Recurring concern

Unreliable recording of service-user movements

First to latest report 20 Feb 2015 — 8 Jun 2023

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
4

What this concern includes

Includes failures in dedicated records or processes for recording service-user movements into, out of or within a controlled care setting, including incomplete walk books and sign-in/sign-out books, missing entries for short absences, and related checks needed to maintain an accurate movement record.

What is not included
  • Excludes general clinical, care or custody record-keeping failures where service-user movement recording is not the material concern.
  • Excludes failures to supervise, locate or respond to an absent service user when movement records were reliably maintained and the problem is a downstream response failure.
  • Excludes ordinary appointment, leave or discharge records unless they specifically record service-user movements in the same controlled care-setting process.
  • Excludes generic staffing, communication or documentation deficiencies that do not directly impair recording of service-user movements.

Reports and published responses 3 reports

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

  1. Inner North London

    AI-generated summary

    Hilary Clare (Billy) Guedalla · 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

    Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

    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 record service-user movements in the unit sign-in/sign-out book

    Wider context from the report

    “4. The “Sign in/Sign out” book which was supposed to record the movements of service users in the unit was frequently not completed, particularly when service users went out for short periods. ”

    Source location

    Hilary Clare (Billy) Guedalla · 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

    Relocate and revise inpatient Sign In/Sign Out books to capture leave, return, documentation, belongings and search information.

    Verbatim wording from the response

    “I have been provided with assurances that the process for managing the Sign In/Sign Out book (the “book”) on all inpatient units in City and Hackney has been improved. The book is now located at the nursing office to enhance completion. It has been revised to include the following information: service user name, whether leave is escorted (and by whom) or not, location of planned leave, time left and time returned, the validity of Section 17 leave papers for detained patients, description of items taken, and whether search on return was completed.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 22 June 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

    Spot-check each Sign In/Sign Out book once per shift and develop a more robust audit system.

    Verbatim wording from the response

    “Presently, either the nurse in charge or the shift coordinator spot checks the book to ensure completion one time per shift. However, work is being done to develop a more robust audit system.”

    Source location

    Response from East London NHS Foundation Trust
    Page 4 · response
    Published 22 June 2023

    Open published response

  2. Manchester South

    AI-generated summary

    David Michael little · 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

    David Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.

    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 keep clear records of inpatient radiology transfers, purposes, procedures and ward returns

    Wider context from the report

    “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day. ”

    Source location

    David Michael little · 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

    Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.

    Verbatim wording from the response

    “Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.”

    Source location

    2016-0237-Response-by-Tameside-Hospital-NHS-Trust
    Page 2 · response
    Published 28 June 2016

    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 and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.

    Verbatim wording from the response

    “In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.”

    Source location

    2016-0237-Response-by-Tameside-Hospital-NHS-Trust
    Page 2 · response
    Published 28 June 2016

    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 was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.

    Verbatim wording from the response

    “1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.”

    Source location

    2016-0237-Response-by-Tameside-Hospital-NHS-Trust
    Page 1 · response
    Published 28 June 2016

    Open published response

  3. Southampton and the New Forest

    AI-generated summary

    Daniel Stickland · 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 Stickland, aged 17, was found collapsed after falling from his bed at his residential school on 14 May 2014, following two seizures earlier that day. He was taken to hospital and pronounced dead the following day; concerns included inadequate handovers, inaccurate or inaccessible logs, and no clear central method for recording significant medical events.

    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 movement logs accurately and with sufficient detail

    Wider context from the report

    “(2)Movement log that was not completed accurately or with enough detail ”

    Source location

    Daniel Stickland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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

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Data last updated 7 September 2026