7 Sep 2022 Demet AKCICEK · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to produce clear and sufficient clinical notes 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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Demet AKCICEK · 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
Demet Akcicek was found dead in bed beside her sleeping seven-year-old son on the morning of 27 May 2022. The inquest determined that she died after taking an excess of prescribed and online-obtained medication, and that she did not intend to take her life. Concerns included a failure by a mental health service worker to arrange follow-up after a welfare call, and an insufficiently clear record of that call.
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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 produce clear and sufficient clinical notes
Wider context from the report “When the duty worker from Islington complex depression, anxiety and trauma (CDAT) service rang Ms Akcicek for a welfare check on 25 November 2021, Ms Akcicek reported feeling “quite bad” and that she wanted to cry. She explained that she had difficulty performing everyday activities such as cooking and taking her child to school. She said that two nights earlier, her son reported that she had woken chanting, “I don’t want to die, I don’t want to die”.
The duty worker (a registered mental health nurse) formed the view that Ms Akcicek needed to be seen by the service, but failed to put her name on the board, and so she was not discussed at the multi disciplinary team meeting and no follow up was arranged. In addition, the duty worker accepted in court that her note of the conversation was insufficient . I found the note difficult to understand and the duty worker was not able fully to explain its meaning .
The duty worker told me that she will not make such mistakes again. However, I did not hear evidence of what steps, if any, Camden & Islington Trust has taken to avoid such a situation arising in future.
” Source location Demet AKCICEK · 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 Remind staff of clinical record-keeping requirements and monitor compliance through supervision and record-keeping audits.
Verbatim wording from the response “In regard to record keeping, the team has been reminded that in accordance with both Trust policy and professional obligations, clinical records should be full, accurate and entered in a timely manner. This will continue to be monitored through individual staff supervision and record keeping audits.” Source location Response from Camden and Islington NHS Foundation Trust
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22 Aug 2022 Eliot HARRIS · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to fully record Multi Team Meetings and decision rationales in clinical records View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Eliot HARRIS · 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
Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.
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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 fully record Multi Team Meetings and decision rationales in clinical records
Wider context from the report “3) Multi Team Meetings were not fully and properly recorded in the clinical records . At the inquest, evidence was heard there “is still some way to go” with regard to improving record keeping and for ensuring important matters such as rationale for decisions is fully recorded
” Source location Eliot HARRIS · 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 Improve MDT record completeness using a meeting aide memoire and recorded daily brief reviews of patients.
Verbatim wording from the response “Comprehensive recording of the Multi-Disciplinary Team (MDT) meeting is essential as this supports high quality effective care. Record keeping is an essential action to support the evidence of care provided. The ward has developed an aide memoire to guide staff as to the areas to be considered as part of the MDT review. This serves as a Terms of Reference for the meeting in order to improve the comprehensiveness of record keeping. In addition, the MDT hold a daily brief review of each patient which is recorded in the patient’s records. An audit of the quality of MDT meetings was completed in August by the Nurse Consultant which demonstrated on sustained improvement. An anonymised copy of the audit is attached. The changes are being monitored on a monthly basis with results fed back to the team by the Nurse Consultant.” Source location Response form Norfolk and Suffolk 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 Monitor MDT meeting quality monthly and provide results and feedback to the ward team.
Verbatim wording from the response “Comprehensive recording of the Multi-Disciplinary Team (MDT) meeting is essential as this supports high quality effective care. Record keeping is an essential action to support the evidence of care provided. The ward has developed an aide memoire to guide staff as to the areas to be considered as part of the MDT review. This serves as a Terms of Reference for the meeting in order to improve the comprehensiveness of record keeping. In addition, the MDT hold a daily brief review of each patient which is recorded in the patient’s records. An audit of the quality of MDT meetings was completed in August by the Nurse Consultant which demonstrated on sustained improvement. An anonymised copy of the audit is attached. The changes are being monitored on a monthly basis with results fed back to the team by the Nurse Consultant.” Source location Response form Norfolk and Suffolk Foundation Trust
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3 Aug 2022 Alison June Dallow · Prevention of Future Deaths report Herefordshire
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Concerns raised 1
Failure to record information given to patients View source
This report raised 2 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
Alison June Dallow · 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
Alison June Dallow died from a pulmonary thromboembolism due to deep vein thrombosis after a fractured left tibial plateau and reduced mobility associated with the fracture and a knee brace. The concerns included unclear advice about weight-bearing, unclear hospital policy on reducing venous thromboembolism risk for outpatients, and unavailable evidence of information given to the patient.
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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 information given to patients
Wider context from the report “(3) Evidence of any information given to the patient was unavailable at the Inquest.
” Source location Alison June Dallow · Prevention of Future Deaths report
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7 Jul 2022 Seema Pravin HARIBHAI · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to record relevant clinical history and symptoms View source
This report raised 11 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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Seema Pravin HARIBHAI · 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
Seema Haribhai, who had increasingly disabling psoriatic arthritis, took herbal remedies prescribed by an Ayurvedic practitioner and developed liver failure, dying some weeks later. The investigation determined that she died as a consequence of the administration of Ayurvedic medicines intended to treat psoriatic arthritis. Concerns included the practitioner’s failure to recognise the possible harm from the medicines or advise their immediate cessation, the lack of regulation and evidence of quality control, and shortcomings in the GP’s assessment and response to her symptoms and abnormal blood test.
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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 relevant clinical history and symptoms
Wider context from the report “However, the GP did not record the detail of the history, he did not record exactly when the yellow discolouration first appeared, and he did not record the absence of any other signs and symptoms . He did not ask for attendance at the surgery so that he could perform a physical examination. He did not advise immediate cessation of the Ayurvedic medicines.
” Source location Seema Pravin HARIBHAI · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to record skin integrity or breakdown in daily care records View source
This report raised 10 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
Joan RICHARDSON · 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
Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.
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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 skin integrity or breakdown in daily care records
Wider context from the report “(brief summary of matters of concern)
Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;-
1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc.
2. When Joan complained of pain -the matter was not escalated as it should have been.
3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital.
4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment.
5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly.
6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required.
” Source location Joan RICHARDSON · Prevention of Future Deaths report
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1 Jul 2022 Shona Christine Michaela Campbell · Prevention of Future Deaths report Manchester City
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Concerns raised 2
Lack of appropriate contemporaneous clinical record keeping by support workers View source Lack of appropriate contemporaneous clinical record keeping by nurses 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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AI-generated summary
Shona Christine Michaela Campbell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.
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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 appropriate contemporaneous clinical record keeping by support workers
Wider context from the report “2. The lack of appropriate contemporaneous clinical record keeping by the Support Workers .
” Source location Shona Christine Michaela Campbell · 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 Lack of appropriate contemporaneous clinical record keeping by nurses
Wider context from the report “1. The lack of appropriate contemporaneous clinical record keeping by the nurse in charge as well as other nurses .
” Source location Shona Christine Michaela Campbell · Prevention of Future Deaths report
Open source report
Concerns raised 1
Limited documentation of wound management and pressure care View source
This report raised 2 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
Julie Elizabeth Nolan · 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 Elizabeth Nolan had underlying diabetes, hypertension, chronic kidney disease and peripheral vascular disease, and was admitted to a care home with existing pressure damage to her left foot. She later developed further pressure damage and acute osteomyelitis, deteriorated with breathing difficulties and low oxygen saturations, and died in hospital on 30 January 2022. Concerns included limited documentation of wound management and pressure care, uncertainty about whether care plans were followed, and the Manager and Registered Nurse being the designated nurse for two consecutive days.
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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 Limited documentation of wound management and pressure care
Wider context from the report “1. The deceased was a resident in Astor Lodge Care Home. I am concerned there was limited documentation of wound management and pressure care and it is unclear the extent to which wound management and repositioning was provided in line with the care plans.
” Source location Julie Elizabeth Nolan · Prevention of Future Deaths report
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25 Apr 2022 Kathryn Lynda Millard · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2
Failure to record clinical attendance and patient assessment in the medical records View source Failure to document senior clinician treatment directions in the medical records View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Medway 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
Medway NHS Foundation Trust
Remind medical doctors of required healthcare record-keeping standards.
View source
Medway NHS Foundation Trust
Audit adherence to national and Trust record-keeping standards monthly and share results through local and divisional governance boards.
View source
Medway NHS Foundation Trust
Remind all staff to record every patient contact in the medical record in line with national and Trust guidelines.
View source
Medway NHS Foundation Trust
Conduct an annual Trust-wide audit of healthcare record keeping, including compliance with relevant Trust policy.
View source
Medway NHS Foundation Trust
Roll out documentation standards within the Ward to Board Assurance and Accreditation Process.
View source
Medway NHS Foundation Trust
Report record-keeping audit results through the Trust’s quality governance structures, including outcomes and exceptions.
View source
Medway NHS Foundation Trust
Undertake ongoing regular record-keeping audits through the Trust Gather reporting system and use findings to inform local audit programmes.
View source
Medway NHS Foundation Trust
Discuss the Serious Incident Investigation findings at the junior doctor grand round.
View source See 5 more actions
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Kathryn Lynda Millard · 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
Kathryn Lynda Millard fell down stairs at a property where she was working on 10 May 2021 and was admitted to hospital with a fractured spine. She later developed green vomit, suffered a cardiac arrest on 13 May 2021, and could not be resuscitated; the jury recorded pulmonary embolism and deep venous thrombosis as the medical cause of death. Concerns included failure to document and implement a senior clinician’s direction, lack of awareness among nursing staff about anti-embolic stockings, and inadequate recording and communication following a review of her deteriorating presentation.
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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 clinical attendance and patient assessment in the medical records
Wider context from the report “(3) The nursing staff were concerned on the 12 May 2021 as to the presentation and prognosis of the deceased. Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs Millard’s medical records . It is concerning that the Trust were not able to identify this individual and that they did not discuss the patient’s presentation and prognosis with the nursing staff.
” Source location Kathryn Lynda Millard · 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 document senior clinician treatment directions in the medical records
Wider context from the report “(1) The direction of the most senior clinician, the orthopaedic surgeon, was not documented in the medical records and was not implemented. It is concerning that this treatment plan was not recorded properly in the deceased’s notes .
” Source location Kathryn Lynda Millard · 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 Remind medical doctors of required healthcare record-keeping standards.
Verbatim wording from the response “Medical doctors have been reminded of the importance and principles of effective healthcare record keeping, which is a minimum standard. The quality of records should meet the Generic Record Keeping Standard, General Medical Record keeping Standards (Royal Academy of Physicians) and Standards for the structure and content of patient records (Academy of Medical Royal Colleges).” Source location Response from Medway 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 Audit adherence to national and Trust record-keeping standards monthly and share results through local and divisional governance boards.
Verbatim wording from the response “The adherence to national and Trust standards will be audited on a monthly basis and the results of the audit will be shared at local and divisional governance board meetings to ensure compliance and improvement in practice.” Source location Response from Medway 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 Remind all staff to record every patient contact in the medical record in line with national and Trust guidelines.
Verbatim wording from the response “As you highlighted, the Trust was unable to ascertain if Mrs Millard was indeed assessed by a clinician on 12 May 2021 when her condition deteriorated as there is no record of this care taken place. This does not meet the standards we would expect and all staff have been reminded that all patient contacts are to be recorded in the patient medical record in line with national and Trust guidelines.” Source location Response from Medway 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 Conduct an annual Trust-wide audit of healthcare record keeping, including compliance with relevant Trust policy.
Verbatim wording from the response “An audit of healthcare record keeping (including compliance with relevant Trust policy) will take place on an annual basis Trust wide. In addition, compliance with the expected documentation standards are included in the Ward to Board Assurance and Accreditation Process, which will be rolling out from 27 June 2022.” Source location Response from Medway 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 Roll out documentation standards within the Ward to Board Assurance and Accreditation Process.
Verbatim wording from the response “An audit of healthcare record keeping (including compliance with relevant Trust policy) will take place on an annual basis Trust wide. In addition, compliance with the expected documentation standards are included in the Ward to Board Assurance and Accreditation Process, which will be rolling out from 27 June 2022.” Source location Response from Medway 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 Report record-keeping audit results through the Trust’s quality governance structures, including outcomes and exceptions.
Verbatim wording from the response “The results of such audits will be reported via the Trust’s Governance structures for Quality, including outcomes and exceptions. In addition, ongoing regular audits will be undertaken using the Trust ‘Gather’ reporting system by Care Groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.” Source location Response from Medway 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 Undertake ongoing regular record-keeping audits through the Trust Gather reporting system and use findings to inform local audit programmes.
Verbatim wording from the response “The results of such audits will be reported via the Trust’s Governance structures for Quality, including outcomes and exceptions. In addition, ongoing regular audits will be undertaken using the Trust ‘Gather’ reporting system by Care Groups to ensure that ongoing record keeping is of the required quality. This will help to inform local audit programmes and to measure the impact of actions taken, supporting improvement activity.” Source location Response from Medway 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 Discuss the Serious Incident Investigation findings at the junior doctor grand round.
Verbatim wording from the response “In relation to the concern of poor record keeping by the medical doctor, the Orthopaedic team have discussed the outcome of the Serious Incident Investigation report at the junior doctor’s grand round.” Source location Response from Medway NHS Foundation Trust
Open published response
22 Apr 2022 Matthew Alexander CASEBY · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Inaccuracies in clinical records View source
This report raised 6 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
Priory Group
Issue and disseminate bulletins requiring accurate records and comprehensive, consistent shift handovers.
View source
Priory Group
Update monthly Quality Walk Round assessments to check consistency between patient records and handover notes.
View source
Priory Group
Review and reissue Policy H62 Healthcare Records, prohibiting copying and pasting between patient records.
View source
Priory Group
Continue compliance reviews of CareNotes records for accuracy during inspections.
View source
Priory Group
Update documentation Quality Walk Round checks to identify inaccurate records and copying between patient records.
View source See 2 more actions
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AI-generated summary
Matthew Alexander CASEBY · 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
Matthew Caseby was detained under the Mental Health Act after being found on railway lines and in a school playground, and was transferred to the Priory Hospital in Birmingham. He absconded from the hospital courtyard on 7 September 2020 after being left unattended, and was fatally injured after stepping in front of a train on 8 September 2020. The principal concerns included inadequate recording and communication of absconding risks, failure to update risk assessments, lack of a courtyard observation policy and risk assessment, and inadequate courtyard safety.
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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 Inaccuracies in clinical records
Wider context from the report “2. Record Keeping quality: There were numerous inaccuracies in Matthew’s medical records , eg his status was written as informal when he was formal, he was described as violent when he was not and was described as "she". Staff were unable to explain how that occurred. The investigation witness from the Priory thought there was an element of cutting and pasting into the records from another patient’s records. I have serious concerns about the accuracy of the clinical record at the Priory for what are some of the most vulnerable patients.
” Source location Matthew Alexander CASEBY · 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 Issue and disseminate bulletins requiring accurate records and comprehensive, consistent shift handovers.
Verbatim wording from the response “Communications to staff: During May 2022 two bulletins were issued to all colleagues in the Healthcare Division via the Priory intranet. The first bulletin, issued as part of the monthly Safety First initiative, emphasised the importance of accurate and detailed record keeping. The second bulletin detailed the importance of conducting thorough and comprehensive shift handovers. The bulletins each emphasise that the content of the daily care record must correspond with the content of the handover record. The bulletins have been discussed at Woodbourne governance meetings and in staff supervision.” Source location Response from Priory Group
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 Update monthly Quality Walk Round assessments to check consistency between patient records and handover notes.
Verbatim wording from the response “• The monthly Quality Walk Round template has been updated so that patient records and handover notes will be assessed for consistency. A Quality Walk Round involves a senior member of the hospital team scrutinising particular areas of ward practice using sampling methodology.” Source location Response from Priory Group
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 Review and reissue Policy H62 Healthcare Records, prohibiting copying and pasting between patient records.
Verbatim wording from the response “Changes to Policy: Policy H62 Healthcare Records has been reviewed and re-issued. The policy also makes reference to the fact that “cutting and pasting” between patient records is not acceptable.” Source location Response from Priory Group
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 Continue compliance reviews of CareNotes records for accuracy during inspections.
Verbatim wording from the response “Monitoring: The following checks are being undertaken to ensure that records are accurate:” Source location Response from Priory Group
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 Update documentation Quality Walk Round checks to identify inaccurate records and copying between patient records.
Verbatim wording from the response “• The monthly documentation Quality Walk Round template has been updated and includes a requirement for accuracy checks to be carried out on CareNotes records (including ensuring there is no “cutting and pasting” between patient records).” Source location Response from Priory Group
Open published response
19 Apr 2022 Name not published · Prevention of Future Deaths report Manchester City
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Concerns raised 1
Inadequate or incomplete clinical record keeping View source
This report raised 5 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
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The deceased had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.
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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 Inadequate or incomplete clinical record keeping
Wider context from the report “1. The repeated instances of inadequate or incomplete necessary clink clinical record keeping .
” Source location Name not published · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.