Recurring concern

Failure of care and safety auditing to identify deficiencies

First to latest report 28 May 2014 — 16 Jun 2026

Reports that mention this concern
69
Times this concern has been raised
76
Stated actions linked to this concern
85

What this concern includes

Includes failures of audits or compliance-assurance processes specifically examining care and safety records, assessments, reviews, interventions, documentation or related operational practice where the audit fails to identify a material deficiency.

What is not included
  • Excludes generic weaknesses in governance, staffing, training or documentation unless the report directly ties them to failure of a care and safety audit.
  • Excludes deficiencies in the underlying care or safety process when no audit or assurance failure is identified.
  • Excludes audits of non-care public-safety activities, such as roads, signage or controlled-drug processes, unless they are explicitly part of the same care and safety auditing concern.

Reports and published responses 69 reports

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

  1. Dorset

    AI-generated summary

    Frazer Charlie 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

    Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.

    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 ACCT quality assurance between day 7 and post-closure review

    Wider context from the report

    “vii. The lack of ACCT quality assurance, or audit, between day 7 of the ACCT and the post closure review. ”

    Source location

    Frazer Charlie Williams · Prevention of Future Deaths report
    Page 6 · 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

    Share ACCT process concerns with regional commissioners and request monitoring through contract reviews and feedback to the Health and Justice Oversight Delivery Group.

    Verbatim wording from the response

    “7. The lack of Assessment Care in Custody and Teamwork (ACCT) quality assurance or audit between day 7 of the ACCT and post closure review.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 6 June 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

    Conduct weekly ACCT completion checks and monthly regional ACCT summaries.

    Verbatim wording from the response

    “The Custodial Manager within the Safety function is responsible for ensuring that ACCTs are completed and a weekly basis. The Regional team also attend GM monthly and undertake ACCT summary.”

    Source location

    Response from HMPPS / HMP Guys Marsh
    Page 3 · response
    Published 6 June 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

    Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.

    Verbatim wording from the response

    “With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 6 June 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

    HMPPS is responsible for overseeing the ACCT process, including establishment-level training, and is responding independently to ACCT concerns.

    Verbatim wording from the response

    “The points above relating to the ACCT process (annex-to-psi-64-2011-acct .docx (live.com)) will be shared with NHS England’s regional Health and Justice commissioners, with a request that they monitor this in contract review meetings and feedback via the Health and Justice Oversight Delivery Group (HJODOG).”

    Source location

    Response from NHS England
    Page 4 · response
    Published 6 June 2024

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Gareth Michael Etchells-Heights · 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

    Gareth Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate record keeping.

    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 an audit system to check records

    Wider context from the report

    “4. Record Keeping There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records. ”

    Source location

    Gareth Michael Etchells-Heights · Prevention of Future Deaths report
    Page 3 · 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

    Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.

    Verbatim wording from the response

    “The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team. An audit of quality compliance will be incorporated into the existing cycle of biannual record keeping audits. Results from the audits will be reflected and acted through our local ward governance processes.”

    Source location

    Response from Sheffield Health and Social Care
    Page 2 · response
    Published 12 December 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

    Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.

    Verbatim wording from the response

    “We will request regular reporting on clinical record keeping audits and monitor progress via our Directorate Leadership Teams into the Clinical Quality and Safety Group.”

    Source location

    Response from Sheffield Health and Social Care
    Page 2 · response
    Published 12 December 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

    Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.

    Verbatim wording from the response

    “In addition to the positive impact of the electronic record implementation this year, we have also commissioned a new clinical record keeping policy and training, which aligned to the quality improvement programme we noted in our letter (3 November), will be rolled out to all staff teams. Built alongside this will be a robust audit programme which will include Trustwide clinical audit and team level audits through supervision and spot check audits as part of our Quality Assurance programme. We anticipate the policy will be completed by May 2024 and the training will commence roll out, alongside a clear communication plan from June 2024.”

    Source location

    Response from Sheffield Health and Social Care
    Page 3 · response
    Published 12 December 2023

    Open published response

  3. North West Wales

    AI-generated summary

    Jennifer Lydia Campbell · 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

    Jennifer Lydia Campbell, aged 73, died on 24 February 2022 after an ERCP referral for obstructing gallstones was not received by the endoscopy department. She became severely unwell and died from infection and pneumonia associated with the obstructing gallstones. The principal concerns were the absence of an investigation into the lost referral, lack of learning or audit to prevent recurrence, and continued reliance on paper-based referrals.

    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 audit for other lost patient referrals

    Wider context from the report

    “c. There was no evidence that any audits had taken place to review whether any other patients’ referrals had become ‘lost’. ”

    Source location

    Jennifer Lydia Campbell · 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

    Audit referral forms received between 1 October 2021 and 30 November 2023 for missing forms.

    Verbatim wording from the response

    “Following this incident, I can however confirm there has been learning and we have made improvements. A new standing operating procedure for all endoscopy referrals has been implemented in November 2023 to ensure all paper referrals are scanned into the endoscopy email inbox, even if received in a paper format by the endoscopy booking clerks. An audit has been completed of referral forms dating 01 October 2021 to 30 November 2023 to ensure no other forms have been lost.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 1 November 2023

    Open published response

  4. Norfolk

    AI-generated summary

    Eileen Marguerite WALSH · 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

    Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.

    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 home audits to identify care concerns

    Wider context from the report

    “8. The Care Quality Commission carried out an inspection in February 2023, nearly 3 years following Mrs Walsh’s death, and raised similar concerns as raised during this inquest, including: a) Safeguarding concerns had not always been appropriately identified and referred b) Risks relating to falls were not dealt with, including a faulty sensor mat was still in place some days later c) Since a historic issue of staff neglect, further incidents of poor staff performance were identified and effective action had not always been taken. It is stated this failure to learn lessons placed people at risk of harm d) Recent audits carried out by the Home had not identified concerns found by the CQC ”

    Source location

    Eileen Marguerite WALSH · Prevention of Future Deaths report
    Page 3 · 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

    Arrange monthly visits from the external compliance company to identify continuous-improvement needs and support new systems and processes.

    Verbatim wording from the response

    “We have recently engaged them to do a more thorough 3-day inspection and are arranging monthly visits from them going forward to assist the Care Manager in identifying areas of continuous improvement and putting in new systems and processes in place, as required, and are appropriate to the service. The DTO from Careskills Academy is a source of remote advice and support and uses their knowledge of the health and social care sector to build systems, processes and reporting tools should they be needed to improve the service further. They meet with the Care Manager on a weekly basis to determine what actions are needed and discuss the completion of compliance records. This is a source of support for the Care Manager in keeping all parts of the service on track.”

    Source location

    Response from Broadland View Care Home
    Page 7 · response
    Published 4 August 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

    Recent audits did identify relevant issues; the inspection did not review the daily notes audit and disputed report terminology caused confusion.

    Verbatim wording from the response

    “i. Daily notes audits are carried out daily and pick up in real time when observations are entered. On the day of inspection, the CQC Inspector asked to see the night spot checks, which were shown. This is a record of what happened at that moment in time when the Manager appears unannounced in”

    Source location

    Response from Broadland View Care Home
    Page 6 · response
    Published 4 August 2023

    Open published response

  5. Manchester South

    AI-generated summary

    Christine Mary Dickinson · 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

    Christine Mary Dickinson, who had follicular lymphoma and was receiving Rituximab, became gravely ill after a final hospital admission in October 2022 and died on 15 November 2022. The inquest raised concerns about multiple systems being used to record chemotherapy administration and the absence of a recent audit of record-keeping on the Laurel Unit, particularly after another patient’s details appeared in Mrs Dickinson’s record.

    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 undertake recent audits of record-keeping

    Wider context from the report

    “1. During the course of the inquest, the court heard evidence that staff on the Laurel Unit previously used a variety of systems (including one system not routinely accessible by staff elsewhere in the hospital) to record the administration of Chemotherapy. 2. Whilst the Consultant Haematologist told the court the requirement to use a single method of recording administration of Chemotherapy has been reinforced, in view of the above together with the fact that details pertaining to another patient entirely appear to have been entered into Mrs Dickinson’s record from September 2022, it is a matter of concern that no recent audit has been undertaken in respect of record-keeping on the Laurel Unit. ”

    Source location

    Christine Mary Dickinson · 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 a documentation audit of randomly selected Laurel Suite patient records.

    Verbatim wording from the response

    “Matron ████████ has completed a documentation audit following Mrs Dickinson’s inquest. Twenty Laurel Suite patients’ records were randomly selected between March 2023 and August 2023. For all twenty records there was: relevant documentation on AdvantisCDS regarding the attendance, no incorrect patient details present and relevant information on iQemo relevant to the AdvantisCDS record.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 3 · response
    Published 21 July 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

    Conduct monthly Laurel Suite record-keeping audits and review results quarterly through the Division of Medicine Quality Group.

    Verbatim wording from the response

    “To further assure you the following actions have also been taken: - A monthly record keeping audit will be completed for Laurel Suite documentation and the results will be reviewed quarterly at the Division of Medicine’s Quality Group meeting. - The team will be implementing a day case nursing admission documentation booklet for consistent documentation. This will be a proforma ‘live’ in AdvantisCDS for the nursing staff to add their information to which includes a question relating to any recent new diagnosis or hospital admission that may influence the decision to administer chemotherapy. This is currently in a pilot phase on paper with the intention to go electronic in the future. Whilst being piloted, at the end of each day the paper information is scanned into AdvantisCDS so it is available on the day of administration.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 3 · response
    Published 21 July 2023

    Open published response

  6. Berkshire

    AI-generated summary

    Lucy Anne Walles · 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

    Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.

    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 safeguarding audit systems to identify and address ongoing issues

    Wider context from the report

    “Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. ”

    Source location

    Lucy Anne Walles · Prevention of Future Deaths report
    Page 3 · 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

    Work with the Safeguarding Adults Review panel and respond to its recommendations.

    Verbatim wording from the response

    “The resourcing of mental health care remains a challenge. However, patient safety is at the heart of everything that we as a Trust do, and we feel that the initiatives we have implemented, and which are ongoing will optimise the deployment of available resources to ensure we support and safeguard our patients as best we can. We are aware that further learning may arise from the ongoing Safeguarding Adults Review (“SAR”), we are working closely with the panel and will respond to the recommendations.”

    Source location

    Response from Berkshire Healthcare NHS Foundation Trust
    Page 5 · response
    Published 23 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

    Appoint a Senior Safeguarding Lead to strengthen managerial oversight, audit cases and provide expert management of complex Section 42 enquiries.

    Verbatim wording from the response

    “The other improvement in process in the management of safeguarding contacts through the Customer Contact Centre and the Safeguarding Team is that, since the creation of a dedicated senior Safeguarding Lead role for Reading in June this year, there are daily consultations between the Safeguarding Team and the Customer Contact Centre to ensure appropriate referral processes are followed and there is priority flagging of high-risk safeguarding referrals.”

    Source location

    Response from Reading Borough Council
    Page 2 · response
    Published 23 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

    Strengthen safeguarding case auditing and worker supervision to identify and address practice issues.

    Verbatim wording from the response

    “As noted earlier the West of Berkshire Safeguarding Adults Board provides the framework policies and procedures for all safeguarding in Reading and staff must adhere to those and operate to those, with due regard to the requirements for safeguarding set out in the Care Act (2014) and other legislation and guidance. Any issues identified with the procedures and policies are picked through the SAB as described in 5 (above) and any individual skills deficits with individual workers are addressed through managerial oversight and guidance as work is subject to auditing of cases and worker supervision which has been strengthened in Reading in the last 6 months. Themes from audits and the learning from them are shared with staff in “Learning Together” sessions which are led by the Principal Social Worker and Principal Occupational Therapist.”

    Source location

    Response from Reading Borough Council
    Page 5 · response
    Published 23 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

    Introduce a Quality Assurance Framework with a programme of internal and external audits of safeguarding referrals and related learning feedback.

    Verbatim wording from the response

    “In July 2023 Adult Social Care in Reading introduced a Quality Assurance Framework for the service which includes an audit programme which supports auditing of safeguarding referrals, not just at team level but also incorporating wider auditing by managers and some external commissioned audits undertaken by specialists. The individual learning from these audits is fed back to workers and their managers and any themes for learning which emerge, from the subject of workshops with appropriate staff. This Quality Assurance Framework systematises case audit in a more thorough form from previous auditing activity and allows for more rigorous consideration of any gaps in processes, policies or practice skills.”

    Source location

    Response from Reading Borough Council
    Page 6 · response
    Published 23 June 2023

    Open published response

  7. Birmingham and Solihull

    AI-generated summary

    Carol Ann CLEMENTS · 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

    Carol Ann CLEMENTS was a resident at Perry Trees Centre following surgery for a hip fracture. She was incorrectly assessed as being at medium rather than high risk of falls, fell unwitnessed, and sustained a further hip fracture. She later developed pneumonia and sepsis and died in hospital on 23 October 2022. The concerns included gaps in enhanced supervision training, induction and falls-risk assessment training for staff including agency staff, and audits that checked compliance but not correctness.

    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 audit falls risk assessments for correctness

    Wider context from the report

    “3. I was told that since this incident, falls risk assessments are being audited for compliance. I was also told that they are not being audited for correctness. I am therefore concerned that errors, and consequently, staff training needs, would not be picked up in these audits. ”

    Source location

    Carol Ann CLEMENTS · 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

    Create an action plan covering falls assessment, enhanced supervision training and falls-risk-assessment auditing.

    Verbatim wording from the response

    “An in-depth action plan has been created around improvement to our falls assessment training, our enhanced supervision training, and how audit falls risk assessments, led by the Divisional Director of Nursing and Therapies for the Adult & Specialist Rehabilitation (A&SR) Division. This will set out both the Trust wide and divisional actions required to address your concerns, along with agreed action owners and timescales for delivery. This action plan will be submitted to the Chief of Nursing and Therapies for approval by 25 July 2023.”

    Source location

    Response from Birmingham Community Healthcare NHS Foundation Trust
    Page 1 · response
    Published 2 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

    Conduct spot-check reviews of falls-risk assessments during care rounding.

    Verbatim wording from the response

    “The completion of a falls risk assessment has been audited for compliance for some time as part of the Trust’s Essential Care Indicators (ECIs) audit. ECI’s take place monthly in the inpatient areas and are undertaken by the matron for each site. The discussion and learning from the round table has prompted additional measures to be introduced which will ensure that the assessment accurately reflects the risk of the patient falling and interventions required. The Matron will be undertaking spot check reviews of falls risk assessments as part of the current care rounding. In addition, the division will develop a quarterly falls prevention effectiveness audit. This will audit correctness of falls risk assessments and impact of care plans. The findings of the audits, and progress with subsequent actions, will be shared and monitored within the Inpatient Quality & Safety Committee.”

    Source location

    Response from Birmingham Community Healthcare NHS Foundation Trust
    Page 3 · response
    Published 2 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

    Develop a quarterly falls-prevention effectiveness audit covering assessment correctness and care-plan impact.

    Verbatim wording from the response

    “The completion of a falls risk assessment has been audited for compliance for some time as part of the Trust’s Essential Care Indicators (ECIs) audit. ECI’s take place monthly in the inpatient areas and are undertaken by the matron for each site. The discussion and learning from the round table has prompted additional measures to be introduced which will ensure that the assessment accurately reflects the risk of the patient falling and interventions required. The Matron will be undertaking spot check reviews of falls risk assessments as part of the current care rounding. In addition, the division will develop a quarterly falls prevention effectiveness audit. This will audit correctness of falls risk assessments and impact of care plans. The findings of the audits, and progress with subsequent actions, will be shared and monitored within the Inpatient Quality & Safety Committee.”

    Source location

    Response from Birmingham Community Healthcare NHS Foundation Trust
    Page 3 · response
    Published 2 June 2023

    Open published response

  8. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Thomas Victor HUNTLEY · 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

    Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.

    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 ACCT audits to identify inadequate document completion

    Wider context from the report

    “The second relates to the quality and effectiveness of ACCT audits. We heard evidence that ACCT documents are reviewed annually. The case manager mentioned above advised that he had not received any adverse feedback about the quality of his ACCT documents and no issues with them had been identified. Given the inadequate nature of the ACCT document opened on Mr Huntley and apparent lack of understanding about completing the documents the quality of the audits is brought into question. ”

    Source location

    Thomas Victor HUNTLEY · Prevention of Future Deaths report
    Page 3 · 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

    Operate an accountability system for ACCT quality assurance, feeding findings back to staff and rectifying serious concerns.

    Verbatim wording from the response

    “assurance checks take place at three main stages. The first takes place within 48 hours from the opening of the ACCT, conducted by the Safety Team, assessing the effectiveness of the immediate steps taken and quality of the documentation. The second check is by the Custodial Manager who checks the ongoing record and the case reviews, ensuring that entries are detailed and meaningful, and whether previously identified actions or identified concerns continue to be taken into account and built on. Following ACCT closure, the Safety Team then review the full ACCT document including the seven day post closure monitoring procedure and the post closure reviews.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 November 2023

    Open published response

  9. Manchester North

    AI-generated summary

    Ania Sohail · 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

    Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation 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 of 1:5 observation records to evidence five-minute checks

    Wider context from the report

    “(6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes. Instead the current documentation, simply requires one signature per hour. There is therefore no mechanism by which observations can be effectively audited. ”

    Source location

    Ania Sohail · Prevention of Future Deaths report
    Page 3 · 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

    Adopt five-minute observation recording sheets and audit completion at least weekly.

    Verbatim wording from the response

    “The current Trust observation policy does have a 1:5 minute recording sheet that requires a signature every 5 minutes. This has now been adopted by the service and its completion is audited by the ward manager as a minimum weekly.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 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

    Review observation policy and practices against best-practice standards, guidance and potential digital innovations.

    Verbatim wording from the response

    “The Trust is currently undertaking a review of our Observation policy and practices through a task and finish working group which to date has reviewed best practice standards and guidance on the management and practice of therapeutic observations & engagement including the review of any digital innovations to support practice.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 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

    Develop a staff training package and competency assessment framework for therapeutic observations and engagement.

    Verbatim wording from the response

    “Senior members of this group have attended workshops facilitated by the CQC who acknowledge that carrying out and recording observations is a National issue. A training needs analysis of the requirements for staff training and education is being undertaken and a training package and competency assessment framework is being developed.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 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

    The current observation policy already requires signatures every five minutes, with completion audited weekly by the ward manager.

    Verbatim wording from the response

    “(6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes. Instead, the current documentation, simply requires one signature per hour. There is therefore no mechanism by which observations can be effectively audited.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 2023

    Open published response

  10. 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 of NEWS2 compliance auditing to reliably monitor adherence

    Wider context from the report

    “1.(HEALTHCARE) Lack of safe system, supported by training, guidance, and compliance auditing, for the provision of physical healthcare assessment and monitoring by NEWS2 for acutely unwell patients in a secure setting. The Jury found shortcomings in the healthcare afforded to Alex at HMP Nottingham in the form of "continuous failures to provide adequate healthcare, which probably more than minimally contributed to his death". I heard evidence that staff were not consistently assessing acutely unwell patients using the NEWS2 system, despite the scoring system having been adopted across the NHS over the past decade and having been adopted by this Trust many years prior. In 2017, when relaunching the NEWS system, the Royal College of Physicians noted, "Every so often, someone comes up with an idea that is so obvious, no one can understand why it wasn’t thought of before. I am proud that the RCP’s National Early Warning Score (NEWS) is one of those initiatives – not just a chart (or iPad) at the end of the bed to record the patient’s physical signs and symptoms, but the chart at the end of the bed – a single point of truth to unify recording of symptoms across the NHS, consolidate training for doctors and nurses in the recording of symptoms, and thereby improve patient safety. When the RCP launched the NEWS in 2012, we hoped to see the score adopted across the NHS. What has been more astonishing is the adoption of the score internationally, with requests to use NEWS coming from health services across the world from Europe to India and the USA, including the US Naval Air Forces!" I heard evidence of an inconsistent application of NEWS2 by staff, an inconsistent awareness of NEWS2 across the staff body, and an absence of clear and robust training supported by guidance, ensuring staff were aware of the expectations of their employer with regards to the use of NEWS2 in monitoring acutely unwell patients. Sadly, Alex’s is not an isolated case. I have been repeatedly assured at a senior level from Nottinghamshire Healthcare NHS Foundation Trust that they are seeking to embed NEWS2 across their Directorates, yet successive inquests have heard of patients failed by the lack of use of the system by the clinical staff responsible for their medical care. If this issue is not addressed across the Trust, with sufficient urgency, patients will continue to die in Trust settings due to a failure to recognise the deteriorating patient, and to arrange for timely healthcare intervention. Further, I heard evidence that the newly implemented compliance audit plans for NEWS2 are not safe or robust because the audit is limited to monitoring the emergency review template on Systmone, which staff are routinely failing to utilise, instead preferring to add free text entries to the running record, which cannot be audited with ease. If the Trust is incapable of monitoring compliance with the initiative, there will be repeated missed opportunities to provide support and guidance to Directorates, wards or individual staff who are deviating from expected practice with regards to NEWS2. ”

    Source location

    Alexander Michael BRAUND · 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