6 Jun 2023 Alexander Shone BLEWITT · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure of treating doctors to make accurate clinical notes of major presenting symptoms View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Alexander Shone BLEWITT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.
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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 treating doctors to make accurate clinical notes of major presenting symptoms
Wider context from the report “[4] I was concerned that the treating doctor made aaneous note on the 9th July 2022 at Mr Blewitt's first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence , which Mr Blewitt had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit .
” Source location Alexander Shone BLEWITT · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to make timely and complete clinical records documenting assessment, care planning and decision-making rationale View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Odessa Carey · 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
Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.
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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 make timely and complete clinical records documenting assessment, care planning and decision-making rationale
Wider context from the report “7. Record Keeping Documentation
I am concerned that entries in the RiO medical records were not made in line with Trust guidance in a timely, complete manner or at all.
I am concerned that evidence of clinical assessment, care planning and the reasoning behind clinical decision making were not recorded.
” Source location Odessa Carey · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to complete the daily care log View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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Caroline Victoria Forte · Prevention of Future Deaths report
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Report summary
Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.
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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 complete the daily care log
Wider context from the report “The Jury in their findings found the following matter contributed to the death of Caroline namely 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline's family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.
During the course of the evidence we heard that:-
a) The daily care log was not completed so it was not possible to ascertain who was the last person to see Caroline leave the ward.
b) There was no record to show which nurse carried out a risk assessment before she left.
c) There was no overnight care plan.
d) The “My care and safety plan” had not been updated with regards to “My family will do” section.
e) The family were not provided with a copy of the Section 17 leave form
f) At the time of this leave the family were unaware that Caroline had self-harmed in the hospital by tying a ligature. Therefore, the family told the Inquest that they therefore had no strategies in place to minimise the risks of such an event. Similarly there was no communication with the hospital as to how to minimise Caroline’s risk.
f) Senior Officers from the ward showed a lack of knowledge of the Trust’s own Section 17 leave policy and Safe and Effective Assessment & Management of Clinical risk: Risk Management Police and Procedure.
” Source location Caroline Victoria Forte · 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 the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.
Verbatim wording from the response “During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.” Source location Response from Sussex Partnership 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 Review the new Record of Patient Leaving Ward document’s effectiveness after three months and report findings to the Acute Care Forum.
Verbatim wording from the response “During the aforementioned improvement works, it was recognised that the existing 'log' did not sufficiently enable staff to be prompted to capture all relevant information, and needed improving in a number of areas. So, new documentation has now been created, in the form of a new 'Record of patient leaving ward' document, a copy of which I attach. This will be introduced on the Trust's wards from 1 July, with local training being provided to staff to ensure the importance of its consistent use is fully understood. As with any new documentation there will then be a review of the new documentation's efficacy; this will be done in 3 months' time and the findings reported through the Trust's Acute Care Forum.” Source location Response from Sussex Partnership Foundation Trust
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27 Feb 2023 Sharon Elizabeth Langley · Prevention of Future Deaths report Essex
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Concerns raised 1
Inaccurate and outdated risk information in ward records View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sharon Elizabeth Langley · Prevention of Future Deaths report
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Report summary
Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.
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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 Inaccurate and outdated risk information in ward records
Wider context from the report “(8) Quality of record keeping was not deemed to be appropriate by senior staff during evidence:
a. Significant examples of cut and paste including out-of-date risk information at all grades of ward staff , and
b. omissions in multi-disciplinary decision-making and risk of self-harm with no rationale for the level of observations set for the patient and a plan for how risks should be managed
” Source location Sharon Elizabeth Langley · 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 Audit inpatient and urgent-care record keeping, identify copying-and-pasting issues, and agree follow-up actions for affected care groups.
Verbatim wording from the response “- A recent Trust-wide inpatient and urgent care pathway audit for record keeping was finalised in April 2023. Questions related to copy and pasting within records was included in the audit and this was broken down into care groups. Care groups identified to have an issue with the copying and pasting in records are in the process of the agreeing next steps. For mental health inpatient areas, they are reviewing assurance processes such as Matron’s Assurance audit which will feature some questions regarding copying and pasting.” Source location Response from Essex Partnership University 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 Conduct local clinical-record spot checks and daily-huddle and supervision reviews to identify and address inappropriate copying and pasting.
Verbatim wording from the response “- In the meantime, local assurance to capture incidents of copying and pasting have been embedded. The Ward Manager and Matron completed spot checks of clinical records, and discuss at the daily huddles involving Ward Managers, Matron and Service Manager will identify incidents of copy and paste within the previous 24 hours of documentation so this can be addressed with individual staff members where required. In addition, clinical documentation is reviewed in individual staff supervision” Source location Response from Essex Partnership University 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 Disseminate record-keeping guidance through an animated video, live learning event and Safety Learning Alert, with managers completing resulting actions.
Verbatim wording from the response “- Across the wider organisation, EPUT’s Lessons Team produced a short animated video with record keeping tips included, and this was cascaded across the organisation on 25th January 2023. On 1st February, the Lessons Team hosted a live learning event entitled “Learning Matters: Your Monthly Insight”. The topic of discussion focused on record keeping, themes of good practice and also the legalities around medical records.” Source location Response from Essex Partnership University NHS Foundation Trust
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9 Feb 2023 George Frederick Kearsey · Prevention of Future Deaths report East London
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Concerns raised 1
Poor maintenance of clinical records of fluid administration View source
This report raised 3 other concerns. 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. 5
BHRUT
Conduct and continue unannounced cross-site fluid-management audits on every COTE ward, monitoring Careflow Vitals recording and appropriate follow-up.
View source
BHRUT
Conduct peer fluid-monitoring audits between COTE wards and share results through governance meetings and daily huddles.
View source
BHRUT
Provide nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.
View source
BHRUT
Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.
View source
BHRUT
Carry out a clinical safety assessment to identify and mitigate hazards affecting entry or viewing of fluid-balance data.
View source See 2 more actions
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George Frederick Kearsey · Prevention of Future Deaths report
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Report summary
George Frederick Kearsey sustained injuries in a fall at home, was admitted to hospital, developed aspiration pneumonia, and died on the evening of 8 June 2022. Concerns included inconsistent administration of IV fluids, missing fluid balance charts, poorly maintained clinical records, and inadequate review of fluid monitoring during consultant-led ward rounds.
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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 maintenance of clinical records of fluid administration
Wider context from the report “3. Clinical records were poorly maintained , resulting in an unclear picture of fluid administration .
” Source location George Frederick Kearsey · 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 Conduct and continue unannounced cross-site fluid-management audits on every COTE ward, monitoring Careflow Vitals recording and appropriate follow-up.
Verbatim wording from the response “• Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by senior nursing teams (Matrons, Ward Managers, Practice Development Nurses).” Source location Response from Barking, Havering and Redbridge University Hospitals
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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 Conduct peer fluid-monitoring audits between COTE wards and share results through governance meetings and daily huddles.
Verbatim wording from the response “• Peer audits are being undertaken - The first phase of the audits has been completed. The nursing staff on all wards have been informed of the expectation for fluid monitoring and recording this on Careflow Vitals. We have also introduced peer audits where ward teams will conduct random audits on other COTE wards for the next 6 months. The format of these audits will mirror those conducted by the wards. The feedback from these audits will be shared with the matron and ward manager of that area and relevant action taken, if required. An example is if a patient is on fluid restriction and their fluid intake has not been recorded on careflow vitals. This can have an adverse effect on the patient’s treatment. The ward manager will discuss the importance of fluid management and monitoring with staff.” Source location Response from Barking, Havering and Redbridge University Hospitals
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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 nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.
Verbatim wording from the response “• Nursing staff have received additional training on Careflow vitals to reinforce the importance of staff compliance with the Trust policy on the completion of fluid monitoring. In addition, nursing staff have had 1:1 sessions with matrons and practice development nurses. Since the implementation of the audits, an improvement has been noted in fluid balance monitoring. For example, on 15 February 2023, Clementine A only scored 70% compliance. The gaps were discussed and addressed immediately with the nursing teams. This improved the compliance on Clementine A, with audits now showing 100% compliance.” Source location Response from Barking, Havering and Redbridge University Hospitals
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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 Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.
Verbatim wording from the response “• We identified that some medical staff were not familiar with using Careflow Vitals to access patients’ fluid balance. Face to face training, by the Careflow team has now been provided for all medical staff, to ensure they are all aware of how to access the fluid balance on Careflow Vitals. Medical staff were all made aware that paper fluid charts will not be completed in the future.” Source location Response from Barking, Havering and Redbridge University Hospitals
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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 Carry out a clinical safety assessment to identify and mitigate hazards affecting entry or viewing of fluid-balance data.
Verbatim wording from the response “In addition to the above a Clinical Safety Assessment is to be carried out by the end of April 2023. The purpose of the assessment is to identify any hazards, risks or issues to mitigate any issues of not being able to enter data or view fluid balance records. Thirteen staff completed the clinical safety (CS) officer training on the 29th /30th March. The CS role is in the recruitment process and will be interviewed for on the 18th April 2023.” Source location Response from Barking, Havering and Redbridge University Hospitals
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25 Jan 2023 Andrew Mark Largin · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to document hot debriefs in notes or medical records View source Failure to record reasons for crisis-team pathway decisions 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
Andrew Mark Largin · 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
Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.
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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 document hot debriefs in notes or medical records
Wider context from the report “6. It is believed, I was told, that there was a hot de-brief after Mr Largin’s death. However, no notes were made of that and no entry was made on Mr Largin’s medical record .
” Source location Andrew Mark Largin · Prevention of Future Deaths report
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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 reasons for crisis-team pathway decisions
Wider context from the report “3. However, the SI report did not identify that the crisis team member who made the decision on 2 February simply to advise that Mr Largin should be dealt with by the neighbourhood team failed to record any reasons for her decision .
” Source location Andrew Mark Largin · Prevention of Future Deaths report
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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 Review how learning from incidents is investigated and recorded through implementation of the Patient Safety Incident Response Framework.
Verbatim wording from the response “5. HOT DE-BRIEF RECORD” Source location Response from East London NHS Foundation Trust
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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 Hot debriefs are not recorded in clinical notes because they are informal staff-support processes; learning is captured through 48-hour and serious incident reports.
Verbatim wording from the response “Following serious incidents such as violence, aggression or death, clinical teams at the Trust hold a debrief as soon after the incident as is practicable. The debrief is usually facilitated by the manager or the team psychologist to explore thoughts and feelings around the incident, the impact on staff, the service user and the team. These incidents are not documented in the clinical notes as it is focused on initial staff reactions and is not a formal process to look at lessons learned.” Source location Response from East London NHS Foundation Trust
Open published response
Concerns raised 1
Poor completion of nursing care plan documentation View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Portsmouth Hospitals University NHS 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. 6
Portsmouth Hospitals University NHS Trust
Audit completion and updating of clinical documentation.
View source
Portsmouth Hospitals University NHS Trust
Update documentation systems to improve clinical record completeness and accessibility.
View source
Portsmouth Hospitals University NHS Trust
Deliver documentation education through the reviewed preceptorship programme for newly registered nurses and healthcare support workers.
View source
Portsmouth Hospitals University NHS Trust
Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
View source
Portsmouth Hospitals University NHS Trust
Continue ward accreditation assessments, including care-plan and patient-record reviews, feedback, action planning and governance reporting.
View source
Portsmouth Hospitals University NHS Trust
Complete the decision-making process on adopting electronic clinical-note forms to improve completion of mandated fields.
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Anthony David Blower · 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
Anthony David Blower died at home on 25 October 2020 after sustaining multiple falls, bilateral subdural haematoma and further bleeding following hospital admission and surgery. The concerns identified included nursing care-plan risk assessments not being updated, poor documentation, and inadequate oversight of hydration, with Mr Blower becoming seriously dehydrated during his admission.
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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 completion of nursing care plan documentation
Wider context from the report “1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower’s arrival on the ward, had been updated during his stay. I heard evidence that there are changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments. The multi factorial falls risk assessment had not been fully updated after an in-patient fall by Mr Blower.
The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes.
I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that records with documentation remained poor . The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority .
” Source location Anthony David Blower · Prevention of Future Deaths report
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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 Audit completion and updating of clinical documentation.
Verbatim wording from the response “Good documentation is vital to the provision of good quality clinical care as you acknowledge above, and as is explained in the letter of 20th December 2022, (attached) the Trust does audit documentation and is in the process of updating its systems.” Source location Response from Portsmouth Hospitals University (2)
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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 Update documentation systems to improve clinical record completeness and accessibility.
Verbatim wording from the response “Good documentation is vital to the provision of good quality clinical care as you acknowledge above, and as is explained in the letter of 20th December 2022, (attached) the Trust does audit documentation and is in the process of updating its systems.” Source location Response from Portsmouth Hospitals University (2)
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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 Deliver documentation education through the reviewed preceptorship programme for newly registered nurses and healthcare support workers.
Verbatim wording from the response “With regard to nursing staff, the trust has recently reviewed its preceptorship programme for all newly registered nursing staff and for the new HCSW workforce. This includes a comprehensive overview of documentation as part of a fundamentals of care education package.” Source location Response from Portsmouth Hospitals University (2)
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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 Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Verbatim wording from the response “The current hybrid between paper and electronic records on the wards creates greater complexity and inefficiency for our staff in terms of recording information. It also leads to there being a more fragmented overall record which makes it harder for members of the multidisciplinary team to be aware of all the information that has been recorded for any given patient. The ambition of PHU and similar NHS Trusts who have not already done so, is to move to a true paper free Electronic Patient Record (EPR). We are working with the Integrated Care Board (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time.” Source location Response from Portsmouth Hospitals University (2)
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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 Continue ward accreditation assessments, including care-plan and patient-record reviews, feedback, action planning and governance reporting.
Verbatim wording from the response “The trust is in a transitional period with many of our systems moving over to digital formats. This hybrid system makes auditing more challenging in the short term, but I would like to provide you with assurance that auditing does continue, in a variety of ways.” Source location Response from Portsmouth Hospitals University
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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 Complete the decision-making process on adopting electronic clinical-note forms to improve completion of mandated fields.
Verbatim wording from the response “iii) As you may be aware, the trust is currently transitioning towards an electronic solution for clinical notes (digital forms) which will enable an improvement in the completion of key mandated fields. This will be about 3-6 months in the decision-” Source location Response from Portsmouth Hospitals University
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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 Existing ward accreditation and clinical audit processes are considered sufficient to address nursing documentation and care-plan completion concerns.
Verbatim wording from the response “The trust is in a transitional period with many of our systems moving over to digital formats. This hybrid system makes auditing more challenging in the short term, but I would like to provide you with assurance that auditing does continue, in a variety of ways.” Source location Response from Portsmouth Hospitals University
Open published response
15 Nov 2022 Frederick Robert Peter King · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Failure to maintain complete records of fluid provision and pad status 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
Frederick Robert Peter King · 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
Frederick Robert Peter King was a resident at Birchwood Care Home and died in hospital on 9 September 2021 from an acute kidney injury caused by dehydration, with frailty and vascular dementia contributing to his death. The concerns included inadequate fluid provision, incomplete care records, and the absence of a care-home manager on the ground in the three days before his death.
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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 maintain complete records of fluid provision and pad status
Wider context from the report “(2) Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete for example in terms of what recording timings of fluid provision, whether pads were wet/dry and also family concerns regarding health were not recorded and conveyed.
” Source location Frederick Robert Peter King · Prevention of Future Deaths report
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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 The provider has taken sufficient action to mitigate risks and prevent future deaths.
Verbatim wording from the response “We sent an urgent letter to the provider West Berkshire Council to confirm CQC had received the regulation 28 report and asked them to set out in writing evidence of the actions they had taken to date following this death and any additional action they intended to take in response to the prevention of future death report. We received a detailed response from the provider. We are satisfied the provider has taken sufficient action according to section 6 of the regulation 28 report to mitigate risks to people and prevent future deaths.” Source location Response from Care Quality Commission
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4 Nov 2022 Peter Mantador Ross · Prevention of Future Deaths report East London
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Concerns raised 2
Poor maintenance of clinical records View source Failure to record identified CT Spine abnormalities View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Peter Mantador Ross · 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 Mantador Ross sustained a subdural haemorrhage and cervical spine fracture after falling down stairs at home on 8 July 2020. The spinal fracture was misinterpreted and remained undiagnosed; later failures to maintain immobilisation and delays in MRI contributed to cardiac arrest and severe neurological injury. He subsequently developed pneumonia following an aspiration episode, and the inquest found that neglect contributed to his death. Concerns also included failures to review and communicate CT findings and poor clinical record-keeping.
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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 maintenance of clinical records
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained , exacerbating the lapses in communication between those treating Mr Ross.
” Source location Peter Mantador Ross · 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 record identified CT Spine abnormalities
Wider context from the report “1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
1. A CT C-spine requested on the admission on 8 July 2020 was misreported as normal.
2. Following that report, during the initial referral of Mr Ross to neurosurgery, the reviewing surgeon noticed an abnormality in Mr Ross’s CT Spine, made no note of his finding and did not escalate his finding to any other clinician.
3. Prior to burr-hole surgery, the neurosurgical team did not review the CT C spine images.
4. Repeated failures in communication between; neurosurgical, emergency medicine, nursing staff, and physiotherapists led to serious harm to Mr Ross.
5. Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr Ross.
” Source location Peter Mantador Ross · Prevention of Future Deaths report
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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 Audit documentation on the trauma neurosurgical pathway and provide refresher and induction training on record keeping.
Verbatim wording from the response “5) The department recognise there were failures in the standard of medical record keeping for this case. The neurosurgical specialty has taken this very seriously and will undertake documentation audit on the trauma neurosurgical pathway. Routine refresher training will be made available as well as training during local induction for new staff. This includes” Source location Response from Barking, Havering and Redbridge University Hospitals
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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 an electronic patient record system to improve access to records, communication, decision-making and patient planning.
Verbatim wording from the response “orientation of our records system. The Trust is currently in the process of implementing electronic patient record system. The purpose of the new system is to provide clinicians with an easier to access tool to aid good communication, decision making and clear patient planning.” Source location Response from Barking, Havering and Redbridge University Hospitals
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13 Sep 2022 Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report Worcestershire
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Concerns raised 2
Failure to improve record keeping and record retention View source Failure to complete nursing records of residents’ medical conditions View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.
Read the report on judiciary.uk
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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 improve record keeping and record retention
Wider context from the report “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff.
” Source location Mr Peter Antony Joseph Pearson · 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 complete nursing records of residents’ medical conditions
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day . Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.
” Source location Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.