25 Oct 2021 Alan Harry Hunter · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Poor documentation of diet and weight monitoring 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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Alan Harry Hunter · 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
Alan Harry Hunter was admitted to hospital after a fall, with a urinary tract infection, confusion and delirium. He experienced incorrectly calculated BMI and MUST scores, rapid weight loss, increasing frailty, Covid-19 and a further urinary tract infection before dying at Fernlea Care Home; concerns focused on poor documentation and inadequate monitoring of his diet, weight and nutritional risk.
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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 documentation of diet and weight monitoring
Wider context from the report “The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight . The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers.
” Source location Alan Harry Hunter · 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 Develop and cascade a standardised nutrition and MUST briefing covering malnutrition, assessments, food charts and protected mealtimes.
Verbatim wording from the response “A seven minute briefing document has been developed related to nutrition and MUST assessment and cascaded to teams. The seven minute briefing format is a standardised method of communication used at Stockport NHS Trust to provide teams with key information to improve patient and staff safety. The Nutrition and MUST seven minute briefing provides an overview of malnutrition, MUST assessments and the use of food charts, and the importance of protected mealtimes.” Source location Response from NHS Stockport
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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 ward-based toolbox training on MUST, fluid balance, food charts and specialist referrals.
Verbatim wording from the response “Within the investigation report a robust action plan has been provided that gives additional updates on the continuation of improvements across the Trust. This includes the identification of Nutrition and Hydration Champions across wards, tool box training sessions provided across ward areas between July and October 2021 covering MUST, fluid balance, food charts and specialist referrals and the development of Nutrition and Hydration Information Boards in ward areas.” Source location Response from NHS Stockport
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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 twice-weekly Matron quality assurance checks of nutrition assessments, fluid-balance charts and documentation standards.
Verbatim wording from the response “The action plan also describes the audit processes now in place to ensure oversight of the MUST assessment and the completion of food charts. The Quality Assurance Checks completed by Matron twice weekly include a patient care section which looks at completion of nutrition assessment, that the assessment is up to date, and that fluid balance charts are up to date. The documentation section of the Quality Assurance Check audits that the MUST assessments are completed to the required standard and that standards of documentation are upheld, for example that all nursing entries are legible, signed, dated and timed. Alongside regular audit, daily safety huddles with the matron and ward managers take place to review any concerns in regard to patients. This holistic review includes a review of any nutrition and hydration concerns.” Source location Response from NHS Stockport
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23 Oct 2021 Margaret Kinsey · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of a standard approach for documenting and signing off supervisory clinical discussions View source
This report raised 3 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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Margaret Kinsey · 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
Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.
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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 a standard approach for documenting and signing off supervisory clinical discussions
Wider context from the report “3. The inquest heard that there was no standard approach as to how the details of information shared/discussions between clinicians should be detailed or signed off in the notes when one clinician was acting in a supervisory capacity . Given the regular movement of junior doctors across the NHS this meant documentation quality was inconsistent .
” Source location Margaret Kinsey · Prevention of Future Deaths report
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20 Oct 2021 Freeda GLAUSIUSZ · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to record crisis-line calls in the medical record 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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Freeda GLAUSIUSZ · 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
Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.
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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 crisis-line calls in the medical record
Wider context from the report “1. I was shocked when I listened to the recording of the call that █
████████ made to the crisis line the day before his daughter died.
The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis.
In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled.
The clinician then made no note of the call in the medical records, even retrospectively.
I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts.
• This is not the first time that I have made a PFD report to ELFT about its crisis line.
• Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record . He said that he had made a note on a piece of paper, but he did not now have that piece of paper.
• When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance.
” Source location Freeda GLAUSIUSZ · 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 Provide medical-records training for senior nurses and Trust managers on record keeping, observations and retrospective entries.
Verbatim wording from the response “To address this matter, medical records training for all senior nurses was provided on 24 November 2021 to all senior nurses and managers at the Trust. The focus of the training was good record keeping, observations and retrospective record keeping.” Source location Response from East London NHS Foundation Trust
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16 Sep 2021 Eldine Loretta Lashley · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to accurately record the frequency of checks in progress notes View source
This report raised 1 other concern. 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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Eldine Loretta Lashley · 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
Eldine Loretta Lashley suffered an unwitnessed fall at a care home on 6 April 2021, sustaining a subdural haemorrhage, and died at home on 14 April 2021 despite medical intervention. Concerns were raised that her mobility care plan was not updated to reflect increased monitoring needs and that progress notes did not accurately record the frequency of checks carried out.
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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 accurately record the frequency of checks in progress notes
Wider context from the report “1. Mrs Lashley's mobility care plan was not updated in response to developments in her care needs – specifically she need to observe her more frequently than once per hour.
2. Progress notes created by nursing and care staff did not accurately reflect the frequency of checks carried out on Mrs Lashley.
” Source location Eldine Loretta Lashley · Prevention of Future Deaths report
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23 Aug 2021 Norma Rushworth · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of written documentation to cover communication challenges affecting community care View source
This report raised 4 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
Norma Rushworth · 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
Norma Rushworth underwent surgery for diverticulitis and was later readmitted for emergency surgery after developing an abdominal dehiscence associated with an unidentified wound infection. She deteriorated after developing a chest infection and suffering a cardiac arrest, and died at Tameside General Hospital on 10 October 2020. Concerns included limited support and monitoring after discharge, unclear communication with community health professionals and family, and delayed recognition of her deterioration in the community, with pandemic restrictions contributing to communication 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 of written documentation to cover communication challenges affecting community care
Wider context from the report “2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused . Her deteriorating health in the community was not as a result recognised at an early stage.
” Source location Norma Rushworth · Prevention of Future Deaths report
Open source report
22 Jul 2021 John Dickinson · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 2
Inconsistent and insufficiently detailed recording of general wellbeing View source Lack of a single document providing a holistic view of the person View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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John Dickinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.
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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 Inconsistent and insufficiently detailed recording of general wellbeing
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing .
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Source location John Dickinson · 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 Lack of a single document providing a holistic view of the person
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained .
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Source location John Dickinson · Prevention of Future Deaths report
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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 A formal investigation was not commenced because the apparent recording failures were individual and likely concerned people outside enforcement powers.
Verbatim wording from the response “In line with CQC’s regulatory responsibilities, we continue to monitor statutory notifications and enquiries related with this service. Having considered the evidence and information available in this case, we have made the decision not to commence a formal Registered Provider investigation into Mr Dickinson’s death. Whilst we acknowledge there were some apparent failures in the recording of care,” Source location 2021-0310-Response-from-CQC_Published
Open published response
20 Jul 2021 Ben Buster KING · Prevention of Future Deaths report Norfolk
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Concerns raised 2
Failure to record pertinent medication history on discharge documentation View source Failure of staff to complete important care records View source
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
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Ben Buster 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
Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.
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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 pertinent medication history on discharge documentation
Wider context from the report “5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication.
” Source location Ben Buster KING · 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 of staff to complete important care records
Wider context from the report “3. Basic dietary advice and guidance provided was not followed by staff.
4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation
5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations
” Source location Ben Buster KING · 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 Develop and improve the Pandora information system through a staff user group.
Verbatim wording from the response “6. The MD and members of the GAT have access to every resident’s care file, we also have access to a whole range of information on each resident, all of which we can access remotely. The GAT carries out regular service reviews and unannounced inspections. Where there are deficiencies, the GAT will work with the Registered Manager to correct these deficiencies which may include report writing, care planning, risk assessments and healthy living plans. As an example, the GAT recently found inconsistencies in recording of information on Pandora, with some confusion as to record entries. This led to the establishment of a Pandora User Group, to work with homes to improve consistency of recording and content.” Source location 2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Open published response
11 Jul 2021 Johanna Marie MORELAND · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to record required observation levels in medical 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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Johanna Marie MORELAND · 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
Johanna Marie Moreland died on 8 March 2021 at Medway Maritime Hospital following intra-abdominal haemorrhage after a liver biopsy, in the context of advanced hepatocellular carcinoma. Concerns included delays in receiving lumbar puncture results and starting antiviral treatment, and failure to follow or record required observations after the biopsy due to miscommunication between Trust staff.
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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 required observation levels in medical records
Wider context from the report “(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records .
” Source location Johanna Marie MORELAND · 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 Develop a post-procedure handover form for use after every procedure.
Verbatim wording from the response “This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.” Source location 2021-0240-Response-from-Medway-Maritime-Hospital_Published
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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 written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.
Verbatim wording from the response “This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.” Source location 2021-0240-Response-from-Medway-Maritime-Hospital_Published
Open published response
7 Jul 2021 Dorothy Seekings · Prevention of Future Deaths report Warwickshire
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Concerns raised 1
Failure to record resident aggression incidents in care plans View source
This report raised 2 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. 3
Crosscrown Limited
Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.
View source
Crosscrown Limited
Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.
View source
Crosscrown Limited
Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.
View source
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Dorothy Seekings · 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
Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.
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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 resident aggression incidents in care plans
Wider context from the report “(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████.
(2) the failure to raise a safeguarding alert with the local authority regarding the above incident.
(3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident
” Source location Dorothy Seekings · 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 Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.
Verbatim wording from the response “The two key changes are the acceleration of the implementation of a digital care management software system called CareDocs. This was being gradually introduced into the Homes run by Crosscrown during the Summer of 2019 but the events of August 8th accelerated the implementation of the new system and it is now in place in all Crosscrown Homes including Clifton Court and has been for some time. The digital CareDocs system allows Care Plans to be created that meet the specific requirements of individual service users and it allows the creation of a care plan reflective of the needs and preferences of the individual user.” Source location 2021-0230-Response-from-Crosscrown-Ltd_Published
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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 Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.
Verbatim wording from the response “The Operations Team has implemented an enhanced agenda for the fortnightly staff meetings that are held at Clifton Court to include inter alia infection control – Covid, health and safety and accurate and systematic recording of behavioral issues.” Source location 2021-0230-Response-from-Crosscrown-Ltd_Published
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 Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.
Verbatim wording from the response “Under the new scheme such behaviour is recorded on the CareDocs system which prompts the completion of an Antecedent Behaviour Consequences form on the CareDocs system. The Care Home Manager at Clifton Court checks on a daily basis for amongst other things any ABC charts which may have been completed by members of staff. Should any safeguarding issues be recorded then the Manager will contact Adult Social Services and complete that process. The Operations Team are copied into all emails in relation to any safeguarding issues. In the last eighteen months Clifton Court has made eight referrals to the Adult Social Services Team at Warwickshire County Council all of which were closed down without an action by the Council. The issue of safeguarding is also now part of the Monthly Managers Report and is analysed by the Operations Team and evaluated for any patterns or learning issues.” Source location 2021-0230-Response-from-Crosscrown-Ltd_Published
Open published response
2 Jul 2021 Mr Khairul Rahman · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of contemporaneous or accurate retrospective documentation of the timing of clinical interactions View source
This report raised 2 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. 4
Practice Plus Group
Work with NHSE/I and HMPPS to resolve mobile-connectivity challenges supporting SystmOne use on prison wings and during emergencies.
View source
Practice Plus Group
Reinforce contemporaneous record keeping through staff reminders, supervision, and regular documentation audits.
View source
Practice Plus Group
Update the record-keeping training package to cover accurate timing of retrospective SystmOne entries.
View source
Practice Plus Group
Share the updated record-keeping training package with HMP Pentonville staff by 30 September 2021.
View source See 1 more action
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AI-generated summary
Mr Khairul Rahman · 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 Khairul Rahman became unwell during a COVID-19 outbreak at HMP Pentonville, was later admitted to hospital, and died on 22 January 2021 from COVID-19. Concerns included inaccurate or non-contemporaneous documentation of clinical interactions, intervals between observations that did not align with the NEWS2 scoring system, reliance on prisoners to self-report deterioration, and the lack of a clear effective alternative system for monitoring in the prison healthcare setting.
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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 contemporaneous or accurate retrospective documentation of the timing of clinical interactions
Wider context from the report “1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions . I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered ;
2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern.
The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover.
Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting.
” Source location Mr Khairul Rahman · 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 Work with NHSE/I and HMPPS to resolve mobile-connectivity challenges supporting SystmOne use on prison wings and during emergencies.
Verbatim wording from the response “Although it is currently beyond Practice Plus Group’s control to ensure all clinical interactions are contemporaneously recorded on SystmOne, we are committed to continuing to work closely with NHSE/I and HMPPS, via the NHSE/I Digital Assurance Board, to resolve the challenges with mobile connectivity in order to support the use of SystmOne when working on the wings or responding to emergencies.” Source location 2021-0226-Response-from-Practice-Plus-Group_Published
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 Reinforce contemporaneous record keeping through staff reminders, supervision, and regular documentation audits.
Verbatim wording from the response “Practice Plus Group regularly remind all staff of the importance of contemporaneous record keeping in accordance with Documentation and Record Keeping Guidelines, Nursing and Midwifery Council (2018). This is shared through full staff meetings, management supervision and clinical supervision. In addition a documentation audit for both prescribing and non-prescribing clinicians is undertaken regularly as part of the HIJ Audit Schedule for Practice Plus Group. The quality of record keeping in this case was commented on within the external clinical review:” Source location 2021-0226-Response-from-Practice-Plus-Group_Published
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 the record-keeping training package to cover accurate timing of retrospective SystmOne entries.
Verbatim wording from the response “In addition to the above, Practice Plus Group has also recently updated a record keeping training package to be shared with all staff which includes the importance of correctly recording the time of any interaction within the SystmOne record when making retrospective entries. This will be made available to staff HMP Pentonville by 30th September 2021.” Source location 2021-0226-Response-from-Practice-Plus-Group_Published
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 the updated record-keeping training package with HMP Pentonville staff by 30 September 2021.
Verbatim wording from the response “In addition to the above, Practice Plus Group has also recently updated a record keeping training package to be shared with all staff which includes the importance of correctly recording the time of any interaction within the SystmOne record when making retrospective entries. This will be made available to staff HMP Pentonville by 30th September 2021.” Source location 2021-0226-Response-from-Practice-Plus-Group_Published
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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 Contemporaneous SystmOne recording cannot always be ensured because prison connectivity limitations prevent reliable use of portable devices.
Verbatim wording from the response “Unfortunately, as a result of the prison environment the contemporaneous recording of clinical interactions on the electronic patient record (SystmOne) is often not possible. The limitations of the prison estate, notably the lack of Wi-Fi within HMP Pentonville makes the use of portable devices linking directly to SystmOne very challenging.” Source location 2021-0226-Response-from-Practice-Plus-Group_Published
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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 Lack of contemporaneous SystmOne documentation does not necessarily hamper clinical response times because care and escalation can occur before retrospective entry.
Verbatim wording from the response “Practice Plus Group does not agree that response times to clinical care are hampered by the lack of contemporaneous documentation on SystmOne because treatment, escalation measures and/or referrals can be made prior to retrospective entry onto SystmOne. Indeed if a” Source location 2021-0226-Response-from-Practice-Plus-Group_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.