Recurring concern

Failure to conduct safety debriefs after serious incidents

First to latest report 18 Aug 2022 — 14 Oct 2024

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 5

What this concern includes

Includes failures to arrange, conduct, include relevant staff in, document or use a clinical, team or comparable safety debrief after a serious patient, resident or operational incident where the debrief is intended to identify learning and inform subsequent risk planning or care.

What is not included

Excludes generic incident investigation, root-cause analysis, organisational learning or corrective-action failures where no post-incident debrief is the deficient control.
Excludes individual psychological or trauma debriefing for staff or service users when it is not a safety debrief intended to inform care, risk assessment or prevention of recurrence.
Excludes failures in the underlying incident response, clinical care or environmental risk control where no failure to conduct a post-incident safety debrief is identified.
Excludes routine meetings and debriefs unrelated to a serious incident or to subsequent safety planning.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Cygnet Health Care Limited1

NHS England1

Tees, Esk and Wear Valleys NHS Foundation Trust1

York and Scarborough Teaching Hospitals NHS Foundation Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

14 Oct2024
North Yorkshire and York
Concerns raised1
1. Failure to debrief choking-incident staff within 72 hours
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions 1
1. York and Scarborough Teaching Hospitals NHS Foundation Trust
  Implement and use a policy requiring a hot debrief or other incident response after relevant events.
AI-generated summary

Stephen Frederick DULLING · 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

Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to debrief choking-incident staff within 72 hours
Wider context from the report
“4. I heard evidence of a number of omissions and lapses in the care afforded Mr Dulling by registered nurses during his admission to York District Hospital. My concerns relate to the following findings – a) No evidence of any direct inquiry being made of Mr Dulling’s primary carer in respect of his nutritional needs, despite Mr Dulling being deemed to lack capacity; b) It being recorded and acted upon that a regular diet was appropriate for Mr Dulling, despite a) above; c) No food chart being implemented and maintained despite the outcome of Mr Dulling’s malnutrition risk assessment; d) No assessment or escalation of Mr Dulling’s refusal of intravenous fluids; e) Evidence of a delayed response by a staff nurse to the information that Mr Dulling was choking; f) The absence of a de-brief of staff involved in the choking incident by a nurse of the requisite level within the period of 72 hours after the event. This, together with the subsequent delay in undertaking and completing the patient safety investigation review, resulted in important gaps in the evidence supplied both to the review and the inquest. 5. My concern is that the above reflects a series of lapses in basic nursing care identified in respect of a single patient, a repetition of any of which could present a risk of future deaths to others. ”
Source location
Stephen Frederick DULLING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 use a policy requiring a hot debrief or other incident response after relevant events.

Verbatim wording from the response
“It is to be noted that at the time of the incident the Trust followed its previous policy on incident management. The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged the investigation undertaken following this incident was not timely nor optimal. This has been reviewed with the Medicine Care Group and the new policy requiring either hot”

Source location
Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
Page 2 · response
Published 15 October 2024
Open published response
18 Aug2022
South Yorkshire (Western)
Concerns raised1
1. Failure to debrief prior ligature and self-harm incidents for future risk planning
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Cygnet Health Care Limited
Stated actions 4
1. Cygnet Health Care Limited
  Change debrief terminology and policy to post-incident review, and train staff to engage young people after incidents.
2. Cygnet Health Care Limited
  Implement flexible post-incident review approaches, including informal reviews or reviews conducted by a person selected by the young person, and communicate them to staff.
3. Cygnet Health Care Limited
  Provide hot and cold incident debriefs, weekly reflective practice and access to hospital-wide cover when staff need breaks or additional support.
1. Cygnet Health Care Limited
  Disseminate local, regional and group lessons learned through bulletins, governance meetings, incident learning events, clinical networks and conferences.
AI-generated summary

Chelsea Blue Louise Mooney · 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

Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to debrief prior ligature and self-harm incidents for future risk planning
Wider context from the report
“4. There was no evidence of debrief after prior incidents of ligatures or other self-harm attempts and therefore crucial information about Chelsea's state of mind, motivation and methods was missing from future planning and risk assessments. ”
Source location
Chelsea Blue Louise Mooney · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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
Change debrief terminology and policy to post-incident review, and train staff to engage young people after incidents.

Verbatim wording from the response
“Changes implemented following Chelsea’s death”

Source location
Response from Cygnet Health Care
Page 7 · response
Published 3 October 2022
Open published response
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 flexible post-incident review approaches, including informal reviews or reviews conducted by a person selected by the young person, and communicate them to staff.

Verbatim wording from the response
“27. Different approaches have now been agreed by the young people in the community meetings with regards the completion of post incident reviews. The”

Source location
Response from Cygnet Health Care
Page 7 · response
Published 3 October 2022
Open published response
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 hot and cold incident debriefs, weekly reflective practice and access to hospital-wide cover when staff need breaks or additional support.

Verbatim wording from the response
“28. Certain staff members carry radios that are allocated to security, response (which does not include the staff member carrying out the observations), nurse in charge and any staff member on 1:1 or above. All staff members carry an alarm and every ward has a ‘response’ member of staff allocated that can attend to any incident in the hospital. This is again emphasised in training to avoid any future delays. This process allows the staff member who has identified the incident to step back if required and/or carry on with the checks without impacting on a young person’s safety.”

Source location
Response from Cygnet Health Care
Page 8 · response
Published 3 October 2022
Open published response
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
Disseminate local, regional and group lessons learned through bulletins, governance meetings, incident learning events, clinical networks and conferences.

Verbatim wording from the response
“76. The Group Director of Nursing for Cygnet ████████ sends out a Lessons Learnt bulletin with any updates of shared learning. This is accessible on the Cygnet Portal at any time.”

Source location
Response from Cygnet Health Care
Page 18 · response
Published 3 October 2022
Open published response