Recurring concern

Unsafe provision of one-to-one care

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First reported 6 Nov 2013•Latest report 24 Apr 2026

Definition

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.

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
11

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
16

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.

Department of Health and Social Care2
Swansea Bay University Local Health Board2
1st Care 4U Ltd1
Daughter of the deceased1
Essex Partnership University NHS Foundation Trust1
Healthcare Inspectorate Wales1
Holcroft Grange1
London Borough of Hounslow1
Mid Yorkshire Teaching NHS Trust1
Minster Care Management Limited1
Nottinghamshire Healthcare NHS Foundation Trust1
Nursing and Midwifery Council1
Royal Bolton Hospital1
St George'S University Hospitals NHS Foundation Trust1
The Children's Trust1

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. 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
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Data last updated 7 September 2026