13 Mar 2025 Mr Paul Timothy Dunne · Prevention of Future Deaths report South London
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Concerns raised 1
Failure to complete required duplicate A&E clinical record entries by mental health staff View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Paul Timothy Dunne · 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 Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E 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 complete required duplicate A&E clinical record entries by mental health staff
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records. MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” Source location Mr Paul Timothy Dunne · 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 Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Verbatim wording from the response “1. We recognise the distress and concern these events have caused and acknowledge the importance of accountability where there are apparent shortfalls in professional conduct or decision-making. However, it is important to clarify that the Care Quality Commission’s regulatory remit, as established under the Health and Social Care Act (2008) and the associated Regulated Activities Regulations (2014), is focused on assessing and holding providers rather than individual staff accountable for meeting fundamental standards of care. While we do not have the authority to investigate or act against individual healthcare professionals, we expect providers to ensure that their staff are competent, appropriately trained, and supported to deliver safe and effective care.” Source location Response from Care Quality Commission
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3 Mar 2025 JAVED IQBAL · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to maintain accurate contemporaneous records of behaviour and mood View source
This report raised 7 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. 2
All Care in One
Provide supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.
View source
All Care in One
Revise internal safeguarding policies to clarify recognition, escalation and record-keeping for acute mental health issues.
View source
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AI-generated summary
JAVED IQBAL · 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
Javed died on 1 June 2024 after deliberately igniting his room with flammable liquid and sustaining major burn injuries and smoke inhalation, followed by multi-organ failure. The report identified concerns that staff did not recognise and appropriately act on serious acute mental health issues, including not escalating worsening mood and irrational behaviour to the GP in writing. It also identified the absence of a formal internal post-death investigation and outstanding internal training that had not addressed these concerns.
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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 accurate contemporaneous records of behaviour and mood
Wider context from the report “The evidence demonstrated there is a continuing risk that All Care In One Ltd staff will not recognise and take appropriate action when a service user presents with serious acute mental health issues. For example:
(1) At a fundamental level staff did not understand what is in the best interests of a service user:
(a) Carers did not want to embarrass Javed, therefore they felt justified in making repetitive inaccurate contemporaneous records recording behaviour and mood as well despite having serious concerns about his worsening mental health and triggering an urgent call to his GP; (b) Then, having contacted the GP two days before his death, the care co-ordinator did not action the request from the GP to send an email setting out these serious concerns in writing.
(2) There was no formal internal post-death investigation report.
(3) Whilst some post-death internal training has been identified it remains outstanding despite 8 months passing since the death. However, I was not satisfied this training has recognised the above concerns.
” Source location JAVED IQBAL · 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 supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.
Verbatim wording from the response “Action plan: Guidance and Development: We are Ensuring that carers and coordinators fully understand their duties, including acting in the best interests of service users and recognizing signs of deteriorating mental health.” Source location Response from All Care In One Ltd
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise internal safeguarding policies to clarify recognition, escalation and record-keeping for acute mental health issues.
Verbatim wording from the response “appendix 8
Reviewed new policies and procedures of the safeguarding.” Source location Response from All Care In One Ltd
Open published response
20 Feb 2025 Duncan HOLLOWAY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Lack of a minimum standard for psychotherapy consultation note keeping 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
Duncan HOLLOWAY · 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
Duncan Holloway died after jumping from a bridge at approximately 5am on 18 July 2024, being killed by the impact with the railway tracks below. The concerns included psychotherapy note-keeping, training and response to suicidality, whether psychotherapists unable to manage suicidality should practise with at-risk clients, and a lack of joined-up care between agencies.
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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 minimum standard for psychotherapy consultation note keeping
Wider context from the report “1. Mr Holloway’s BCAP accredited psychotherapist did not make any notes of her consultations with him, because he had asked her not to. She gave evidence that she is not bound by law or ethics to keep any notes.
Is it appropriate that there is no minimum standard of note keeping following psychotherapy consultations ?
” Source location Duncan HOLLOWAY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require members to keep accurate, necessary and data-protection-compliant records.
Verbatim wording from the response “All BACP members must adhere to BACP’s Ethical Framework.” Source location Response from BACP
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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 members with evidence-based guidance resources on confidentiality and record keeping.
Verbatim wording from the response “In addition to BACP’s comprehensive Ethical Framework and Professional Conduct procedure, BACP also provides all its members with access to a range of Good Practice in Action (GPiA) resources. Our GPiA resources are based on current research and evidence and reviewed by member-led focus groups and experts in the field. We provide four guidance documents that relate to the keeping of records:” Source location Response from BACP
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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 Existing ethical and contractual requirements, alongside client choice and practitioner judgment, are considered sufficient to govern psychotherapy record keeping.
Verbatim wording from the response “All BACP members must adhere to BACP’s Ethical Framework.” Source location Response from BACP
Open published response
17 Feb 2025 Carl Edmond EASTMAN · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Deficiencies in basic clinical record keeping 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
Royal Free London 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. 5
Royal Free London NHS Foundation Trust
Deliver regular falls-prevention simulation training, including protocol, post-fall management, documentation, escalation and prevention, to nursing and medical staff.
View source
Royal Free London NHS Foundation Trust
Update electronic patient records to capture falls assessments, interventions, care planning and post-fall management at admission, after falls and when condition changes.
View source
Royal Free London NHS Foundation Trust
Reinforce accurate falls documentation requirements with ward staff through divisional governance education.
View source
Royal Free London NHS Foundation Trust
Monitor compliance with falls documentation through audits, the Falls Steering Group and clinical safety governance committees.
View source
Royal Free London NHS Foundation Trust
Send a Trust-wide safety bulletin reminding staff to document falls assessments, interventions and post-fall management.
View source See 2 more actions
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AI-generated summary
Carl Edmond EASTMAN · 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
Carl Eastman was admitted to hospital after a fall at home and later suffered an unwitnessed fall on 28 July 2024 while in hospital. He sustained an irreversible brain bleed and died in hospital that evening as a direct result of the injury. Concerns included delays in CT scans after falls, widespread communication and record-keeping issues, failure to follow post-fall procedures, and possible wider skills or knowledge deficits among 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 Deficiencies in basic clinical record keeping
Wider context from the report “2. There was evidence of what I considered to be ‘widespread communication issues’ in the care provided to Mr Eastman. These included:
• When the on-call doctor attended to review Mr Eastman at approximately 02:45 on 28 July 2024, ward staff (incorrectly) told the doctor that nobody had fallen on the ward, which lead to the doctor leaving the ward without Mr Eastman having been reviewed. As the consultant geriatrician said in his evidence, communication between the ward staff and medical staff was not good.
• The evidence revealed that there were deficiencies in basic record keeping .
” Source location Carl Edmond EASTMAN · 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 Deliver regular falls-prevention simulation training, including protocol, post-fall management, documentation, escalation and prevention, to nursing and medical staff.
Verbatim wording from the response “There is agreement that a robust and sustainable education plan for falls must be implemented. Following the death of Mr. Eastman, a post falls simulation programme was developed and is in the process of being delivered to all nursing staff. All Clinical Practice Educators have been trained as champions to deliver the falls simulation training to ward staff. Progress of the establishment of this body of work is currently being monitored through the Senior Nurse Matrons’ meeting which takes place weekly, and all areas involved are required to report progress of this implementation by early May 2025.” Source location Response from Royal Free London 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 Update electronic patient records to capture falls assessments, interventions, care planning and post-fall management at admission, after falls and when condition changes.
Verbatim wording from the response “A review of the medical and nursing notes identified gaps in documentation. The Trust is committed to improving this and is in the final stages of approving changes to how falls assessments, interventions, care planning, and post-fall care are recorded in all patients’ medical records within Electronic Patient Record (EPR). Accordingly, the updated falls assessment will be completed in EPR when a patient is admitted to the ward, after any inpatient fall, or if there are changes in their medical condition.” Source location Response from Royal Free London 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 Reinforce accurate falls documentation requirements with ward staff through divisional governance education.
Verbatim wording from the response “b. The importance of documenting falls assessments, interventions and post fall management will be reiterated to all ward staff.
Owner: Head of Nursing AMEDEC in collaboration other divisional directors of nursing
Action deadline: 01 May 2025
Evidence if necessary: Agenda from monthly divisional governance meeting, and minutes from senior nurse/matrons meeting” Source location Response from Royal Free London 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 Monitor compliance with falls documentation through audits, the Falls Steering Group and clinical safety governance committees.
Verbatim wording from the response “Compliance on the completion of these audits will be monitored through an action plan and quarterly audits, with results reported to the Trust Falls Steering Group. Oversight of this data will be provided in the Clinical Performance and Patient Safety Committee (CPPS), chaired by the hospital’s Medical Director and attended by senior divisional leaders.” Source location Response from Royal Free London 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 Send a Trust-wide safety bulletin reminding staff to document falls assessments, interventions and post-fall management.
Verbatim wording from the response “d. A Safety Bulletin will be sent to all staff Trust-wide, reminding them of the importance of documentation in relation to falls.
Owner: Head of Patient Safety and Risk
Action deadline: 25 April 2025
Evidence if necessary: Copy of the Safety Bulletin uploaded to Freenet” Source location Response from Royal Free London NHS Foundation Trust
Open published response
17 Jan 2025 Vauna LEEMING · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3
Failure to complete documentation of Enoxaparin administration View source Failure to complete documentation of compression stocking fitting and use View source Insufficient nurse awareness of the duty to complete important documentation View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Worcestershire Acute Hospitals 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. 4
Worcestershire Acute Hospitals NHS Trust
Reinforce requirements to sign prescription charts through daily safety huddles and team meetings.
View source
Worcestershire Acute Hospitals NHS Trust
Update and recirculate Trust-wide learning on mechanical thromboprophylaxis and signing prescriptions.
View source
Worcestershire Acute Hospitals NHS Trust
Request that the digital team ensure new electronic prescribing charts meet all requirements before launch.
View source
Worcestershire Acute Hospitals NHS Trust
Increase VTE compliance monitoring through regular divisional audits of prescription-chart signing and monthly reports to the Improving Safety Action Group.
View source See 1 more action
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AI-generated summary
Vauna LEEMING · 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
Vauna Leeming was admitted to hospital after an accidental fall at home that caused a fractured right neck of femur. After surgery, her condition deteriorated, she tested positive for Covid-19, suffered a pulmonary embolism and died in hospital. Concerns included incomplete documentation of anticoagulation and compression-stocking measures, failures to report omissions, and insufficient awareness among employed and agency nurses of these duties.
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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 documentation of Enoxaparin administration
Wider context from the report “1) Following Mrs. Leeming’s surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication (Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between her surgery and Mrs. Leeming’s death:
(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered ;
(b) on a total of 15 days (including 5 consecutive days in one week ) no documentation was completed by nurses to show whether compression stockings had been fitted and were being worn;
” Source location Vauna LEEMING · 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 documentation of compression stocking fitting and use
Wider context from the report “1) Following Mrs. Leeming’s surgery on 8.2.24, measures were put in place to prevent the formation of a deep vein thrombosis and/or pulmonary embolism. Those measures were prescriptions for anticoagulation medication (Enoxaparin ) and for compression stockings. The inquest heard evidence that over the 46 days between her surgery and Mrs. Leeming’s death:
(a) on 2 days ( 10 and 13.2.24 ) no documentation was completed by nurses to show whether Enoxaparin had in fact been administered;
(b) on a total of 15 days (including 5 consecutive days in one week ) no documentation was completed by nurses to show whether compression stockings had been fitted and were being worn ;
” Source location Vauna LEEMING · 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 Insufficient nurse awareness of the duty to complete important documentation
Wider context from the report “4) I am concerned that the evidence in this case highlights that there is still insufficient awareness among employed and agency nurses at the Trust’s hospitals of their professional duty :
(a) to complete important documentation such as prescription charts ; and
(b) to report any omissions in the completion of such documentation to a senior colleague.
” Source location Vauna LEEMING · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce requirements to sign prescription charts through daily safety huddles and team meetings.
Verbatim wording from the response “i. Ward managers and Matrons, in their daily safety huddles and team meetings, are reinforcing the direction that staff must sign prescription charts.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and recirculate Trust-wide learning on mechanical thromboprophylaxis and signing prescriptions.
Verbatim wording from the response “ii. To update and re-circulate the lesson of the week Trust-wide on mechanical thromboprophylaxis and the importance of signing prescriptions” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request that the digital team ensure new electronic prescribing charts meet all requirements before launch.
Verbatim wording from the response “iii. The CMO will write to the digital team creating the electronic medical prescribing charts, formally requesting that they ensure that the new charts meet all requirements, prior to being launched (e.g. prescribing of TEDS)” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase VTE compliance monitoring through regular divisional audits of prescription-chart signing and monthly reports to the Improving Safety Action Group.
Verbatim wording from the response “• To increase the monitoring of VTE compliance via our Improving Safety Action Group (ISAG), chaired by the Chief Nursing Officer/CMO.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
Concerns raised 2
Failure to clearly document medical advice obtained after resident falls View source Failure to maintain accessible and retained resident 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
Four Seasons Health Care Group
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
Four Seasons Health Care Group
Prompt visiting healthcare professionals to sign in, accompany visits with senior staff, document advice and recommendations, and record information for handovers and audit.
View source
Four Seasons Health Care Group
Deliver record-keeping, care-plan and documentation training covering contemporaneous entries, professional visits, emerging risks, RADAR records and archiving.
View source
Four Seasons Health Care Group
Publish and distribute an archiving guide setting standards for record storage, safekeeping and retention across the Group.
View source
Four Seasons Health Care Group
Develop and roll out additional learning-management guidance on GDPR and the safekeeping and storage of records.
View source
Four Seasons Health Care Group
Conduct daily documentation checks, monthly file checks and regular care-plan sampling to identify omissions, errors and compliance issues.
View source
Four Seasons Health Care Group
Pilot electronic care records at several homes to support digitisation of intensive manual record-keeping processes.
View source See 3 more actions
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AI-generated summary
Sylvia Margaret Louisa SAVAGE · 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
Sylvia Margaret Louisa Savage died on 25 April 2023 at the University Hospital of North Durham from bronchopneumonia, following a fall from her bed at Redwell Hills Care Home on 18 March 2023 and subsequent injuries and decline in health. The concerns included unclear fall-reporting arrangements, ineffective monitoring of her mobilisation, inadequate post-fall medical assessment, missing or insufficient care records, and failure to promptly reassess her care plan after falls.
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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 clearly document medical advice obtained after resident falls
Wider context from the report “3. Mrs Savage's fall in February 2023 was it appears reported to her GP by her daughter and that led to a nurse attending the home to examine her. Staff at the home do not appear to have done so themselves. It is of concern that after a fall the staff within the home should have a mechanism to ensure medical advice is obtained in a timely fashion and that it is documented clearly and not be reliant on family members summoning help for residents themselves when they have become aware of an incident.
” Source location Sylvia Margaret Louisa SAVAGE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain accessible and retained resident records
Wider context from the report “4. The absence of records has hindered my investigation into Mrs Savage's death. The expert in her evidence made it clear - good recording keeping allows staff to monitor changes in condition, allows new staff or those returning from time off to reacquaint themselves with residents condition and allows clinicians to make diagnosis - without access to good records I can see a clear risk to the care of residents . It is also surprising to me the complete reliance on paper records which in Mrs Savage’s case have been lost . I would have expected to see electronic recording of information and electronic storage of it. I note the roll out of this in the company has been paused whilst the company is awaiting sale and my concern is whether the electronic recording and storage will be implemented - to me immediate access to records of a resident or the absence of them creates a concern .
” Source location Sylvia Margaret Louisa SAVAGE · 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 Prompt visiting healthcare professionals to sign in, accompany visits with senior staff, document advice and recommendations, and record information for handovers and audit.
Verbatim wording from the response “All visiting professionals including General Practitioners will now be prompted and requested to complete the Visitors Book on arrival to the Home and to await a member of the team to announce their arrival so that they can be accompanied on all visits by a senior member of the care or clinical team, to ensure that any advice or recommendations can be communicated as needed. Senior Care Assistant staff or a Unit Manager on duty will go with the healthcare practitioner when they attend and review and treat our residents. The Senior Carer will then document information in the Healthcare Professionals Visit form. The information recorded will confirm the time and date of the visit and the name of the practitioner.” Source location Response from Four Seasons Healthcare
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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 Deliver record-keeping, care-plan and documentation training covering contemporaneous entries, professional visits, emerging risks, RADAR records and archiving.
Verbatim wording from the response “We acknowledge the shortcomings in record-keeping at Redwell Hills as addressed in the Home Manager’s statement of 1 December 2023. Record-keeping training and guidance has been heavily promoted within the Home since the issues were identified in connection with Mrs Savage’s death. All existing clinical and care team members have been required to refresh mandatory courses on record-keeping training. Care plan and documentation training was booked for team members at the Home as a face-to-face course following the incident and has taken place regularly with multiple sessions covering the full care team, the last taking place on 8 August 2024. The courses have covered contemporaneous noting of daily events, professional visits and emerging risks, entries in the Group’s incident management system, RADAR, and proper archiving.” Source location Response from Four Seasons Healthcare
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 Publish and distribute an archiving guide setting standards for record storage, safekeeping and retention across the Group.
Verbatim wording from the response “A new “How to Guide” for archiving was published and distributed throughout the Group in October 2024, providing clear standards and expectations around the care, storage and safe keeping of records. A training module on the Group’s learning management system is also being developed and roll out is expected shortly. This will be additional guidance for the Home’s teams in relation to GDPR and the safekeeping and storage of records.” Source location Response from Four Seasons Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out additional learning-management guidance on GDPR and the safekeeping and storage of records.
Verbatim wording from the response “A new “How to Guide” for archiving was published and distributed throughout the Group in October 2024, providing clear standards and expectations around the care, storage and safe keeping of records. A training module on the Group’s learning management system is also being developed and roll out is expected shortly. This will be additional guidance for the Home’s teams in relation to GDPR and the safekeeping and storage of records.” Source location Response from Four Seasons Healthcare
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 daily documentation checks, monthly file checks and regular care-plan sampling to identify omissions, errors and compliance issues.
Verbatim wording from the response “• The Senior Care team and Home Manager are completing daily checks of room documentation and the information recorded on that to ensure quality and accurate content.” Source location Response from Four Seasons Healthcare
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 Pilot electronic care records at several homes to support digitisation of intensive manual record-keeping processes.
Verbatim wording from the response “The process for daily record-keeping and storage of records has been explained to each member of the team and recorded in supervision notes, countersigned to confirm understanding. Throughout 2024 the Group rolled-out electronic medicines administration records (‘eMAR’) as part of continued investment in our homes, notwithstanding a sales process launched in June 2024. The system removes a lot of the paper in the medication process and with live reporting supports improved visibility at home and regional level. This investment in eMAR followed a wholesale Wi-Fi upgrade programme and serves to modernise and digitise a key area of how we work. The Group is piloting electronic care records at several homes as part of continued efforts to digitise intensive manual processes. In the meantime, the importance of proper record-keeping and archiving is a regular agenda item at flash meetings.” Source location Response from Four Seasons Healthcare
Open published response
13 Dec 2024 LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Failure to maintain contemporaneous and accurate Labour Ward medication records View source Failure to record Labour Ward vital signs on required MEOWS charts View source
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Mid and South Essex NHS Foundation Trust Royal College of Obstetricians and Gynaecologists
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
Mid and South Essex NHS Foundation Trust
Use electronic prescribing and medication administration records for medications across all Trust sites, except unsupported variable-rate infusions.
View source
Mid and South Essex NHS Foundation Trust
Upload patient notes digitally before multidisciplinary meetings so attendees can scrutinise records across meeting formats.
View source
Royal College of Obstetricians and Gynaecologists
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
View source
Royal College of Obstetricians and Gynaecologists
Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
View source
Mid and South Essex NHS Foundation Trust
Train staff on MEWS charts and eliminate photocopied versions to support accurate scoring and escalation.
View source
Mid and South Essex NHS Foundation Trust
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
View source See 3 more actions
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AI-generated summary
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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
Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain contemporaneous and accurate Labour Ward medication records
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Source location LAURA-JANE KIRSTEN NICOLE SEAMAN · 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 Labour Ward vital signs on required MEOWS charts
Wider context from the report “(1) The acute Trust 72-hour investigation did not identify:
a. The absence of a contemporaneous Labour Ward medication chart for a patient that was administered medications on the ward
b. Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023
c. Vital signs for patients on the labour ward being annotated on a piece of cardiotocograph paper and the absence of required MEOWS charts
d. Communication issues with Trust staff and sharing of information
e. Lack of compliance with national guidance and training
f. Absence of contemporaneous blood testing results for Laura-Jane as a patient at high risk of post-partum haemorrhage in labour taken at
i. 00:40 hours for cross matching, and
ii. urgent blood tests taken at approximately 04:45 for a deteriorating patient
g. Lack of compliance with the triggering of the major haemorrhage protocol
” Source location LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
Open source 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 Use electronic prescribing and medication administration records for medications across all Trust sites, except unsupported variable-rate infusions.
Verbatim wording from the response “All Mid and South Essex Hospital NHS Foundation Trust (‘MSE’) sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record. This aides staff communication as it is clear who has been involved in the prescription of medications, and any queries or escalations can be quickly actioned. A new ‘e-chart’ is automatically started when there is a new patient admission which limits the risk of drug errors and allows for re-evaluation of a patient’s medication.” Source location Response from Mid & South Essex NHS 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 Upload patient notes digitally before multidisciplinary meetings so attendees can scrutinise records across meeting formats.
Verbatim wording from the response “The division acknowledges that the use of multiple medication charts was not included as a specific line of inquiry at the Rapid Review stage, and it should have been. We have reflected on the MDT meeting undertaken for Laura-Jane’s incident and we have made improvements to our processes. We now ensure that patient notes are uploaded as a digital copy in readiness for all MDT meetings so that whether meetings take place in person, online or hybrid, all staff attending have access to review and scrutinise the patient’s notes. Therefore, minimising the risk that important factors such as accuracy and quality record keeping are missed.” Source location Response from Mid & South Essex NHS 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 Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Verbatim wording from the response “The RCOG’s clinical guidance in this context includes the following:” Source location Response from Royal College of Obstetricians and Gynaecologists
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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 Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
Verbatim wording from the response “2. Maternal Collapse in Pregnancy and the Puerperium⁴ (Green-top Guideline No. 56). Clearly states that: “An obstetric modified early warning score chart should be used for all women undergoing” Source location Response from Royal College of Obstetricians and Gynaecologists
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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 staff on MEWS charts and eliminate photocopied versions to support accurate scoring and escalation.
Verbatim wording from the response “Our Rapid Review identified this issue, and several immediate actions were taken including urgent training delivered to staff to increase awareness and improve knowledge of MEWS charts.” Source location Response from Mid & South Essex NHS Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Verbatim wording from the response “The service identified these issues in the initial review of the incident. Since Laura-Jane’s death there has been an implementation of a new MEWS package with escalation policy. This includes the trigger response/medical emergency team once a score of 7 or above is reached.” Source location Response from Mid & South Essex NHS Trust
Open published response
Concerns raised 1
Care and support placement records omitting identified stair-related fall risks View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jean MULLEN · 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
Jean Mullen, an 87-year-old woman, was found collapsed and unresponsive at the bottom of the stairs at home after her pendant alarm was triggered on 22 June 2024; the inquest concluded that her death was accidental, involving a fall from height, fracture of the neck and subdural haemorrhage. Concerns included the failure to provide a recommended grab rail, failure to escalate a fall in the shower or reassess her mobility and equipment needs, and incomplete recording of stair-related risks.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Care and support placement records omitting identified stair-related fall risks
Wider context from the report “During the course of the inquest I heard evidence regarding communications between various departments of Adult Social Care and Home First and in particular STEPS. There had been an assessment by the therapist at Doncaster Royal Infirmary regarding Mrs Mullen returning to a safe home environment and what support and equipment would be required to allow that to take place. This included an assessment in the home with social workers present. A care package was provided by STEPS and it quickly became apparent that long term care and support would be required in the home and thus an application was completed on the 12th April. Mrs Mullen's family referred to them being informed that a grab rail would be required at the top of the stairs near the bathroom to help Mrs Mullen navigate to the bathroom thus reducing the risk of falls. This was not provided.
A fall occurred when Mrs Mullen was in the shower but the carers failed to escalate this and made no referrals for any further assessment to take place in relation to Mrs Mullen's mobility and ability to continue living safely at her home address. Further this was a missed opportunity to assess whether any other aids or equipment were needed to support her. Had this taken place it is likely that the absence of the grab rail would have been identified. This was a further missed opportunity.
Finally, the care and support placement referred to in the second exhibit to ████████'s report made no reference to the issue of stairs and the risk of falling that they presented.
” Source location Jean MULLEN · 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 Continue staff training and reinforce accurate recording of falls and other health-related events.
Verbatim wording from the response “➢ All of our social care staff undergo specific training as a matter of course on the need for detailed accurate records to be maintained in care settings, including the recording of slips and falls and general health related events.” Source location Response from Doncaster Council
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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 Council had no record that concerns about deteriorating ability on stairs were reported by family, carers or the individual.
Verbatim wording from the response “The Council does not have any record of Patricia Mullen informing social care that the stairs were becoming too much for her mother and neither was this identified as an issue by the carers. If any concern had been expressed by Patricia Mullen, and carers or Mrs Mullen herself (who had full capacity), this would have been recorded and investigated.” Source location Response from Doncaster Council
Open published response
Concerns raised 1
Failure to record mental health or medication reviews View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Dearne Valley Group Practice
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
Dearne Valley Group Practice
Create and implement a mental health template that standardises coding of mental health and medication reviews in clinical records.
View source
Dearne Valley Group Practice
Review all current SSRI patients, prioritising those discharged from mental health services, using the new template and completing mental health and medication reviews.
View source
Dearne Valley Group Practice
Inform the clinical team that reviews must include clear coding and wording in patient records for all patients.
View source
Dearne Valley Group Practice
Use scheduled reminders to prompt clinicians to complete patients’ mental health and medication reviews.
View source See 1 more action
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AI-generated summary
David Stables · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Stables had a history of mental health issues and attended his GP in February and March 2024 with anxiety, sleep difficulties and poor appetite. The inquest concluded that he died by suicide, with bilateral transection of the ulnar arteries and incised wounds to the wrists. The principal concern was that no mental health or medication reviews were recorded between April 2020 and February 2024, and it was unclear whether reviews had taken place but were not recorded or had not taken place when they should have.
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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 mental health or medication reviews
Wider context from the report “(1) I am concerned that there were no recorded mental health or medication reviews from April 2020 until February 2024 when David attended the GP asking for help. I was unable to establish whether these reviews had taken place and just not been recorded or whether full mental health reviews had not taken place when they should have been.
(2)
(3)
” Source location David Stables · 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 Create and implement a mental health template that standardises coding of mental health and medication reviews in clinical records.
Verbatim wording from the response “1. On December 18, 2024, we held a clinical meeting specifically to address the concern raised in the Regulation 28 Report. As a practice, we agreed a process which will assist current and future clinicians to correctly code into the clinical record when they have completed a mental health review and/ or a mental health medication review. To do this we have created a new mental health template to standardise the procedure which all clinicians now use.” Source location Response from Dearne Valley Group Practice
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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 all current SSRI patients, prioritising those discharged from mental health services, using the new template and completing mental health and medication reviews.
Verbatim wording from the response “2. We have reviewed each patient who is currently taking a selective serotonin reuptake inhibitors (SSRI) medication using the new template, starting with patients who have been discharged from a mental health service, as was Mr Stables. All patients have received a mental health review and a mental health medication review, who have been discharged from a mental health service.” Source location Response from Dearne Valley Group Practice
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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 Inform the clinical team that reviews must include clear coding and wording in patient records for all patients.
Verbatim wording from the response “It has been made very clear to all the clinical team that in addition to undertaking reviews it is necessary that coding and clear wording of ‘mental health review’/ ‘medication review’ is included in order for clarity in the patient record so that it is clear to third parties that these have taken place, not just for mental health patients, but for all patients.” Source location Response from Dearne Valley Group Practice
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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 Use scheduled reminders to prompt clinicians to complete patients’ mental health and medication reviews.
Verbatim wording from the response “4. Patients starting an SSRI for the first time will also be seen every 1 to 4 weeks until they are stable, after which they will also be reviewed every 6 months whilst they are taking the medication. If patients choose to stop the medication themselves without our knowledge, this will be picked up at the review date and a mental health review and discussed with the patient. We are using scheduled tasks for” Source location Response from Dearne Valley Group Practice
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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 Mental health and medication reviews had occurred; the material problem was missing clinical-record coding.
Verbatim wording from the response “We recognise the concerns you have raised about the lack of recording of mental health review and medication reviews. I have been assured that reviews had taken place, but they were not clearly or accurately recorded by the clinicians who consulted with Mr Stables. I am writing to set out the steps we have taken to assure that we will record this correctly going forward.” Source location Response from Dearne Valley Group Practice
Open published response
6 Dec 2024 Michael John THOMPSON · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to record key aspects of surgery 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
Michael John THOMPSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael John THOMPSON underwent hindquarter amputation for chondrosarcoma and later collapsed after vomiting; post-mortem examination found an internal hernia through a peritoneal defect, leading to aspiration. Concerns were raised that the peritoneal defect and repair were not recorded in the operation note, and that the Trust’s investigation did not address this issue or adequately support learning from the 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 record key aspects of surgery
Wider context from the report “1. During the surgery on 08/04/24 a defect was made in the peritoneum whilst dissecting this away from the tumour and the defect was repaired with sutures. The operation note did not record this complication and other staff were unaware of it . This raises a concern about the adequacy of record keeping in the Trust as a key aspect of the patient’s surgery was not recorded .
” Source location Michael John THOMPSON · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.