Recurring concern

Unreliable district nursing assessment and monitoring of patients

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First reported 7 Aug 2013•Latest report 6 Jul 2017

Definition

What this concern includes

Includes failures in district nursing processes for baseline or initial assessment, ongoing clinical monitoring, reassessment and recognition of changes in patients’ conditions where these controls support safe district nursing care.

Not included

Excludes wound-specific assessment and treatment failures where the dedicated district nursing wound-care concern is the more specific supported boundary.
Excludes district nursing staffing, referral, communication, scheduling or visit-coordination failures where assessment or monitoring is not the shared unsafe condition.
Excludes generic clinical assessment or monitoring failures outside district nursing services.
Excludes failures to act on reliably completed district nursing assessments or monitoring where the assessment-and-monitoring process itself was adequate.

Reports: 3
Individual concerns: 3
Date range: 2013–2017
Stated actions: 16

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Cwm Taf Morgannwg University Local Health Board1

Gloucestershire Health and Care NHS Foundation Trust1

Pennine Care NHS Foundation Trust1

Practice 1, Keir Hardie Health Park1

Recipient name withheld1

Senedd Cymru1

Welsh Government1

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.

6 Jul2017
Gloucestershire
Concerns raised1
1. Insufficient monitoring of patients’ ongoing conditions by the district nursing service
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 16
1. Action
  Implement re-engineered electronic records with structured assessments, care planning, deterioration reporting, non-adherence prompts and NEWS/sepsis prompts.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
2. Action
  Undertake refresher training on the National Early Warning Score.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progress
3. Action
  Drive a deteriorating-patient quality improvement programme to strengthen detection and communication of clinical deterioration.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progress
1. Action
  Create a combined National Early Warning Score and sepsis management policy.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
2. Action
  Ratify the combined National Early Warning Score and sepsis policy and use it as cascade teaching material.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated planned
3. Action
  Appoint a Clinical Lead for deteriorating-patient practice.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
4. Action
  Use the Clinical Lead to embed consistent deteriorating-patient practices across services.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated in progress
5. Action
  Operate a capacity-and-demand model to allocate community nursing patients and time appropriately.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
6. Action
  Use an unscheduled-care ledger with daily shift-lead oversight of workloads and urgent care demands.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
7. Action
  Support planned nurse attendance at GP practice meetings and daily links with affiliated practices for complex and high-risk patients.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
8. Action
  Double Professional Lead and Senior District Nurse capacity for the Gloucester locality.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
9. Action
  Employ an additional District Nurse to support workload and patient care for the relevant team.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
10. Action
  Run monthly professional development sessions covering pressure-ulcer risk and malnutrition screening.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
11. Action
  Embed Braden, MUST and physical top-to-toe assessments in records, issue clinical guidance and review completion through quality assurance visits.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
12. Action
  Issue weighing scales to each locality for pressure-ulcer and malnutrition assessment.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
13. Action
  Produce and operate a structured handover procedure with protected handover time, standard formats and electronic recording.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
AI-generated summary

Rose Workman · 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

Rose Workman, a 76-year-old woman with bilateral leg ulcers and other health problems, was admitted to hospital after a general decline, dehydration and leg ulcers. She developed pneumonia and died at 6.15am on 17 June 2016 despite treatment. The report raised concern about whether district nursing services had sufficient measures to monitor patients’ ongoing conditions effectively, noting periods when Rose’s condition was not tracked because of staff shortages and unclear assessment requirements.

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 monitoring of patients’ ongoing conditions by the district nursing service
Wider context from the report
“Whether the district nursing service employs sufficient measures to ensure that patients are effectively monitored of their ongoing condition(s). ”
Source location
Rose Workman · 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 re-engineered electronic records with structured assessments, care planning, deterioration reporting, non-adherence prompts and NEWS/sepsis prompts.

Verbatim wording from the response
“Firstly our electronic clinical patient record “SystmOne” has undergone extensive re-engineering with all our community multidisciplinary integrated team “units” (sections of the record split into localities). This re-engineering was clinically led, including”

Source location
Rose-Workman-Response
Page 1 · response
Published 6 July 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
Undertake refresher training on the National Early Warning Score.

Verbatim wording from the response
“Refresher training for the National Early Warning Score (NEWS) is being undertaken, as detailed in our Duty of Candour letter submitted as part of the inquest evidence. The Trust is also currently driving forward a “deteriorating patient” quality improvement programme. This reflects the current work of many NHS organisations who are trying to generally improve the competencies of their qualified and non-qualified clinical workforce to be able to detect a deterioration in a patient’s health status quickly and effectively and; then feeling more equipped to communicate any changes to other clinicians in a standardised way using this evidence based approach for patient care.”

Source location
Rose-Workman-Response
Page 2 · response
Published 6 July 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
Drive a deteriorating-patient quality improvement programme to strengthen detection and communication of clinical deterioration.

Verbatim wording from the response
“Refresher training for the National Early Warning Score (NEWS) is being undertaken, as detailed in our Duty of Candour letter submitted as part of the inquest evidence. The Trust is also currently driving forward a “deteriorating patient” quality improvement programme. This reflects the current work of many NHS organisations who are trying to generally improve the competencies of their qualified and non-qualified clinical workforce to be able to detect a deterioration in a patient’s health status quickly and effectively and; then feeling more equipped to communicate any changes to other clinicians in a standardised way using this evidence based approach for patient care.”

Source location
Rose-Workman-Response
Page 2 · response
Published 6 July 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
Create a combined National Early Warning Score and sepsis management policy.

Verbatim wording from the response
“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location
Rose-Workman-Response
Page 2 · response
Published 6 July 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 the combined National Early Warning Score and sepsis policy and use it as cascade teaching material.

Verbatim wording from the response
“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location
Rose-Workman-Response
Page 2 · response
Published 6 July 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
Appoint a Clinical Lead for deteriorating-patient practice.

Verbatim wording from the response
“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location
Rose-Workman-Response
Page 2 · response
Published 6 July 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
Use the Clinical Lead to embed consistent deteriorating-patient practices across services.

Verbatim wording from the response
“The Trust has a quality improvement working group which has refreshed the NEWS paperwork and algorithms to ensure they are commensurate with the work programme of the South West Academic Health Science Network. In addition to this, a policy has recently been created that combines two previous policies which covered NEWS and the management of sepsis. This policy is due for ratification at the Trust’s Clinical Reference Group in July 2017 and will be used as cascade teaching material in clinical teams. In order to ensure that this work is fully driven and embedded within multidisciplinary and hospital teams across the Trust, a “Clinical Lead” has been appointed and will work immediately with our clinicians to ensure that there are consistent clinically led deteriorating patient practices occurring across all of our services.”

Source location
Rose-Workman-Response
Page 2 · response
Published 6 July 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
Operate a capacity-and-demand model to allocate community nursing patients and time appropriately.

Verbatim wording from the response
“Workload capacity and its effective management within our clinical services also needs to be satisfactory for patients to be effectively monitored. A “capacity and demand” model was introduced into Community Nursing service in October 2016. This was developed by clinicians and supports the planned and timely allocation of patients who receive care. This resource allocation tool supports suitable time allocation for wound care and colleagues have been strongly advised to apply a rating score and work to a standard operating procedure that supports patient care.”

Source location
Rose-Workman-Response
Page 3 · response
Published 6 July 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
Use an unscheduled-care ledger with daily shift-lead oversight of workloads and urgent care demands.

Verbatim wording from the response
“An ‘unscheduled care’ ledger (on SystmOne) was also introduced to reduce the impact on those workloads associated with unplanned visits which are referred into our nursing team for an urgent patient contact. This ensures that there are nurses holding the position of shift lead each day and who have an overview of all colleagues’ workloads, demands and unpredicted care requirements.”

Source location
Rose-Workman-Response
Page 3 · response
Published 6 July 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
Support planned nurse attendance at GP practice meetings and daily links with affiliated practices for complex and high-risk patients.

Verbatim wording from the response
“To enhance communications nurses are now supported to attend GP practice based meetings on a planned basis to discuss those patients with more complex needs and those that are identified to be an unplanned hospital admission risk, as well as those at the end of their life. In addition all teams have a process for linking with their affiliated GP practice at least daily, either by telephone or in person. We are also progressing with having more scheduled multidisciplinary cluster meetings which will act as an open forum for nurses, physiotherapists and occupational therapists to discuss and care plan for particular patients on their caseloads.”

Source location
Rose-Workman-Response
Page 3 · response
Published 6 July 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
Double Professional Lead and Senior District Nurse capacity for the Gloucester locality.

Verbatim wording from the response
“Recruitment to Staff Nurse level posts remains strong across the Trust; however recruitment to District Nurse posts remains challenging (as mirrored nationally). The Trust has mitigated some of the risk by doubling the number of Professional Leads, Senior District Nurses for the Gloucester locality from October 2016. Colleagues work in assigned teams attached to identified GP practices. For the team in question with the RW case a second District Nurse was also employed in August 2016 to support the workload and patient care. We recognise that risks remain where there may be high levels of sickness; however this is monitored closely by operational managers who continue efforts with recruitment.”

Source location
Rose-Workman-Response
Page 3 · response
Published 6 July 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
Employ an additional District Nurse to support workload and patient care for the relevant team.

Verbatim wording from the response
“Recruitment to Staff Nurse level posts remains strong across the Trust; however recruitment to District Nurse posts remains challenging (as mirrored nationally). The Trust has mitigated some of the risk by doubling the number of Professional Leads, Senior District Nurses for the Gloucester locality from October 2016. Colleagues work in assigned teams attached to identified GP practices. For the team in question with the RW case a second District Nurse was also employed in August 2016 to support the workload and patient care. We recognise that risks remain where there may be high levels of sickness; however this is monitored closely by operational managers who continue efforts with recruitment.”

Source location
Rose-Workman-Response
Page 3 · response
Published 6 July 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
Run monthly professional development sessions covering pressure-ulcer risk and malnutrition screening.

Verbatim wording from the response
“Our Professional Leads for Community Nursing run monthly Continuous Professional Development sessions for community nurses across the localities; the Braden Risk”

Source location
Rose-Workman-Response
Page 3 · response
Published 6 July 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
Embed Braden, MUST and physical top-to-toe assessments in records, issue clinical guidance and review completion through quality assurance visits.

Verbatim wording from the response
“Braden, MUST and physical top-to-toe assessments are now incorporated fully into our clinical record system (SystmOne). For example, for documenting wound care the improved record system provides the facility for wounds to be better described including the date the wounds started, were reviewed and healed. Another example is the top-to-toe assessment which is a question-prompt template with blank boxes for different parts of the body which are required to be completed. Clear professional guidance has been issued to all nurses regarding the need to conduct these assessments at admission to the caseload and re-assessed at a frequency according to need. This clinical practice is now reviewed as part of quality assurance visits across all localities to ensure it is carried out.”

Source location
Rose-Workman-Response
Page 4 · response
Published 6 July 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
Issue weighing scales to each locality for pressure-ulcer and malnutrition assessment.

Verbatim wording from the response
“Weighing scales have been issued to each locality and where a patients weight cannot be obtained to calculate the MUST score the ulnar measurement is used as advocated by Trust policy.”

Source location
Rose-Workman-Response
Page 4 · response
Published 6 July 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
Produce and operate a structured handover procedure with protected handover time, standard formats and electronic recording.

Verbatim wording from the response
“A Standard Operating Procedure for handovers was produced in August 2016, two months after RW’s death. This now provides structure and expectation for handovers within each of our community nursing teams. Time to complete the handover is applied to the SystmOne ledgers previously mentioned and colleagues are strongly encouraged to attend them. A quality review visit has identified that occasionally due to operational pressures nurses have not been able to attend some handovers. However, this is currently being actively monitored by our operational managers to determine whether this is a significant issue.”

Source location
Rose-Workman-Response
Page 5 · response
Published 6 July 2017
Open published response
11 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Risk of unmonitored or unactioned failure to complete delegated INR testing
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Ronald Francis Bonfield · 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 Ronald Francis Bonfield sustained a head injury at home on 29 September 2014, was admitted to Prince Charles Hospital on 1 October, and died there on 2 October 2014. The inquest recorded that he was taking Warfarin, was over-anticoagulated, and that his INR levels were not being monitored as required. The substantive concerns related to inconsistent procedures for monitoring delegated INR testing and the risk of unmonitored over-anticoagulation.

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
Risk of unmonitored or unactioned failure to complete delegated INR testing
Wider context from the report
“(2) The practices and procedures implemented by Practice 1, Keir Hardie Health Park Surgery act as a check and balance to reduce the risk of an unmonitored/unactioned failure on the part of the District Nurse service to undertake the task(testing the patients INR level) delegated to them by the GP practice concerned. ”
Source location
Mr Ronald Francis Bonfield · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Aug2013
Manchester (West)
Concerns raised1
1. Lack of baseline assessments by district nursing teams
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jean Miller · 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

Jean Miller was admitted for incisional hernia repair, discharged home under district nursing care, and later readmitted with a purulent wound discharge before dying in hospital on 24 January 2013. The report identified concerns about the district nursing team’s lack of baseline wound assessments, failure to involve tissue viability specialists, absence of thermometers, poor record keeping, and poor communication with the GP.

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 baseline assessments by district nursing teams
Wider context from the report
“1. The quality of care offered by the district nursing team arising from poor practices being in place in particular a lack of baseline assessments and poor understanding of the need to involve tissue viability specialists in such cases as Mrs Miller’s ”
Source location
Jean Miller · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient monitoring of patients’ ongoing conditions by the district nursing service

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.16

Concerns raised1

Risk of unmonitored or unactioned failure to complete delegated INR testing

Concerns raised1

Lack of baseline assessments by district nursing teams

Actions described in response 16