an intra-peritoneal bleed associated with splenic tears. The concern was that he was not under the close supervision intended despite his assessed falls risk, and that plans for implementing an enhanced care and observation procedure were unclear.

    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 clear implementation plans for the Enhanced Care/Observation Standard Operating Procedure

    Wider context from the report

    “I heard evidence about a draft Enhanced Care/Observation Standard Operating Procedure (SOP), and copies were provided to me and the family. Although a SOP is to be piloted, I am further concerned that the plans for its implementation are not clear. Hence this Report to you. I emphasised in Court that this Report is not to be construed as any form of censure, but rather a means to clarify the actions to be taken and firm timescales. ”

    Source location

    Mr James Trevor Vinson · 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

    Develop and pilot an Enhanced Care SOP with a risk assessment tool and criteria for heightened observation of vulnerable adult inpatients.

    Verbatim wording from the response

    “As you will note from the enclosed action plan, the Trust is currently developing an Enhanced Care Standard Operating Procedure (SOP) to assess vulnerable adult in-patients’ observation and care requirements. The SOP incorporates an Enhanced Care Risk Assessment Tool and defined criteria for heightened levels of observation. The purpose of this SOP is to ensure our staff maintain an environment which is safe and reduces the risk to patients and others by providing heightened levels of observation for patients within the stated criteria.”

    Source location

    2017-0316-Response-by-City-Hospitals-Sunderland-NHS-Trust
    Page 1 · response
    Published 3 December 2017

    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

    Ratify and roll out the Enhanced Care SOP across the Trust.

    Verbatim wording from the response

    “As you will note from the enclosed action plan, the Trust is currently developing an Enhanced Care Standard Operating Procedure (SOP) to assess vulnerable adult in-patients’ observation and care requirements. The SOP incorporates an Enhanced Care Risk Assessment Tool and defined criteria for heightened levels of observation. The purpose of this SOP is to ensure our staff maintain an environment which is safe and reduces the risk to patients and others by providing heightened levels of observation for patients within the stated criteria.”

    Source location

    2017-0316-Response-by-City-Hospitals-Sunderland-NHS-Trust
    Page 1 · response
    Published 3 December 2017

    Open published response
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Data last updated 7 September 2026