Recurring concern

Unsafe provision of one-to-one care

First to latest report 6 Nov 2013 — 24 Apr 2026

Reports that mention this concern
11
Times this concern has been raised
14
Stated actions linked to this concern
16

What this concern includes

Includes deficiencies in the initiation, staffing, training, competence, communication, monitoring, documentation or delivery of one-to-one care when the deficiency is specifically dedicated to ensuring safe one-to-one care.

What is not included
  • Excludes generic staff training, staffing or documentation deficiencies that are not specifically tied to one-to-one care.
  • Excludes failures concerning other observation, monitoring or support arrangements unless they explicitly concern one-to-one care.
  • Excludes deficiencies in unrelated care processes or broad organisational governance.

Reports and published responses 11 reports

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

  1. Manchester South

    AI-generated summary

    William Joseph Wilkinson · 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

    William Joseph Wilkinson slipped on the pavement while shopping on or about 9 December 2012, fractured his ankle, was admitted to hospital, and later died after complications. Concerns included the availability of ordered one-to-one nursing, difficulties logging onto the hospital computer system, an incomplete Fluid Balance Chart, and the lack of direct orthopaedic input in the Emergency Department.

    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

    Unavailability of required one-to-one nursing

    Wider context from the report

    “(1) I was told that despite one-to-one nursing being required for Mr Wilkinson and indeed being ordered, this is not always available. There was clear evidence that had such nursing standards been available Mr Wilkinson may not have developed the problems which led to his death. ”

    Source location

    William Joseph Wilkinson · 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