4 Jun 2025 DAVID HEFFER · Prevention of Future Deaths report Essex
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Concerns raised 1
Lack of complete medical records containing pertinent and relevant information View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
DAVID HEFFER · 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
David Heffer died on 13 April 2024 from septicaemia due to acute peritonitis following duodenal and omental perforation after an ERCP performed for obstructive jaundice. He was discharged on the day of the procedure and readmitted the next day in severe pain with biliary sepsis and perforation. Concerns included failure to inform the treating doctor of the readmission and incomplete or illegible medical records.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of complete medical records containing pertinent and relevant information
Wider context from the report “(2) The medical records did not contain all of the pertinent and relevant information and some were illegible causing difficulty in interpretation.
” Source location DAVID HEFFER · Prevention of Future Deaths report
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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 Implement the EPIC electronic patient record system with centralised, legible records, mandatory clinical fields, structured endoscopy templates and alerts for required actions.
Verbatim wording from the response “The Trust is in the process of implementing a new electronic patient record system, provided by EPIC, to transition their patient records system to an electronic system, meaning that by October 2025, all ESNEFT patient record keeping will be done electronically.” Source location Response from East Suffolk and North Essex NHS Foundation Trust
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28 May 2025 Julie Sheila Beasley · Prevention of Future Deaths report Essex
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Concerns raised 1
Poor clinical record keeping and documentation of decision-making rationale View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Essex Partnership University NHS Foundation Trust
Require full biopsychosocial mental health assessments, with documented rationale for omissions.
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Essex Partnership University NHS Foundation Trust
Issue a Trust-wide safety alert reinforcing completion of electronic assessment documentation.
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Essex Partnership University NHS Foundation Trust
Develop an electronic handover tool documenting follow-up actions and emerging risks.
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Essex Partnership University NHS Foundation Trust
Conduct monthly evidence-based assessment quality audits and provide feedback on findings.
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Julie Sheila Beasley · 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
Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor clinical record keeping and documentation of decision-making rationale
Wider context from the report “(5) Multiple experienced members of the mental health teams had contact with Mrs Beasley between January and March and did not make detailed entries into the medical or ask questions of Mrs Beasley about what additional information she had to provide about her risks of harm and suicidal ideation, review of her medication given her deteriorating mental health and calls to the crisis team disclosing increasing suicidal thoughts and ideation accompanied by acts and plans. There was a lack of professional curiosity and poor record keeping and rationale for decision-making .
” Source location Julie Sheila Beasley · Prevention of Future Deaths report
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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 Require full biopsychosocial mental health assessments, with documented rationale for omissions.
Verbatim wording from the response “Response:
The Trust has continued to review our assessment processes to ensure that the appropriate reviews are undertaken in a timely manner and are supported through the MDT approach which then supports a joined up approach to patient assessments. Staff in the Mental Health Crisis team are required to undertake a mental health assessment for all patients, which is monitored and audited via supervision meetings and compliance reviews.” Source location Response from Essex Partnership University NHS Trust
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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 Issue a Trust-wide safety alert reinforcing completion of electronic assessment documentation.
Verbatim wording from the response “Further, the Trust issued a Trust-wide safety alert, in respect of Electronic Assessment Documentation, which re-enforces and reminds colleagues that all sections of the Initial Assessment form should be completed or a clear rationale for why it is not possible to complete a section should be given e.g ‘Patient is unable to provide this information at present due to their current presentation’.” Source location Response from Essex Partnership University NHS Trust
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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 Develop an electronic handover tool documenting follow-up actions and emerging risks.
Verbatim wording from the response “In addition, the Trust has developed a new electronic handover tool process which will aid clearer documentation and clarity in respect of follow up actions.” Source location Response from Essex Partnership University NHS Trust
Open published response
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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 Conduct monthly evidence-based assessment quality audits and provide feedback on findings.
Verbatim wording from the response “Monitoring of the quality of assessments, noting the concerns above has been enhanced with monthly assessment quality audits. The audits are evidence based (NICE Guidance) and undertaken by each lead reviewing 10 cases each month. The lead will feedback to staff the themes they have found, good practice and areas for improvement, as a means of ‘spot checking’ the assessments that are being carried out. In addition to the team monthly audits, an EPUT wide audit carried out in April 2025 for urgent care, showed overall for the 5 teams, sections regarding Patient Details, Consent & Capacity, Carers, Referral Details and Assessment attained results at 91% or above regarding compliance.” Source location Response from Essex Partnership University NHS Trust
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26 May 2025 Sarah Kathleen Hill · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Lack of documentation about the use of cot sides View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sarah Kathleen Hill · 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
Sarah Kathleen Hill was admitted for an elective ERCP to remove gallstones and developed worsening pancreatitis, perforation, multi-organ failure and cardiac arrest before dying in the early hours of 8 November 2024. Concerns included inadequate falls-risk assessment and reporting, insufficient documentation and monitoring, poor observability in a side room, and understaffing despite escalation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of documentation about the use of cot sides
Wider context from the report “(2) There was a lack of documentation about the use of cot sides and the placement of the call bell within Mrs Hill's reach .
” Source location Sarah Kathleen Hill · Prevention of Future Deaths report
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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 Explore mandatory electronic fields for bed-rail status and call-bell placement, including with the replacement-record supplier.
Verbatim wording from the response “Electronic Documentation Enhancement: The Web V electronic record system is under review to explore the options to introduce mandatory (cannot be bypassed) fields for bed rails status and call bell placement. NB: WebV will be replaced as part of the implementation of a new electronic patient record in 2026 and this feature will be explored with the supplier to ensure any progress made with WebV is not lost.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Nurse-in-Charge checklist to include bed rails, call bells and environmental safety.
Verbatim wording from the response “Daily Spot Checks: The daily Nurse-in-Charge quality checklist will be revised to include specific items on bed rails, call bells and environmental safety.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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12 May 2025 Ian George Stanton SIMPSON · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to label retrospective care records View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Ian George Stanton SIMPSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ian Simpson fell in August 2024, sustained a traumatic spinal injury, and later required a long-term catheter. He was found unresponsive at Magnolia Court Care Home on 16 December 2024, was taken to hospital after a delay in calling an ambulance, and died that evening from sepsis secondary to a urine infection. The principal concerns were the delay in calling an ambulance and inadequate and inaccurate care-home record-keeping, including retrospective or misleading entries.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to label retrospective care records
Wider context from the report “2. The notes from the care home were considered in great detail during the inquest, particularly the care notes from the morning of 16 December 2024. These raised significant concern about their adequacy and accuracy. While the deficiencies in record-keeping did not cause or contribute to death in the specific circumstances of this case, I am mindful of the importance of clear and accurate record-keeping to the delivery of safe and effective care more widely.
The issues included:
• an entry that was plainly not correct and therefore gave a misleading impression of interactions that staff had with Mr Simpson at or about the time of his being found unresponsive;
• an entry suggesting that Mr Simpson was ‘awake and lying in bed’, when he had already been found unresponsive some time earlier, suggesting that the entry was either retrospective (and not labelled as such) or simply incorrect;
• a series of notes, likely to have been retrospective but not labelled as such , giving a misleading impression of the course of events that morning.
While I was provided with some evidence that action had been taken in relation to this matter (such as an audit of records), I found that the evidence provided insufficient reassurance that the risk was sufficiently reduced.
” Source location Ian George Stanton SIMPSON · Prevention of Future Deaths report
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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 Introduce EnabLE digital care planning, handheld devices and staff recording requirements to standardise care records and support auditing.
Verbatim wording from the response “Introduction of EnabLE” Source location Response from Barchester Healthcare Ltd
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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 Provide refresher training on EnabLE functionality, record-keeping expectations, policy and accurate contemporaneous recording.
Verbatim wording from the response “Following the Inquest, we have provided refresher training at the Home in relation to the functionality of the system, the organisation’s expectations and policy in relation to record keeping and the importance of accurate and contemporaneous recording.” Source location Response from Barchester Healthcare Ltd
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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 Continue remotely reviewing Home documentation quality through the assurance audit programme.
Verbatim wording from the response “We have the ability to review the documentation completed by staff at the Home remotely; the Regional Director and Regional Clinical Development Nurse continue to consider the quality of entries as part of the ongoing assurance audit programme. We are currently working on setting up a trial of an integrated digital accident and incident recording system, this will be linked to the digital care planning system to allow for the capture of key information relating to the incident in real time which will support our investigation of incidents in future.” Source location Response from Barchester Healthcare Ltd
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9 May 2025 Janet Alison Anderson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of documentation to capture key discussions and decisions View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Janet Alison Anderson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of documentation to capture key discussions and decisions
Wider context from the report “2. The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication . As a consequence, trust staff were not fully sighted on earlier decisions and her needs .
” Source location Janet Alison Anderson · Prevention of Future Deaths report
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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 Review Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Verbatim wording from the response “GMMH have worked closely with NHS GM and Manchester commissioners to understand internal causes of delay, identify resource priorities, and explore immediate opportunities within existing services to reduce flow pressures. This work includes:” Source location Response from Greater Manchester Integrated Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement documentation of inpatient-related discussions and enquiries with acute trust staff in the GMMH electronic patient record, supported by a Trust-wide MHLT procedure.
Verbatim wording from the response “Any discussions or inquiries undertaken between the acute trust staff relating to an inpatient and the MHLT will be documented in GMMH electronic patient record Paris, even if the patient isn’t under the care of the team, to ensure all communication is captured. This has been communicated to the team involved in Ms Anderson’s care and will be included in the Trust wide Standard Operating Procedure for MHLT’s that is currently in draft format with a plan to be in operation across all MHLT’s by 1st September 2025. This will ensure consistency across all MHLT’s working across the different acute Trusts within the GMMH footprint.” Source location Response from Greater Manchester Mental Health
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issues specifically relating to the patient’s care will be addressed by Manchester University Hospitals and Greater Manchester Mental Health NHS Foundation Trusts.
Verbatim wording from the response “I note that your report has been shared with Manchester University Hospitals NHS Foundation Trust (MFT) and Greater Manchester Mental Health NHS Foundation Trust (GMMH) and trust they will respond to the issues specifically relating to Ms. Anderson’s care. I have responded to the issues you raise in light of the work undertaken by NHS GM as commissioner responsible for health and social care..” Source location Response from Greater Manchester Integrated Care
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9 May 2025 Caroline Cleall and Bernard Cleall · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to record the assessment, discussion and advice about the appropriate telecare package View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Croydon
Record all assessments within the main body of the client record system.
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Caroline Cleall and Bernard Cleall · 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
Caroline and Bernard Cleall, a husband and wife, died together in a house fire at home on 5 January 2022. The report raises concerns that Adult Social Care could not access the earlier assessment and advice about Caroline’s needs and telecare package, limiting proper review of whether an enhanced package with an automatic smoke detector was required.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to record the assessment, discussion and advice about the appropriate telecare package
Wider context from the report “(1) The senior manager from LB Croydon Adult Social Care who gave evidence told me that he and his team were unable to access the record of the assessment carried out with Mrs Cleall at Croydon University Hospital for her discharge back to the community. I was told that the record was held by the LIFE team on an NHS system to which LB Croydon Adult Social Care did not have access.
(2) The evidence was that what should take place at that assessment is an adequate risk assessment and a discussion with the client about which level of telecare package is appropriate. If the client declines a more expensive package against advice, this should be documented. There was no evidence in this case of the content of any assessment, discussion or advice as to the appropriate level of telecare package for Mrs Cleall.
(3) It appears that LB Croydon's Adult Services would also not have access to the record and the assessment when reviewing the client’s situation once the package is in place and underway.
(4) A review by LB Croydon Adult Social Care was due 4-6 weeks after hospital discharge but it appears that the reviewers had no access to the assessment, advice and response from the client which took place at the hospital. This would mean that the review was missing vital information which might have had a bearing on whether the telecare package should have been revised to include the enhanced service with an automatic smoke detector facility.
(5) In summary, I am concerned that the inability of LB Croydon Adult Social Care professionals to access records of an earlier assessment undertaken (and advice given) by their colleagues, together with the NHS LIFE team, deprives LB Croydon Adult Social Care of the ability to review the client’s needs properly (with the necessary information) following discharge into the community.
” Source location Caroline Cleall and Bernard Cleall · Prevention of Future Deaths report
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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 Record all assessments within the main body of the client record system.
Verbatim wording from the response “Practice has since changed. Today, all assessments are now completed within the main body our client record system rather than being attached in the “Documents” section, which avoids the sort of confusion that occurred in this instance.” Source location Response from London Borough of Croydon
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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 Records contained the Careline risk assessment, signed agreement and installation information documenting advice about the service and its cost.
Verbatim wording from the response “Matter 2: The evidence was that that what should take place at that assessment is an adequate risk assessment and a discussion with the client about which level of telecare package is appropriate. If the client declines a more expensive package against advice, this should be documented. There was no evidence in this case of the content of any assessment, discussion or advice as to the appropriate level of telecare package for Mrs Cleall.” Source location Response from London Borough of Croydon
Open published response
1 May 2025 Peter Michael ANZANI · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to properly complete patient records View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Place visual notices reminding staff to record patient observations promptly and accurately.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Make additional observation machines available in relevant clinical areas.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Communicate observation-recording requirements through verbal briefings and written emails.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Complete a re-audit of outpatient observation recording.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Review systems and processes supporting accurate and timely clinical documentation.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Implement the Apollo electronic patient record system Trust-wide to support consistent, legible and auditable clinical documentation.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Develop and implement Vitals recording for outpatient observations.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Implement a standard operating procedure requiring baseline and higher-risk pre- and post-procedure observations in outpatient clinics.
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AI-generated summary
Peter Michael ANZANI · 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 Michael Anzani died in Birmingham Heartlands Hospital on 23 November 2024 from a pulmonary embolism after being admitted with community-acquired pneumonia. He had a spinal cord injury resulting in tetraplegia and had experienced falls and chest infections. Concerns included inadequate recording of clinical observations, possible staff training issues, and prolonged patient waiting lists linked to staffing and funding difficulties.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to properly complete patient records
Wider context from the report “1. I considered evidence from a ████████ who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by the Trust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms ...”.
2. It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff.
3. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed .
” Source location Peter Michael ANZANI · Prevention of Future Deaths report
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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 Place visual notices reminding staff to record patient observations promptly and accurately.
Verbatim wording from the response “Following receipt of the PFD report, the Trust took immediate action to address the issues identified, specifically relating to timely and accurate recording of patient observations.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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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 Make additional observation machines available in relevant clinical areas.
Verbatim wording from the response “Clear and visual notices have been placed in relevant clinical areas to remind staff of the importance of recording patient observations promptly and accurately. Also, additional observation machines have been made available to ensure staff have immediate access to appropriate tools for carrying out vital sign monitoring. In addition, the importance of accurate observation recording has been communicated directly to staff both via verbal briefings and written email communication.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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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 Communicate observation-recording requirements through verbal briefings and written emails.
Verbatim wording from the response “Clear and visual notices have been placed in relevant clinical areas to remind staff of the importance of recording patient observations promptly and accurately. Also, additional observation machines have been made available to ensure staff have immediate access to appropriate tools for carrying out vital sign monitoring. In addition, the importance of accurate observation recording has been communicated directly to staff both via verbal briefings and written email communication.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Open published response
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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 Complete a re-audit of outpatient observation recording.
Verbatim wording from the response “Also, a re-audit was completed on 21 June 2025 in relation to 20 patient who attended the clinic between 16 – 19 June 2025. The results show that a full set of clinical observations was recorded for 100% of patients, including those undergoing procedures. A copy of the audit has been provided in the Trust’s PFD response bundle.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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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 Review systems and processes supporting accurate and timely clinical documentation.
Verbatim wording from the response “Digital record keeping system” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Open published response
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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 Implement the Apollo electronic patient record system Trust-wide to support consistent, legible and auditable clinical documentation.
Verbatim wording from the response “One of the key tools supporting this work is implementation of our new electronic patient record system called Apollo, which is used Trust wide to facilitate consistent, legible and auditable documentation of patients’ clinical notes. The Outpatient Observation Form now includes all baseline observations, and this essentially follows the process used in the Trust’s Main Outpatient Department. A paper format will be utilised during any period of digital downtime, when access to the digital system is limited, or not available.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Open published response
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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 Develop and implement Vitals recording for outpatient observations.
Verbatim wording from the response “In addition to the above, the Trust recognises that it needs to be able to record patient observations taken in the outpatient setting on Vitals (this is a digital platform for recording clinical observations). This is currently in development with the digital team and implementation date is anticipated to be March 2026, although the timeframe is restricted by the external digital company called System C. In the meantime, the Outpatient Observation Form will be the primary source for recording clinical observations for patients attending outpatient appointments.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Open published response
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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 Implement a standard operating procedure requiring baseline and higher-risk pre- and post-procedure observations in outpatient clinics.
Verbatim wording from the response “A new Standard Operating Procedure (SOP) has been developed and is in the process of being implemented to provide a clear, visual guide for clinical staff working in outpatient settings. The SOP includes a flowchart to ensure ease of understanding and practical application across all relevant clinics. It outlines mandatory baseline observations for all outpatient appointments. The SOP is scheduled to be approved at the next Patient Safety Meeting on 08 July 2025.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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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 Implementation of outpatient observation recording on Vitals is restricted by the external digital company's development timeframe.
Verbatim wording from the response “In addition to the above, the Trust recognises that it needs to be able to record patient observations taken in the outpatient setting on Vitals (this is a digital platform for recording clinical observations). This is currently in development with the digital team and implementation date is anticipated to be March 2026, although the timeframe is restricted by the external digital company called System C. In the meantime, the Outpatient Observation Form will be the primary source for recording clinical observations for patients attending outpatient appointments.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Open published response
16 Apr 2025 Iris Joan CARTER · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to adequately record heel-skin inspections in electronic inpatient notes View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Iris Joan CARTER · 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
Iris Joan CARTER had a fall at home on 1 October 2024 and sustained a left distal femur fracture, which was surgically stabilised. After rehabilitation treatment, including treatment for a Grade 4 pressure sore on her left heel, she developed pneumonia and died in hospital on 8 November 2024. The principal concern was that the pressure sore may not have been properly inspected or that inspections were not adequately recorded during her admission at the Queen Elizabeth Hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adequately record heel-skin inspections in electronic inpatient notes
Wider context from the report “2. I heard evidence during the inquest that Iris was at heightened risk of developing pressure sores given her co-morbidities and reduced mobility post her operation and that a Grade 4 pressure sore is the most serious type of pressure sore where bone is exposed and can therefore be at risk of infection.
3. However, apart from one entry on 13th October 2024 in the QEH electronic in patient noting records when it was recorded that Iris was complaining of pain on palpation of her left heel and a pillow was placed under her heel, there is no reference in the noting to it having been observed at any point that Iris had developed a pressure sore to her left heel during her admission at the QEH .
4. This leads to a concern that either the skin to her left heel was not being properly inspected or if it was that such inspections were not adequately noted in the electronic in-patient noting .
” Source location Iris Joan CARTER · Prevention of Future Deaths report
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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 Require the nurse in charge on each shift to check that care assessments, including skin inspection charts, are fully completed.
Verbatim wording from the response “While reviewing the incident in November 2024, the omissions in producing appropriate and accurate levels of documentation outlining all areas of Mrs Carter’s skin were highlighted. In response to these findings, the senior sister and her team highlighted the omission in care to the wider nursing team, whilst reiterating the associated risk and the pressure ulcer prevention strategy within the Trust. The actions taken at the time were to update the pressure ulcer prevention ward information board, and to provide feedback on Mrs Carter’s case at the daily safety huddle on the ward. Another change in practice is that the nurse in charge of each shift will carry out a safety check, ensuring all care assessments, specifically the patient skin inspection charts, are fully completed. The senior sister has also been completing spot checks since December 2024.” Source location Response from UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
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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 Conduct ward spot checks of care documentation to verify completion of required assessments and skin inspection charts.
Verbatim wording from the response “While reviewing the incident in November 2024, the omissions in producing appropriate and accurate levels of documentation outlining all areas of Mrs Carter’s skin were highlighted. In response to these findings, the senior sister and her team highlighted the omission in care to the wider nursing team, whilst reiterating the associated risk and the pressure ulcer prevention strategy within the Trust. The actions taken at the time were to update the pressure ulcer prevention ward information board, and to provide feedback on Mrs Carter’s case at the daily safety huddle on the ward. Another change in practice is that the nurse in charge of each shift will carry out a safety check, ensuring all care assessments, specifically the patient skin inspection charts, are fully completed. The senior sister has also been completing spot checks since December 2024.” Source location Response from UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
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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 Reviews found no pressure damage before 15 October, when a blister was identified, documented, escalated and assessed.
Verbatim wording from the response “Our review of the documentation outlined in the medical noting documents there was no pressure damage noted on 09.10.24 at 14:18 by the Ortho geriatrician team, who noted review of the lower limb and noted oedema present to Mrs Carter’s leg.” Source location Response from UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
Open published response
4 Apr 2025 Hailey Anne Thompson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 1
Failure to record clinical task communications on the medical records system View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Ashton Medical Centre NHS Greater Manchester Integrated Care Board SSP Health
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Ashton Medical Centre and SSP Health
Reinforce use of auditable systems for all clinical communication and prohibit screen messages for clinical referrals.
View source
NHS Greater Manchester Integrated Care Board
Share a GDPR record-keeping reminder through the NHS Greater Manchester Primary Care Newsletter.
View source
NHS Greater Manchester Integrated Care Board
Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
View source
NHS Greater Manchester Integrated Care Board
Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
View source See 1 more action
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AI-generated summary
Hailey Anne 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
Hailey Anne Thompson was found unresponsive at home on 19 December 2022 and died after unsuccessful resuscitation. Her death was attributed to sepsis and pneumonia arising from a Streptococcus A infection. The principal concerns were unclear pathways and guidance for care navigators handling reports of allergic reactions to medication, including referral to an appropriately competent clinician and recording an auditable trail.
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 record clinical task communications on the medical records system
Wider context from the report “2. During a call to the GP surgery, Hailey’s mother spoke with an administrative member of staff (who at the inquest was referred to as a care navigator at a call centre). The staff member referred an appointment to a pharmacist working with the practice to call her.
3. The pharmacist to whom this was assigned was not competent to deal with a paediatric medication enquiry and sent a message back advising of this, albeit not on the medical records system where an auditable trail would exist . On the evidence, the pharmacist was not provided with feedback directly on the need to use the medical records system or involved in the lessons learned process as they were not directly employed by the practice.
4. A further concern arose during the course of evidence from the primary care practice manager that a care navigator may not have a clear pathway on whom to refer a task or action to, or triage tool to recognise that a reported allergic reaction to a medication may require urgent consideration by a doctor to assess any risk of anaphylactic shock.
5. No evidence was provided to:
a. explain how a patient telephoning the practice and being answered by the call centre would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre which is not located within the doctor surgery.
6. These issues are important as I had no reassurance that an administrative member of staff who spoke with a patient contacting the practice, had a clear pathway or guidance on whom the required task should be referred to.
7. Instead, the task could be allocated using judgement (although as above, guidance to apply this was not clear) to a clinician who could not in fact assist, which occurred in this case. The jury who heard the inquest found that there was a missed opportunity to review the antibiotics, which was not causative in this case. In my opinion, there is a risk that an urgent need for appropriate clinical referral may not occur in the above circumstances.
” Source location Hailey Anne Thompson · Prevention of Future Deaths report
Open source report
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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 Reinforce use of auditable systems for all clinical communication and prohibit screen messages for clinical referrals.
Verbatim wording from the response “• We have reinforced the requirement for auditable documentation across all communication channels.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
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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 Share a GDPR record-keeping reminder through the NHS Greater Manchester Primary Care Newsletter.
Verbatim wording from the response “I have reviewed the response from SSP Health to this part of your report and think there is some learning for primary care providers around ensuring efficient and effective access to the right clinician to treat them and the requirement to ensure accurate, detailed and timely record keeping.
To this aim, I will ensure that:” Source location Response from Greater Manchester Integrated Care
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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 Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
Verbatim wording from the response “NHS GM recognises the importance of staff training in all our primary care practices to ensure that patients are navigated correctly and in a timely way as appropriate for the symptoms they are presenting with, including providing appropriate and timely treatment. NHS GM will” Source location Response from Greater Manchester Integrated Care
Open published response
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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 Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
Verbatim wording from the response “NHS GM recognises the importance of staff training in all our primary care practices to ensure that patients are navigated correctly and in a timely way as appropriate for the symptoms they are presenting with, including providing appropriate and timely treatment. NHS GM will” Source location Response from Greater Manchester Integrated Care
Open published response
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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 concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.
Verbatim wording from the response “We acknowledge the concerns raised regarding care navigation, governance, and communication processes, and would like to take this opportunity to provide assurances of the processes that are embedded into the practice. We note that you state that you concluded that the concerns you raised did not contribute to the death and would also point out that the structures and operating procedures which are used at the surgery are consistent with those used in the vast majority of doctors surgeries in the UK. As a result, we would ask you to consider if a Regulation 28 Report is appropriate in these circumstances.” Source location Response from SSP Health and Ashton Medical Practice
Open published response
17 Mar 2025 DARREN NEIL TURNER · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Inadequacy of electronic clinical records View source Failure to maintain accurate patient-specific clinical records View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
DARREN NEIL TURNER · 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
Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.
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 Inadequacy of electronic clinical records
Wider context from the report “(b) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy - with evidence of the ‘cutting and pasting’ of entries including Darren’s initial 72-hour care plan containing details of another patient entirely.
” Source location DARREN NEIL TURNER · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain accurate patient-specific clinical records
Wider context from the report “(b) Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy - with evidence of the ‘cutting and pasting’ of entries including Darren’s initial 72-hour care plan containing details of another patient entirely .
” Source location DARREN NEIL TURNER · Prevention of Future Deaths report
Open source report
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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 Operate the Record Keeping Safety Improvement Programme to investigate copying and pasting and develop systems addressing documentation risks.
Verbatim wording from the response “The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting. This SIP program is focusing on improving patient safety in respect of documentation specifically. The SIP is aiming to understand motivations for copying and pasting and putting systems in to address these. The approach will be to support continuous learning and improvement and regular review.” Source location Response from Essex Partnership University NHS Foundation Trust
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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 Implement the unified NOVA electronic patient record to integrate systems and carry forward risk information.
Verbatim wording from the response “Essex Partnership University Trust and Mid and South Essex NHS Foundation Trust (MSEFT) are working together to implement ‘NOVA’, a new and single Electronic Patient Record (EPR) system across our services, which will pull through risk information which will negate need to repeat information.” Source location Response from Essex Partnership University NHS Foundation Trust
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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 Develop and pilot standardised multidisciplinary-team communication, recording and documentation principles across four sites.
Verbatim wording from the response “The Trust has initiated a MDT Communication SIP due to the findings from patient safety incident investigations. A working group has been established consisting of senior clinicians and service directors to develop key principles for effective MDT working/communication and documentation. This group will considered the concerns raised by this PFD to ensure this learning is considered as part of the project.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.