Recurring concern

Failure of care and safety auditing to identify deficiencies

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First reported 28 May 2014•Latest report 16 Jun 2026

Definition

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.

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: 69
Individual concerns: 76
Date range: 2014–2026
Stated actions: 85

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.

Department of Health and Social Care11

NHS England7

Greater Manchester Mental Health NHS Foundation Trust5

Care Quality Commission4

HM Prison and Probation Service4

Ministry of Justice3

NHS Greater Manchester Integrated Care Board3

Association of Ambulance Chief Executives2

Avery Healthcare Group2

Birmingham and Solihull Mental Health NHS Foundation Trust2

East London NHS Foundation Trust2

Frimley Health NHS Foundation Trust2

Manchester University NHS Foundation Trust2

National Institute for Health and Care Excellence2

Practice Plus Group2

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.

20 Jun2016
London (East)
Concerns raised1
1. Failure to audit pain management for patients presenting to A&E in severe pain
This report raised 3 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 Zawdie Qounseye Bascom · 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 Zawdie Qounseye Bascom developed severe abdominal pain, was assessed and discharged from A&E with a presumed diagnosis of gastritis, and later collapsed and died on 12 May 2014. The post-mortem cause of death was peritonitis due to rupture of an inflamed vermiform appendix. Concerns included inadequate recording and systematic assessment of pain, lack of documented pain relief before discharge, and insufficient attention to persistent severe pain that was unusual for gastritis.

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 pain management for patients presenting to A&E in severe pain
Wider context from the report
“1) Mr Bascom presented in severe pain to A&E. This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E. 2) Analgesic medication was administered at 03:45 and a pain score recorded at 05:15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10. 3) Further analgesia in the form of tramadol was given at 05:30. There was no further pain score recorded following this analgesia. No pain score was recorded prior to discharge. 4) On the basis of the evidence heard I found that Mr Bascom’s pain was not relieved prior to discharge. There was no documentation at all to support pain relief and ████████ confirmed that Mr Bascom continued to require support as a result of the pain, when he left the hospital. The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis. 5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain. 6) No pain score was recorded by any member of the nursing team. There was no evidence of any systematic assessment of pain (for example, response to analgesia). ”
Source location
Mr Zawdie Qounseye Bascom · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Dec2015
Nottinghamshire
Concerns raised1
1. Insufficiently robust auditing of care and safety omissions
This report raised 14 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.
Actions described in response 1
1. Action
  Employ a Quality Manager to audit care homes, monitor managers’ auditing, and address omissions through quality-improvement action plans.
  Stated by Your Health LimitedStated completed
AI-generated summary

Elsie Marjorie Brown · 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

Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

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
Insufficiently robust auditing of care and safety omissions
Wider context from the report
“5. There was an insufficiently robust auditing process, in that the omissions were not identified by Langwith Lodge nor by Your Health Ltd. ”
Source location
Elsie Marjorie Brown · 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
Employ a Quality Manager to audit care homes, monitor managers’ auditing, and address omissions through quality-improvement action plans.

Verbatim wording from the response
“We recruited a Quality Manager in September 2015 who undertakes quality audits at all of our homes to ensure procedures are being followed and care plans are being compiled in a timely manner. All quality audits are supported by an action plan to ensure we continue to make improvements where necessary.”

Source location
Elsie-Brown-Response
Page 2 · response
Published 4 December 2015
Open published response
1 Jun2015
South Yorkshire (Eastern)
Concerns raised1
1. Lack of effective auditing of communication systems
This report raised 3 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

James Savo · 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

James Savo had a longstanding history of depression and died by hanging on 3 December 2013, four days after discharge from inpatient treatment. The concerns identified were insufficient communication with family and carers, inadequate consideration of family concerns and the timing of home-treatment input during discharge planning, and variable understanding and possible inadequacy of the early discharge pathway. The report also identified a lack of effective auditing to ensure communication systems were followed.

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 effective auditing of communication systems
Wider context from the report
“(1) The systems described as being in place which should be followed to ensure effective communication between families/carers appear not to be routinely followed. As this communication is an integral part of a patient's management and future treatment plans it is essential that all staff are aware of the communication, the nature of it and who has primary responsibility for ensuring that it takes place. Furthermore, there is no evidence of any effective auditing process to ensure such systems are being followed. ”
Source location
James Savo · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 May2015
Derby and Derbyshire
Concerns raised1
1. Failure to assess the clinical content and appropriateness of nursing and medical documentation
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

Sheila Johnson · 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

Sheila Johnson died on 15 May 2013 from catastrophic haemorrhage from a femoral graft wound, less than 24 hours after discharge from hospital with an open left groin wound. The report identified failures in responding to recognised bleeding before discharge and concerns about the inadequacy of the Trust’s investigation, including the omission of key witnesses, limited review of clinical documentation, factual inaccuracies, and the lack of an urgent recall system for patients discharged with potentially life-threatening conditions.

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 assess the clinical content and appropriateness of nursing and medical documentation
Wider context from the report
“(1) The court was provided with a copy of the Trust’s Internal Report of the circumstances of Mrs Johnson’s death and heard evidence regarding the findings from the author of the report. (2) The court was of the opinion that any such investigation and report must be sufficiently robust if it is to have any meaning and lessons learnt to prevent future deaths. (3) The court was of the opinion that on this occasion there was insufficiency of inquiry and the investigation was perfunctory and slipshod. (4) Statements of 6 members of staff were taken. Two of those members were interviewed, the court was of the opinion that other key witnesses including the nurse who discharged Mrs Johnson should have been interviewed. (5) An audit of the nursing and medical documentation was undertaken, however this confined itself to establishing that the entries were accurately dated and timed with a legible signature. No consideration was given to the clinical content of those entries and as to whether or not they were appropriate. (6) The report contained serious factual inaccuracies and based on those errors of fact erroneous findings and recommendations were made. (7) The court believes that should future reports be conducted in this manner then patient’s clinical conditions may be compromised and such errors could lead to deaths in the future. (8) The Trust appeared to have no system in place for the urgent recall of patients who had been discharged with potentially life threatening conditions. ”
Source location
Sheila Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Mar2015
Worcestershire
Concerns raised1
1. Failure to audit and track the use of non-controlled medication
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Conduct unannounced spot audits of theatre drug storage and documentation.
  Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completed
2. Action
  Review controls governing controlled and non-controlled medicines.
  Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completed
3. Action
  Continue monitoring drug-usage trends across all Trust areas to identify potential diversion risks.
  Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing controls and professional responsibilities are considered sufficient to mitigate the small residual risk of medicine diversion.
  Stated by the Royal Orthopaedic Hospital NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Leonardus Adrianus VRIES · 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

Leonardus Adrianus Vries apparently obtained medical-grade drugs from his workplace and injected himself at his family home, where he died; the inquest concluded that his death was accidental, involving respiratory depression and combined toxicity of bupivacaine, morphine and diamorphine. The principal concern was inadequate documentation and auditing of medication, particularly non-controlled medication, at the Royal Orthopaedic Hospital, creating an opportunity for abuse or theft.

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 and track the use of non-controlled medication
Wider context from the report
“Whilst the control of controlled medications appears to have been addressed by way of training and increased scrutiny and audit procedures ████████ confirms that there is still no audit of non-controlled medication. Specifically he said that when stocks of non-controlled medication are delivered to wards and departments there is no check as to who uses the medication or for what purpose. It appears to me therefore that there is a significant opportunity for the abuse or theft of non-controlled medication. ”
Source location
Leonardus Adrianus VRIES · 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
Conduct unannounced spot audits of theatre drug storage and documentation.

Verbatim wording from the response
“Since February 2015 a weekly audit of Controlled Drug documentation is carried out by theatres management. Since March 2015 the Chief Pharmacist has carried out unannounced spot audits (normally two per week) on drug storage (all drugs) and documentation in theatres. No concerns regarding diversion or theft of medicines have been identified through this audit cycle and all documentation is correctly completed.”

Source location
2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015
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 controls governing controlled and non-controlled medicines.

Verbatim wording from the response
“In summary, the controls around both Controlled Drugs and “non-controlled” drugs have been reviewed. Standard Operating Procedures for Controlled Drugs have been updated and audits conducted by the Chief Pharmacist have shown compliance with the standards required. Controls around “non-controlled” medicines have been reviewed and found to be compliant with or indeed exceed all national guidance. There remains a small risk that these medicines could be diverted as is the case in all hospitals. This is mitigated by the professional responsibilities of all staff regarding the use of medicines. To further mitigate”

Source location
2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015
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 monitoring drug-usage trends across all Trust areas to identify potential diversion risks.

Verbatim wording from the response
“this risk the Chief Pharmacist will continue to monitor trends in usage of drugs in all areas of the Trust.”

Source location
2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 3 · response
Published 9 March 2015
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
Existing controls and professional responsibilities are considered sufficient to mitigate the small residual risk of medicine diversion.

Verbatim wording from the response
“In summary, the controls around both Controlled Drugs and “non-controlled” drugs have been reviewed. Standard Operating Procedures for Controlled Drugs have been updated and audits conducted by the Chief Pharmacist have shown compliance with the standards required. Controls around “non-controlled” medicines have been reviewed and found to be compliant with or indeed exceed all national guidance. There remains a small risk that these medicines could be diverted as is the case in all hospitals. This is mitigated by the professional responsibilities of all staff regarding the use of medicines. To further mitigate”

Source location
2015-0088-Response-by-Royal-Orthopaedic-Hospital
Page 2 · response
Published 9 March 2015
Open published response
2 Feb2015
Manchester City
Concerns raised2
1. Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations
2. Lack of periodic audits of record keeping in similar cases
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.
Actions described in response 4
1. Action
  Introduce a self-harm indicator in the Public Health Outcomes Framework measuring emergency-department attendances and psychosocial assessments.
  Stated by Department of Health and Social CareStated completed
2. Action
  Provide a single referral pathway with automatic mental health assessment referrals, agreed response times, and interim telephone advice for patients awaiting assessment.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
3. Action
  Review referral delays monthly with partner organisations and monitor referral-response performance through internal reporting and key performance indicators.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
1. Action
  Cooperate with partners to develop an audited process for referrals to mental health liaison teams.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  Existing A&E liaison response targets are closely monitored and performance is regularly scrutinised by the Trust, hospital and commissioners.
  Stated by Greater Manchester Mental Health NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  UHSM should lead development of the audited mental health liaison referral process, with both mental health providers involved.
  Stated by Greater Manchester Mental Health NHS Foundation TrustRedirects responsibility
AI-generated summary

Kimberley Lauren Lindfield · 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

Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.

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 auditing of the appropriateness and timeliness of responses to mental health assessment presentations
Wider context from the report
“1. I am told that all patients presenting with symptoms of mental illness/mental disorder and/or after reported self harm/suicidal behaviour will now be automatically referred for a mental health assessment to be conducted as soon as possible whether that referral is from A& E or any ward. Pending that assessment, mental health staff can give advice by phone concerning the patients interim care and management. Both UHSM and MHSC provided evidence about a joint understanding and approach as well as a training and induction of staff. GMW may also be involved in such a case. That was to a very large extent the assurance I was provided after the death of Mr Dean. There were no plans or thoughts to audit whether or not in practice there was an appropriate and timely response to such presentations to ensure that the new system was actually working. In view of the history I am concerned that without such an auditing process failures of care may take place as identified above. ”
Source location
Kimberley Lauren Lindfield · Prevention of Future Deaths report
Page 7 · 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
Lack of periodic audits of record keeping in similar cases
Wider context from the report
“4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met. ”
Source location
Kimberley Lauren Lindfield · Prevention of Future Deaths report
Page 7 · 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 a self-harm indicator in the Public Health Outcomes Framework measuring emergency-department attendances and psychosocial assessments.

Verbatim wording from the response
“In the Department’s current Public Health Outcomes Framework a new self-harm indicator was introduced; this measures:”

Source location
2015-0036-Response-by-Department-of-Health
Page 2 · response
Published 2 February 2015
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 a single referral pathway with automatic mental health assessment referrals, agreed response times, and interim telephone advice for patients awaiting assessment.

Verbatim wording from the response
“The Trafford Rapid Assessment Interface Discharge (RAID) Team began provision of mental health service into UHSM from the 22nd April 2014. The Trafford RAID team provides assessment of Trafford registered patients within UHSM and assessment of Manchester registered patients on all other wards, except for A&E and its associated wards. The Trafford RAID is commissioned to see patients aged 16 and above. Referrals can be taken from any professional within the acute hospital setting who is concerned about a patient’s mental health; included in this are those patients that present with self harming behaviour or suicidal ideas.”

Source location
2015-0036-Greater-Manchester-West-NHS-Trust
Page 1 · response
Published 2 February 2015
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 referral delays monthly with partner organisations and monitor referral-response performance through internal reporting and key performance indicators.

Verbatim wording from the response
“Trafford RAID at UHSM has a single referral point for access to a mental health assessment. Trafford RAID have an agreed joint operational procedure with UHSM and MMHSCT that provides clear guidance on access to the mental health practitioners and agreed/commissioned target response times to referrals made to mental (Appendix 1). GMW have key performance indicators agreed by GMW and the NHS Trafford Clinical Commissioning Group, which provides an audit of response times at UHSM on all referrals received. This is evidenced in the performance report submitted to commissioners on a monthly basis. This is audited internally to ensure that standards remain high and to identify areas where improvement is required/learning for the team (Appendix 2).”

Source location
2015-0036-Greater-Manchester-West-NHS-Trust
Page 2 · response
Published 2 February 2015
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
Cooperate with partners to develop an audited process for referrals to mental health liaison teams.

Verbatim wording from the response
“In respect of an audited process regarding referrals to mental health liaison teams, we will of course cooperate fully with our colleagues across the local health economy to help develop this. However, since A&E associated ward liaison is provided by MMHSCT, but most other ward liaison services are commissioned from Greater Manchester West (GMW) Foundation Trust’s RAID team, it would seem appropriate that this piece of work is led by UHSM, with the involvement of the two mental health provider organisations.”

Source location
2015-0036-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 2 February 2015
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
Existing A&E liaison response targets are closely monitored and performance is regularly scrutinised by the Trust, hospital and commissioners.

Verbatim wording from the response
“I appreciate your wish to see a timelier referral to mental health services and, as our services are primarily for A&E, we have set target response times which are closely monitored by UHSM, our Trust and commissioners. There is regular scrutiny of our performance in A&E at several fora, including Executive to Executive meetings with the Manchester Clinical Commissioning Groups, System Resilience Groups and locally with senior managers at UHSM.”

Source location
2015-0036-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 2 February 2015
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
UHSM should lead development of the audited mental health liaison referral process, with both mental health providers involved.

Verbatim wording from the response
“In respect of an audited process regarding referrals to mental health liaison teams, we will of course cooperate fully with our colleagues across the local health economy to help develop this. However, since A&E associated ward liaison is provided by MMHSCT, but most other ward liaison services are commissioned from Greater Manchester West (GMW) Foundation Trust’s RAID team, it would seem appropriate that this piece of work is led by UHSM, with the involvement of the two mental health provider organisations.”

Source location
2015-0036-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 2 February 2015
Open published response
22 Dec2014
Gateshead and South Tyneside
Concerns raised1
1. Failure to reinforce effective record keeping through regular management file checks
This report raised 8 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

EDWIN THOMPSON · 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

Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and 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
Failure to reinforce effective record keeping through regular management file checks
Wider context from the report
“The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents. The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard. Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers. ”
Source location
EDWIN THOMPSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Sep2014
Milton Keynes
Concerns raised1
1. Lack of regular audit of Early Warning Observation Chart completion, interpretation and action
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

Peter John White · 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

Peter John White was involved in a road traffic collision on 2 April 2013 and was taken to Milton Keynes Hospital with serious chest injuries. He became unwell and collapsed while undergoing a CT scan, and died on 3 April 2013 from haemothorax. Concerns included incorrect completion and inadequate checking of the Early Warning Observation Chart, ignored triggers, failures to escalate care, and the absence of a regular audit 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
Lack of regular audit of Early Warning Observation Chart completion, interpretation and action
Wider context from the report
“(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. ████████ an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) I was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon. ”
Source location
Peter John White · Prevention of Future Deaths report
Page 1 · concerns
Open source report
28 May2014
Leicester City and South Leicestershire
Concerns raised1
1. Lack of maintained and audited analysis of failed visits and untoward outcomes
This report raised 3 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.
Actions described in response 1
1. Action
  Conduct weekly audits of failed visits and monitor compliance through key performance indicators.
  Stated by Leicestershire Partnership NHS TrustStated in progress
AI-generated summary

Laura Page · 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

Laura Page experienced social stresses, sought medical support, and later took overdoses requiring psychiatric care. She died on 4 December 2012 after taking a substantial overdose. Concerns included failed community-team home visits, inadequate escalation and welfare-check thresholds, incomplete discharge arrangements, and poor inter-agency communication.

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 maintained and audited analysis of failed visits and untoward outcomes
Wider context from the report
“Ms Page was her GP for the crisis team, who carried out an initial assessment and agreed daily home visits. On 3 separate occasions, different clinicians attended the home address but could not gain access, could not leave a note and did not attempt to contact the client as they had no telephone contact details. These failed visits were not brought to the attention of the shift supervisor that day or the Consultant team meeting the following morning. (1) The clinician response to failed visits is not robust. Further practical efforts could be considered, including door access keys where appropriate. (2) The escalation policy should be reviewed to consider specific time targets for action. (3) The threshold for requesting a welfare check should be reconsidered. (4) An analysis of failed visits and untoward outcomes across the service could be maintained and audited to ensure lessons are learnt and best practice shared. ”
Source location
Laura Page · 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
Conduct weekly audits of failed visits and monitor compliance through key performance indicators.

Verbatim wording from the response
“The Crisis Service Manager is now undertaking a weekly audit check on failed visits to assure compliance in line with the new process, and is monitored through key line performance indicators.”

Source location
2014-0254-Response
Page 2 · response
Published 28 May 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to audit pain management for patients presenting to A&E in severe pain

Concerns raised1

Insufficiently robust auditing of care and safety omissions

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.1

Concerns raised1

Lack of effective auditing of communication systems

Concerns raised1

Failure to assess the clinical content and appropriateness of nursing and medical documentation

Concerns raised1

Failure to audit and track the use of non-controlled medication

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Lack of auditing of the appropriateness and timeliness of responses to mental health assessment presentations

Lack of periodic audits of record keeping in similar cases

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.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to reinforce effective record keeping through regular management file checks

Concerns raised1

Lack of regular audit of Early Warning Observation Chart completion, interpretation and action

Concerns raised1

Lack of maintained and audited analysis of failed visits and untoward outcomes

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.1

Actions described in response 1

Actions described in response 3

Respondent positions 1

Actions described in response 4

Respondent positions 2

Actions described in response 1