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. Birmingham and Solihull

    AI-generated summary

    Kamil Iddrisu and Youngson Nkhoma · 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

    Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

    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 clinical oversight board to review or audit near misses

    Wider context from the report

    “Sickle cell trait (SCT) screening process and identifying SCT in candidates: 1. The Inquest heard evidence that since these tragedies there had be 12 (13 as one incident includes 2 people) near misses where the process that had been put in place following these tragedies had not be followed. This resulted in 3 candidates at High Risk for SCT according to their family origins questionnaire undertaking the 2km run. 1 of these had self-identified to a Group Leader prior to the exercise but was directed to complete the RFT(E) run element in any case. This raises a concern about the screening process may be safe and effective. 2. The inquest was told that the Air force and Navy are not screening any candidates for SCT. The Army are. Both services are recruiting from the Commonwealth. Medical evidence at the inquest confirmed screening was the only way to safely identify candidates at risk. This raises a concern that the recruitment process is not safe and effective. Training and Education 1. The near miss incidents lead to a concern that staff involved in the selection process and RFT assessments are still not aware of the risk associated with SCT given that in one case the person was directed to undertake the run despite knowing he was at high risk of developing exertional rhabdomyolysis associated with SCT. 2. The lack of screening in the Navy and Air Force leads to a further concern about the level of understanding regarding the risks associated with SCT – the evidence at the inquest said this risk was unpredictable . 3. The inquest heard evidence that there is no standardised way to identify SCT candidates who are going through the selection process as the different services were considering using different colours wrist bands in different services. The raises a concern about the ability to identify those candidates who have SCT. 4. There should be a review of the wording used and rationale for including questions for candidates regarding ‘cola coloured urine’ in the PMSA. Dr Gupta, an expert haematologist at the inquest, informed the court that this is not always a sign of SCT as an individual can get cola urine from hepatitis. This raises a concern about the level of understanding of the significant of "cola coloured urine" and what it might indicate. Reporting and investigation 1. The inquest heard how Capita have set up a clinical oversight board to review any incidents. First this board did not appear to have reviewed or audited any of the near misses referred to above and second it does not include a representative from the Army. This raises concerns about the lack of joined up thinking for an incident between Capita and the army and the safety of the new process. 2. Reporting of incidents: the majority of the 12 near misses were not investigated at the time they occurred which indicates the present process is not safe and effective. 3. There is no system to audit whether incidents are being correctly processed and investigated. 4. The reporting system continues to use two parallel reporting forms for Capita (Casper) and the Army (Durals). These are on separate IT systems. This raises a concern that there is no "one version of the truth". The inquest heard evidence that Capita were unclear if they had resolved the issue in their Casper system associated with the drop down menu options and the fact that non work related incidents close investigations automatically. 5. It was unclear from the evidence whether the Recruiting Group has a clear identifiable person to take responsibility for the review health and safety incidents and to ensure adequate investigation is undertaken. Specifically it was still not clear that any oversight of the medical incidents fell within the remit of the Capita Head of Health and Safety. 6. It was unclear from the evidence whether the Recruiting Group act as one entity regarding health and safety issues with a clear lines of responsibility for global risk assessment (and promoting information gathering & investigation) of incidents of any nature. The Inquest heard evidence that ‘H&S at work’ is considered differently to any medical risk, which is supported by the lack of investigation of the near misses. Medical response: 1. Inquest heard how Lichfield had specialist medical staff on site in the medical training unit but there was no system for getting urgent medical attention on the base if needed. There was no mechanism to put a tannoy out for a medical emergency but the Inquest heard evidence that this could be done for a cake sale. 2. All the services should consider whether there should be a generic policy for the treatment of exertional collapse (of any cause) as per US Army where during training there is a clear medical plan with availability of essential medical treatment (eg oxygen and fluids) before hospitalisation. ”

    Source location

    Kamil Iddrisu and Youngson Nkhoma · 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 the Joint Lessons Learnt Panel and Learning Account process to investigate incidents, assign recommendations, disseminate learning and monitor completion.

    Verbatim wording from the response

    “Reporting processes have also been enhanced; any similar future incident will be investigated promptly and jointly by the medical and health and safety teams. These include automated notification of Recruiting Group’s Chief Medical Officer and Head of Health and Safety, to enable them to trigger an investigation by a newly established Joint Lessons Learnt Panel. This panel includes senior Recruiting Group and Army colleagues in operational, clinical, and health and safety leadership roles. The Panel has an enduring remit to review all reported accidents and near misses within 96 hours and make appropriate recommendations, although in practice incidents are reviewed within 48 hours. The panel also directs a suitably qualified individual or body (such as Recruiting Group’s Clinical Oversight Board) to conduct a more detailed Learning Account investigation.”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 3 · response
    Published 30 December 2019

    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

    Audit incident processing through Clinical Oversight Board, joint assurance forums, Defence oversight and a commissioned external review of Sickle Cell Trait risk management.

    Verbatim wording from the response

    “As detailed in the response to Matter of Concern 3a above, all actual and ‘near miss’ incidents are reviewed at the monthly Clinical Oversight Board. Audit takes place at the quarterly Joint Health and Safety Executive Manager’s Conference, the quarterly Joint”

    Source location

    2019-0416 - Response from Secretary of State for Defence and Capita
    Page 11 · response
    Published 30 December 2019

    Open published response

  2. Manchester City

    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

    A 78-year-old woman developed severe sepsis and necrotising fasciitis following dental treatment. She was not triaged or assessed promptly at hospital, suffered a cardiac arrest, underwent emergency surgery, and died on 6 July 2019. The concerns included the currency and implementation of sepsis protocols, staff training and awareness, and timely recognition and treatment of sepsis.

    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 periodic audits of sepsis recognition and treatment

    Wider context from the report

    “4. Periodic audits are undertaken to ensure appropriate recognition of sepsis has been made and appropriate treatment commenced in a timely manner. ”

    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

    Establish an eight-member Acute Care team to deliver sepsis education, quality improvement and monthly compliance review across the Trust.

    Verbatim wording from the response

    “MFT has established the Acute Care team which is made up of eight Clinical Acute Care Educators (covering adults, maternity, and paediatrics) whose role is to provide sepsis education, drive sepsis quality improvement work and review the monthly sepsis compliance figures across the Trust. This refers to compliance with sepsis screening as well as the ‘Sepsis Six’ treatment bundle, a set of six key tests and interventions that need to be applied to a patient with red flag sepsis features within 60 minutes of sepsis being suspected. If a specific area/ward is under-performing the team will offer specific targeted sepsis education and review where improvements can be made.”

    Source location

    Response form Manchester University NHS Foundation Trust
    Page 2 · response
    Published 4 October 2022

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    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 inpatient sepsis audits and present findings to the Clinical Effectiveness Committee to monitor recognition and timely treatment.

    Verbatim wording from the response

    “In 2022 an inpatient sepsis audit was established in line with the MFT Acute Care team audits. It has run for two cycles and the findings have been presented to the Clinical Effectiveness Committee. One outcome of the audit was to establish a Sepsis Task and Finish Group to improve sepsis education and awareness across MFT and harness HIVE to access real time meaningful data on sepsis screening compliance.”

    Source location

    Response form Manchester University NHS Foundation Trust
    Page 4 · response
    Published 4 October 2022

    Open published response

  3. West Yorkshire Eastern

    AI-generated summary

    John Francis Heffron · 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

    John Francis Heffron, a 50-year-old wheelchair user, was found confused in his flat and later suffered a cardiac arrest while alone in an A&E cubicle. There was a delay in initiating CPR, including delays in making a crash call and ascertaining his DNAR status; he was resuscitated but sustained a hypoxic brain injury and died in hospital. The concerns included bank and agency nursing staff’s familiarity with emergency procedures, training and induction, and the adequacy and independence of the Trust’s investigation.

    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 audits and spot checks verifying bank and agency nurses’ familiarity with crash call procedures

    Wider context from the report

    “(8) It is acknowledged that some additional refresher training has been carried out since this incident. There is, however, no system of audits, spot checks or dip testing to verify that bank and/or agency nurses are actually familiar with the essential procedures relating to crash calls. ”

    Source location

    John Francis Heffron · 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

    Check for new temporary staff at every shift start and complete a signed first-shift induction covering emergency and resuscitation procedures, equipment locations and reporting processes.

    Verbatim wording from the response

    “Following the patient’s death, and during the investigation into the care provided before it, the Trust identified deficiencies in the training provided for bank and agency staff about the crash call process used by the ED teams and action has been taken to address these.”

    Source location

    Response from The Leeds Teaching Hospital
    Page 3 · response
    Published 3 October 2022

    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 qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.

    Verbatim wording from the response

    “(6) In December 2021 the Trust followed a framework employment checklist for temporary workers on temporary assignments, to establish their qualifications and training prior to them starting work in the ED. This still remains the case. Staff allocated by the preferred provider to work in the EDs should only be staff with prior ED experience. Checks made cover the individual’s qualifications, skills and experience, their DBS status and completion of the Trust’s mandatory and priority training (including refresher training and updating); resuscitation training forms part of this. A CV is received for each candidate in order to verify skills and experience based on previous employment history.”

    Source location

    Response from The Leeds Teaching Hospital
    Page 3 · response
    Published 3 October 2022

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Beryl Simcock · 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

    Beryl Simcock, who lived in a care home because of dementia, suffered several falls, including a fall on 10 June 2021 that caused an impacted fractured neck of femur and led to a severe deterioration in her health. The concerns included inadequate care-plan and risk-assessment reviews, potentially inaccurate records, insufficient oversight, and inadequate information for her family when she was deprived of her liberty.

    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 audit activity to identify deficiencies in care plan and risk assessment reviews

    Wider context from the report

    “I was concerned about the lack of written policies for care planning and review. I was concerned that reviews of care plans and risk assessments were either not done (and the records falsified to suggest that they were) or that they were done by someone unsuited to the task. This was not identified despite audit activity during the relevant period. I was also concerned that at times when Mrs Simcock was deprived of her liberty the care home did not ensure that her family were given adequate and timely information to enable them to provide independent scrutiny of the care and restrictions in place. ”

    Source location

    Beryl Simcock · 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

    Acquire and introduce the QCS online total quality system to improve policy access, change communication and care-home-specific auditing.

    Verbatim wording from the response

    “• In order to improve policy and procedure maintenance and also communication of changes, the Home should introduce an on-line total quality system that is subscription-based and maintained by the provider. This will mean staff have better access to policies and procedures and would be informed of changes automatically.”

    Source location

    Response from Radcliffe Manor House
    Page 1 · response
    Published 27 September 2022

    Open published response

  5. Manchester South

    AI-generated summary

    James John Jude Booth · 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 Booth, who had longstanding mental ill-health and was detained at The Priory, Altrincham, absconded on 7 October 2020 and was found dead on 14 October 2020; the medical cause of death was hanging. The principal concerns were inadequate security of the ward garden, including the fence, inadequate risk assessments, and failures to communicate and document repeated incidents and emerging risk between shifts.

    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 robustly review handover documents

    Wider context from the report

    “Matter Two The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts. In particular, the form specifically designed for this with a section for completion – ‘incidents in last 7 days’ which would have provided an information flow through was not completed. Whilst I heard evidence of steps taken to improve information exchange at a higher level than between ward staff (nurses and HCAs) I was very surprised to hear that no audit of these ‘handover documents’ had been carried out. Given the fundamental importance of the exchange of information between each shift and consecutive shifts I am of the opinion that The Priory have not carried out a sufficiently robust review. Until this failure is addressed there is a significant risk of a breakdown in the communication of adverse events across the shift pattern of several days. The risk of a lack of appreciation of an emerging pattern of behaviour remains. ”

    Source location

    James John Jude Booth · 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

    Attend weekly ward shift handovers and check their content, accuracy and detail.

    Verbatim wording from the response

    “Both ████████ and the Altrincham Hospital Director of Clinical Services, ████████, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT.”

    Source location

    Response from Priory
    Page 1 · response
    Published 27 September 2022

    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

    Monitor handover quality through internal compliance and divisional quality inspections.

    Verbatim wording from the response

    “Both ████████ and the Altrincham Hospital Director of Clinical Services, ████████, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT.”

    Source location

    Response from Priory
    Page 1 · response
    Published 27 September 2022

    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 and trial an electronic handover template that consolidates patient and incident information and enables contemporaneous content audits.

    Verbatim wording from the response

    “Additionally, a detailed handover template is being introduced across the Priory Healthcare sites (and this is currently being trialled on Rivendell ward at Altrincham in response to your Regulation 28 report). The handover template has the capacity to download information from different applications including the electronic patient record (CareNotes) and the incident reporting system (Datix). This will give a detailed picture of the patient’s current health and”

    Source location

    Response from Priory
    Page 1 · response
    Published 27 September 2022

    Open published response

  6. Manchester City

    AI-generated summary

    Shona Christine Michaela 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

    Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

    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 auditing process for care plans and risk assessments

    Wider context from the report

    “7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process. ”

    Source location

    Shona Christine Michaela Campbell · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  7. South Yorkshire (Western)

    AI-generated summary

    Jamie Lee Bennett · 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

    Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency 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

    Lack of auditing of task-list completion and welfare-check performance

    Wider context from the report

    “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately It is my opinion there is a risk that future deaths may occur unless there are: • Clear, written instructions on how to conduct welfare checks • Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff • An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately ”

    Source location

    Jamie Lee Bennett · Prevention of Future Deaths report
    Page 8 · concerns

    Open source report

  8. Birmingham and Solihull

    AI-generated summary

    Natasha Mary ADAMS · 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

    Natasha Mary ADAMS died by suicide at home on 12 August 2021 after presenting to hospital with recent fleeting suicidal thoughts and being assessed as in crisis. The report identified concerns that her level of mental health care had been downgraded without clinicians following the relevant policy, and that an audit of other patients had not been undertaken four months after it was identified as an action.

    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

    Delays in auditing other patients' compliance with the Care Management & CPA/Care Support Policy 2019

    Wider context from the report

    “BSMHFT's Root Cause Analysis Report identified that in July 2021 Natasha's level of care level was downgraded from CPA to Care Support without clinicians following the trust's Care Management & CPA/Care Support Policy 2019. I heard evidence from Natasha's family this had a dramatic impact on Natasha's mental health. The RCA action plan identified the need to conduct an audit of other patients to check the trust's compliance with the Care Management & CPA/Care Support Policy 2019. The RCA Report was released in December 2021. The evidence was that 4 months later no action has been taken and other patients have not yet had their cases audited. The delay is the trust's Clinical Governance Committee needs to approve the audit process, which is unlikely to happen until the summer of 2022, and possibly not until as late as September 2022 because of staff holidays. In my view until such a delay is of serious concern and action should be taken to bring forward the audit. ”

    Source location

    Natasha Mary ADAMS · 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 audit of compliance with the Care Management and CPA/Care Support Policy 2019 across other patients.

    Verbatim wording from the response

    “I understand that the report was given due to the lack of actions taken around the recommendation for the need to conduct an audit of other patients to check the trust's compliance with the Care Management & CPA/Care Support Policy 2019. Firstly I am very sorry that this action has not taken place. As a Trust we are taking our action plans very seriously and are working to improve patient care for the future, where lessons are identified within our Serious Incident reviews.”

    Source location

    2022-0124-Response-from-Birmingham-and-Solihull-Mental-Health-NHS-Foundation-Trust_Published
    Page 1 · response
    Published 29 April 2022

    Open published response

  9. Gwent

    AI-generated summary

    Marvin John RUE · 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

    Marvin Rue was admitted to hospital on 8 January 2021 after a fall and fell five times during his admission. On 2 February 2021, he suffered a fatal head injury after another fall and died on 3 February 2021. The principal concerns were failures to complete falls-risk assessments after admission, hospital transfers and previous falls, resulting in inadequate supervision; the report also identified failures to investigate staff non-compliance and to carry out audits.

    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 complete regular ward audits of falls risk assessments

    Wider context from the report

    “Marvin Rue had fallen prior to his admission to hospital on 8th January 2021 and was therefore, due to his age and circumstances, a “known falls risk”. In evidence I heard that in these circumstances a Multifactorial Risk Assessment (MFRA) should take place within 6 hours of admission to hospital. It was not. Mr Rue was transferred between hospitals during his admission, initially to Nevill Hall Hospital and then to Ysbyty Aneurin Bevan. I heard in evidence that a review of the MFRA should take place after every hospital transfer. Mr Rue had no MFRA undertaken after his transfers. Mr Rue fell 5 times prior to his fatal fall in hospital on 2nd February 2021. Contrary to Health Board Policy, Mr Rue did not have an MFRA undertaken after any of these falls. In fact there was never an MFRA correctly completed for Mr Rue throughout his hospital admission. I heard evidence that during this time the staff were under significant pressure due to the effects of the pandemic, and I accept that. However the care that Mr Rue was denied was basic nursing care. ████████ the Lead Nurse and author of the Serious Concerns Report, indicated that had Mr Rue been assessed, he would have warranted 1:1 supervision . As a result I concluded that the failures in care directly contributed to Mr Rue’s death. During the inquest I have been presented with an action plan, however this is not the first action plan I have been presented with (in very similar circumstances) and sadly I am not convinced that this plan will prevent future deaths for the following reasons. The policies referred to above have been in place for several years. I am informed that although there is bespoke documentation training, all staff are trained in falls risk assessment from the time they are in nurse training. Therefore it is not a lack of understanding or policies which have caused these failures. None of the staff were interviewed during the internal investigation and no evidence was forthcoming as to why staff did not follow the procedures. Without this information I do not consider that the actions plan will prevent future deaths. I refer you to your previous responses to PFDs which have clearly not had the desired outcome. Despite being previously reassured that regular ward audits would take place to ensure that the risk assessment were being undertaken I heard no evidence that audits were completed at this time and so the failures went unnoticed until after Mr Rue’s death. ”

    Source location

    Marvin John RUE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Berkshire

    AI-generated summary

    Colm MCCABE · 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

    Colm McCabe, aged 79, was admitted to hospital with hyperglycaemia after his blood sugar levels were not monitored and insulin administration was not clarified at the care home. He was transferred to hospital on 22 March 2021 and died there on 24 March 2021; the inquest concluded that natural causes were contributed to by neglect. Concerns included staff recruitment, training and appraisal, ineffective auditing, failures to clarify and monitor diabetes care, and the candour and completeness of investigations by the care home.

    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 management effectiveness adequately

    Wider context from the report

    “2. Whilst I was advised that a new management team is working at this care home, I remain concerned about auditing of the effectiveness of this. We heard evidence that auditing was taking place at the time of this death, but this appears to have missed significant factors, including the fact that a 72 hour review was not carried out, that neither the 72 hour review nor any subsequent management of the patient picked up the blood sugar monitoring issue, nor did they seek clarification of this point with the hospital, the GP or community diabetic nurses. ”

    Source location

    Colm MCCABE · 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

    Develop and deliver bespoke training for Home Managers on conducting, documenting and evidencing continuous improvement through audits.

    Verbatim wording from the response

    “2. Through reflection and review, it has been recognised that the Group Governance and Audit system was not utilised at The Berkshire Care Home in the way for which it was intended. The completion of the audit process is reliant upon human elements, namely the importance of understanding the process, an honest and accurate approach to completion and the ability to execute this through comprehensive and open reporting. Accordingly, work is now in progress with the Group Care Quality and Assurance Teams to develop and deliver bespoke training to all Home Managers on how to conduct and document an audit and evidence continuous improvement. Further to this, it is recognised that the completion of audits should not be the responsibility of one individual as this may result in a restricted overview without checks and balances.”

    Source location

    2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
    Page 3 · response
    Published 31 January 2022

    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 audits using multiple and independent sources, and validate audit data through further interrogation of reported outcomes.

    Verbatim wording from the response

    “Accordingly, action has been taken to conduct audits via multiple sources, including completion by team members independent to the homes, promoting a validation approach to audits carried out. The review of data produced by audit has also been improved. Whereas previously if data indicated consistent high outcome scores, this was viewed as assurance that a home was compliant. A different approach is now adopted so that this is now interrogated further utilising an independent team member validation approach to obtain assurance as to the accuracy of the outcomes presented to the wider business.”

    Source location

    2022-0025-Response-from-Four-Seasons-Healthcare-Group_Published
    Page 3 · response
    Published 31 January 2022

    Open published response

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