Recurring concern

Unreliable traceability of retrospective amendments to safety records

First to latest report 15 Feb 2016 — 17 Mar 2026

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
15

What this concern includes

Includes failures of controls dedicated to making retrospective amendments to safety-relevant electronic or structured records apparent and traceable, including amendment history, timing, authorship, reasons and auditability; include the anchor's amendments to electronic medical records and the ACCT-document amendment concern.

What is not included
  • Excludes ordinary incomplete, inaccurate or unavailable record content where retrospective amendment traceability is not the unsafe condition.
  • Excludes generic electronic-record access, retention, validation or usability failures that do not concern identifying later amendments.
  • Excludes failures to record contemporaneous care or observations when no retrospective amendment or audit-trail issue is identified.
  • Excludes ordinary correction of records where the amendment is clearly marked, attributable, dated and reasoned.

Reports and published responses 11 reports

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

  1. South Yorkshire (Eastern)

    AI-generated summary

    Delwyn PREECE · 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

    Delwyn Preece, a 64-year-old man, died at Rotherham Hospital on 19 August 2025 from a hypoxic brain injury following deliberate self-suspension by ligature while he was an informal patient at an acute mental health hospital. The principal concerns were repeated granting of leave without documented mental state examinations or risk assessments, poor and retrospective record-keeping, and shortcomings in the patient safety investigation arising from unfamiliarity with the medical records system.

    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 of patient safety incident investigators to correctly identify retrospective medical record entries

    Wider context from the report

    “3. The Patient Safety Incident Investigation authors were unfamiliar with the medical records system which lead to the retrospective entries not being identified correctly, therefore the investigation did not make any finding. However, with more understanding, it is likely the retrospective entries in the medical records who have been identified and their relevance realised which would have altered the content and findings of the report. ”

    Source location

    Delwyn PREECE · 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 identify and explain retrospective medical record entries

    Wider context from the report

    “2. There was poor documentation throughout the medical records with entries lacking detail, being added retrospectively (up to two days later) without any explanation or referencing the retrospective nature of the entry. ”

    Source location

    Delwyn PREECE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Ian George Stanton SIMPSON · 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

    Ian Simpson fell in August 2024, sustained a traumatic spinal injury, and later required a long-term catheter. He was found unresponsive at Magnolia Court Care Home on 16 December 2024, was taken to hospital after a delay in calling an ambulance, and died that evening from sepsis secondary to a urine infection. The principal concerns were the delay in calling an ambulance and inadequate and inaccurate care-home record-keeping, including retrospective or misleading entries.

    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 label retrospective care records

    Wider context from the report

    “2. The notes from the care home were considered in great detail during the inquest, particularly the care notes from the morning of 16 December 2024. These raised significant concern about their adequacy and accuracy. While the deficiencies in record-keeping did not cause or contribute to death in the specific circumstances of this case, I am mindful of the importance of clear and accurate record-keeping to the delivery of safe and effective care more widely. The issues included: • an entry that was plainly not correct and therefore gave a misleading impression of interactions that staff had with Mr Simpson at or about the time of his being found unresponsive; • an entry suggesting that Mr Simpson was ‘awake and lying in bed’, when he had already been found unresponsive some time earlier, suggesting that the entry was either retrospective (and not labelled as such) or simply incorrect; • a series of notes, likely to have been retrospective but not labelled as such, giving a misleading impression of the course of events that morning. While I was provided with some evidence that action had been taken in relation to this matter (such as an audit of records), I found that the evidence provided insufficient reassurance that the risk was sufficiently reduced. ”

    Source location

    Ian George Stanton SIMPSON · 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

    Introduce EnabLE digital care planning, handheld devices and staff recording requirements to standardise care records and support auditing.

    Verbatim wording from the response

    “Introduction of EnabLE”

    Source location

    Response from Barchester Healthcare Ltd
    Page 2 · response
    Published 21 May 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

    Provide refresher training on EnabLE functionality, record-keeping expectations, policy and accurate contemporaneous recording.

    Verbatim wording from the response

    “Following the Inquest, we have provided refresher training at the Home in relation to the functionality of the system, the organisation’s expectations and policy in relation to record keeping and the importance of accurate and contemporaneous recording.”

    Source location

    Response from Barchester Healthcare Ltd
    Page 3 · response
    Published 21 May 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

    Continue remotely reviewing Home documentation quality through the assurance audit programme.

    Verbatim wording from the response

    “We have the ability to review the documentation completed by staff at the Home remotely; the Regional Director and Regional Clinical Development Nurse continue to consider the quality of entries as part of the ongoing assurance audit programme. We are currently working on setting up a trial of an integrated digital accident and incident recording system, this will be linked to the digital care planning system to allow for the capture of key information relating to the incident in real time which will support our investigation of incidents in future.”

    Source location

    Response from Barchester Healthcare Ltd
    Page 3 · response
    Published 21 May 2025

    Open published response

  3. Norfolk

    AI-generated summary

    Mohammed AMIN AZIZI · 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

    Mohammed Azizi, who had Crohn’s disease and deep vein thrombosis, repeatedly refused food, monitoring, investigations and treatment while in prison and hospital. He died in hospital on 15 May 2023 from cardiac atrophy and failure, with contributing factors including malnutrition, Crohn’s disease, self-neglect and pulmonary thromboembolism and infarction. The principal concerns related to two versions of an ACCT document, apparent signatures that witnesses said they had not added, possible retrospective reconstruction of records, and incomplete disclosure to the court and the PPO.

    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 identify retrospective entries and their reasons

    Wider context from the report

    “We also had evidence from another Officer who said that as part of a Quality Assurance review, she was asked to add notes to an ACCT document after it had been closed, she thought roughly six weeks later (that was to the document that the witnesses said had not been signed by them). This raises concern that an Officer was asked to recreate sections of a document and effectively back date them, without making it clear that this is a retrospective entry and for what reason. The Court was advised by Counsel for the prison that this system has changed, but there was no evidence from the prison to support this and confirm why this could not happen again. ”

    Source location

    Mohammed AMIN AZIZI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. East Riding and Hull

    AI-generated summary

    Ethel Doreen Reed · 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

    Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.

    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 of the electronic patient record system to identify authors of changes to finalised discharge letters

    Wider context from the report

    “(2) An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised. This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to future deaths. ”

    Source location

    Ethel Doreen Reed · 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

    Complete an internal review and consult other Lorenzo users about the Immediate Discharge Summary author-identification process.

    Verbatim wording from the response

    “However, we have completed an internal review of the current process and consulted with other Lorenzo users. The outcome of these discussions is that the Trust is now looking to change the current process of completing the IDS as detailed below:”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 4 · response
    Published 21 February 2024

    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

    A single remedy to identify all authors of Immediate Discharge Summary changes cannot yet be identified because non-clinical staff manage summaries before finalisation.

    Verbatim wording from the response

    “We have not yet been able to identify a single remedy to the issue raised around the identification of all authors making changes to the Immediate Discharge Summary (IDS). The primary barrier to a simple solution to this issue is that there are often non-clinical staff involved in the management of the IDS before it is finalised.”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 4 · response
    Published 21 February 2024

    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 proposed Immediate Discharge Summary process change cannot begin fully until required project, system and stakeholder resources become available and internal approval is completed.

    Verbatim wording from the response

    “This piece of work will require resources of Project Management, Change Management, CDC Form Developer, System Support and Information and reporting. There will also be significant stakeholder engagement required including the pharmacy team. Due to this and other similar concerns raised recently, it has been recommended that this piece of work be given a priority 1 and resources allocated as soon as they become available. The timescales for deployment will depend on the approach, but would likely begin with those areas with a significant number of IDS templates set up currently.”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 4 · response
    Published 21 February 2024

    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

    Responsibility for the Lorenzo system relationship sits directly with trusts and the supplier because NHS England has no contract.

    Verbatim wording from the response

    “Your Report also raised a concern around the Lorenzo electronic patient record keeping system not auto-populating the identification of the author of any changes made in the immediate discharge letter after it has been finalised. NHS England no longer has a contract with Dedalus (Lorenzo system) and therefore the relationship sits directly with the Trust(s) and supplier.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 21 February 2024

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Alexander Michael BRAUND · 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

    Alexander Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.

    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 clearly flag amendments to SystmOne medical records

    Wider context from the report

    “4. (TPP-UK) Amendment of Medical Records without clear evidence of such amendment on the face of the SystmOne patient summary The vast majority of primary care health services across the community and secure settings, such as prisons, utilise an electronic patient health record known as SystmOne. I heard evidence that the system automatically records the date, time, and user, shown along the left-hand side of each entry in the printed patient summary, as below. 17 Apr 2019 08:11 Surgery: ████████ Health Professional Access Role) I was assured by health staff that any retrospective entry or amendment to a previous entry in the patient record would be flagged by a new date and time stamp towards the right-hand side of the entry, as below. 24 Apr 2019 15:55 Surgery: ████████ Health Professional Access Role) Entered: 25 Apr 2019 11:55 However, in this case, I discovered from scrutinising an audit record, that an entry made in Alex’s patient record at 06.46 hours on 10 March 2020, had been amended by way of the deletion of some words, and the addition of others, at 09.30 hours on the same date, without any such time stamp being generated on the right-hand side of the entry. This made it look as if the entire text visible in the record would have been visible from around 06.46 hours that date. The Head of Healthcare was unable to explain how the health professional who made the entry had been able to amend her previous entry, without it being obvious on the face of the record, after it became apparent Alex was critically unwell This potentially raises serious safety issues about the integrity of the patient record, and at the very least, if the record is not as robust as first thought by its users, this ought to be made clear. I shall share this report with TPP-UK, the creators of SystmOne, to see if they can explain the safety features in place to ensure amended records are clearly marked as such, especially as in this case, the witness was not forthcoming about her amendment of Alex’s patient record. Accurate record keeping is integral to learning from incidents and seeking to prevent future deaths. ”

    Source location

    Alexander Michael BRAUND · 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

    Provide a SystmOne audit trail showing amended content, the person making each amendment, and when it occurred.

    Verbatim wording from the response

    “I am replying to section 5 (4) in your regulation 28 report. From the extract you included it appears that you have been presented with a printout taken from SystmOne. This is a routine function in the system that delivers a copy of the medical record into the Microsoft Word application. As such it is not to be used as a representation of the audit trail, and especially not for forensic investigation. The main reason for this was that the word document is editable – that is, entries can be reworked before saving and / or onward transmission and is therefore not to be considered secure. As is usual in IT systems the audit trail is held within SystmOne and is readily accessible to the user.”

    Source location

    Response from TPP
    Page 1 · response
    Published 4 January 2023

    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

    A Word printout is editable and cannot represent the SystmOne audit trail or establish that an entry was amended.

    Verbatim wording from the response

    “I am replying to section 5 (4) in your regulation 28 report. From the extract you included it appears that you have been presented with a printout taken from SystmOne. This is a routine function in the system that delivers a copy of the medical record into the Microsoft Word application. As such it is not to be used as a representation of the audit trail, and especially not for forensic investigation. The main reason for this was that the word document is editable – that is, entries can be reworked before saving and / or onward transmission and is therefore not to be considered secure. As is usual in IT systems the audit trail is held within SystmOne and is readily accessible to the user.”

    Source location

    Response from TPP
    Page 1 · response
    Published 4 January 2023

    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

    SystmOne’s existing audit trail records amendments, users and times and is readily accessible, providing a complete and robust record.

    Verbatim wording from the response

    “I am replying to section 5 (4) in your regulation 28 report. From the extract you included it appears that you have been presented with a printout taken from SystmOne. This is a routine function in the system that delivers a copy of the medical record into the Microsoft Word application. As such it is not to be used as a representation of the audit trail, and especially not for forensic investigation. The main reason for this was that the word document is editable – that is, entries can be reworked before saving and / or onward transmission and is therefore not to be considered secure. As is usual in IT systems the audit trail is held within SystmOne and is readily accessible to the user.”

    Source location

    Response from TPP
    Page 1 · response
    Published 4 January 2023

    Open published response

  6. Manchester South

    AI-generated summary

    Dr Malcolm Dixon · 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

    Dr Malcolm Dixon became unwell in autumn 2019 with what was later diagnosed as a severe depressive illness and was admitted as an informal, voluntary patient to Priory Hospital, Altrincham. He died there on 29 December 2019 following an impulsive act undertaken in the context of severe mental illness. Concerns included inaccurate observation records, electronic care-record timestamps being overwritten, and the absence of professional documentation requirements for some unregistered staff.

    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 of electronic care records to preserve auditable timestamps and record actual entry times

    Wider context from the report

    “2. For similar reasons, it is a matter of concern that automatic time-stamps generated by electronic care records systems can be overwritten by users without the corresponding record showing clearly that this has happened, whilst also recording of the actual time an entry has been made. ”

    Source location

    Dr Malcolm Dixon · 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

    Specification of IT systems used within mental health settings falls outside NHS Digital’s remit.

    Verbatim wording from the response

    “NHS Digital’s remit does not include the specification of IT systems used within Mental Health Settings. Furthermore, from a clinical perspective, it is agreed that electronic patient record systems should allow users to edit automatically-generated time stamps to accurately reflect when an observation actually took place as often it will not be contemporaneous, and that associated audit trail should show the time the record entry was made and subsequent changes to it.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 29 November 2021

    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

    Providers are responsible for assessing system fitness, training staff, intended use and clinical safety because approved digital systems are not mandatory.

    Verbatim wording from the response

    “More generally, NHS Digital’s jurisdiction is limited to operating nationally specified requirements, with deployment of systems that meet such requirements supported by national assurance. This may take the form of independent assurance or through a framework of self-declaration against mandated requirements. NHS Digital does, for example, operate the Digital Care Services catalogue supporting eligible users to buy assured digital tools and systems through approved frameworks. However, the use of these is not mandatory and providers remain responsible for: i) assessing whether the functionality is fit for their purposes; ii) training and ensuring staff use such systems as intended; and iii) ensuring the clinical safety of their patients.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 29 November 2021

    Open published response

  7. East London

    AI-generated summary

    Neil Challinor-Mooney · 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

    Neil Challinor-Mooney was admitted to hospital under the Mental Health Act after an acute relapse in his mental health. After disclosing suicidal thoughts and a plan to hang himself using his shoes, his trainers were not removed, and he was later found suspended by their laces; he died on 18 November 2018. Concerns included failures by nursing staff to follow risk assessment and management policy, and delays and amendments affecting the integrity of electronic medical records.

    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 make amendments to electronic records apparent

    Wider context from the report

    “Another concern arising during the course of the Inquest related to the integrity of the electronic records. The Inquest heard that medical records should be validated very shortly after being entered into the system. The Court saw evidence of multiple entries where there was a significant delay between original entry and validation. Amendments were made to the records after Neil had passed away, but these were not apparent on the records disclosed to the Court. An audit of the records had to be carried out before the amendments were exposed. ”

    Source location

    Neil Challinor-Mooney · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Shropshire, Telford and Wrekin

    AI-generated summary

    Name not published · 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

    The deceased had a history of mental health issues, self-harm and two suicide attempts, and was in contact with mental health services until the evening of 30 April 2018 before taking her own life the next morning. Concerns included a prolonged delay in accessing IAPT counselling and difficulties with the electronic recording, risk assessment and progress-note systems.

    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 of electronic records to preserve and clearly display original entries

    Wider context from the report

    “2. Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written. b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved. ”

    Source location

    Name not published · 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

    Update Rio form guidance to show staff how to find the history of electronic record entries.

    Verbatim wording from the response

    “The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · response
    Published 31 May 2024

    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 the Rio system further to make exact changes between versions of electronic records identifiable.

    Verbatim wording from the response

    “The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · response
    Published 31 May 2024

    Open published response

  9. London Inner (South)

    AI-generated summary

    WILLIAM DICKENS · 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 DICKENS, who was assessed as at high risk of repeat self-harm, died on 10 May 2017 after being discovered hanging by a belt from the bed in his room at a mental health unit. The report raises concerns that required intermittent observations were not carried out, that observation-log entries were made after the event, and that defects in the logging process could create a risk of future deaths.

    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 make contemporaneous observation-log entries

    Wider context from the report

    “(1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with. While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period. (2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died. No note had been made on the log to indicate that the entries were being made after the event. (3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe. (4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event. (5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future. ”

    Source location

    WILLIAM DICKENS · 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

    Issue an internal Blue Light Bulletin to registered nurses using the case to reinforce observation and recording practice standards.

    Verbatim wording from the response

    “1) The Director of Nursing to use the case as the basis of an internal safety alert ‘Blue Light Bulletin’ to be sent out to all registered nurses to reinforce the practice standards. To be completed by 6/07/18”

    Source location

    2018-0137-Response-by-South-London-Maudsley-NHS-Trust
    Page 1 · response
    Published 1 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

    Review the Therapeutic Engagement and Observation Policy, focusing on practice-standard clarity and policy implementation.

    Verbatim wording from the response

    “3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to the clarity of practice standards and the implementation of the policy.”

    Source location

    2018-0137-Response-by-South-London-Maudsley-NHS-Trust
    Page 1 · response
    Published 1 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

    Deliver annual Learning the Lessons presentations on timely observation and recording to newly registered nurses, using the case as teaching material.

    Verbatim wording from the response

    “4) From September 2018 the cohort of newly registered nurses to receive a “Learning the Lessons” presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter.”

    Source location

    2018-0137-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 1 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

    Deliver annual Learning the Lessons presentations on timely observation and recording to nurses in training years one to three, using the case as teaching material.

    Verbatim wording from the response

    “5) From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter.”

    Source location

    2018-0137-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 1 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

    Develop a timeline for transforming mental health safety and engagement observations into the e-observation framework, beginning with scoping.

    Verbatim wording from the response

    “7) The Director of Nursing as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into the e-observation framework. This is a long term project that is complex to deliver, a time frame is difficult to reliably commit to, the aim will be scoping from January 2019.”

    Source location

    2018-0137-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 1 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

    Conduct six-monthly snap audits of compliance with observation standards, report results through quality governance meetings, and take necessary improvement steps.

    Verbatim wording from the response

    “8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate.”

    Source location

    2018-0137-Response-by-South-London-Maudsley-NHS-Trust
    Page 2 · response
    Published 1 July 2018

    Open published response

  10. Inner North London

    AI-generated summary

    Janet WILLIAMS · 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

    Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.

    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 identify retrospective medical-record entries

    Wider context from the report

    “8. Finally, as I know you are aware, the care co-ordinator made several retrospective entries in the medical records that she did not record as being made retrospectively. These entries were made up to eleven months after events, and were made after Ms Williams’ death and mostly after my request for a statement from the care co-ordinator in preparation for the inquest. ”

    Source location

    Janet WILLIAMS · Prevention of Future Deaths report
    Page 3 · 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