Recurring concern

Unreliable patient observation arrangements

Get email alerts

Request correction

First reported 28 Mar 2013•Latest report 24 Jun 2026

Definition

What this concern includes

Includes observation-level assessment, observation policies and support plans, staff allocation and reliable delivery of required intermittent or enhanced patient observations.

Not included

Condition-specific physiological or neurological monitoring
Management auditing of observations where frontline observation arrangements are otherwise reliable
Continuous eyesight or one-to-one observation where that dedicated control supplies a narrower parent

Reports: 139
Individual concerns: 174
Date range: 2013–2026
Stated actions: 328

Reports 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.

Care Quality Commission11

Department of Health and Social Care11

Essex Partnership University NHS Foundation Trust7

NHS England7

Sussex Partnership NHS Foundation Trust5

Devon Partnership NHS Trust4

East London NHS Foundation Trust4

HM Prison and Probation Service4

Greater Manchester Mental Health NHS Foundation Trust3

North London NHS Foundation Trust3

The Queen Elizabeth Hospital, King's Lynn3

University Hospitals Sussex NHS Foundation Trust3

Avon and Wiltshire Mental Health Partnership NHS Trust2

Central and North West London NHS Foundation Trust2

County Durham and Darlington NHS Foundation Trust2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

3 Dec2024
Inner North London
Concerns raised1
1. Failure to establish a plan for close overnight observation
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mnayea ZMF Al Basman · 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

Mnayea ZMF Al Basman, who had significant co-morbidities, underwent a right hemicolectomy for caecal adenocarcinoma and died in hospital on 25 March 2024 after developing sepsis and peritonitis caused by an anastomotic leak. Concerns included failure to escalate aspects of his deterioration to the consultant surgeon, insufficient professional curiosity, inadequate overnight observation planning, and a lack of detail in some records. The report also noted that the events preceding his death had not been subject to an internal investigation, providing little reassurance that these matters had been addressed.

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 establish a plan for close overnight observation
Wider context from the report
“1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend: • a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis; • some entries in the clinical notes may have been ‘falsely reassuring’; • the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team; • there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and • there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024. 2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not. 3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail. Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed. ”
Source location
Mnayea ZMF Al Basman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Nov2024
Norfolk
Concerns raised2
1. Reliance on subjective clinician judgment for decisions to perform physiological observations
2. Lack of a formal structure for the timing and frequency of physiological observations in the community
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Mandate physiological observations during every initial community patient visit and disseminate the updated clinical guidance.
  Stated by East of England Community Health and Care NHS TrustStated completed
2. Action
  Publish and cascade a community patient escalation plan covering deterioration identification, escalation actions and physiological observations.
  Stated by East of England Community Health and Care NHS TrustStated completed
3. Action
  Create a community patient assessment guide containing exploratory questions to identify changes in condition and required further action.
  Stated by East of England Community Health and Care NHS TrustStated in progress
1. Action
  Include the assessment guide and escalation plan in Deteriorating Patient training.
  Stated by East of England Community Health and Care NHS TrustStated planned
AI-generated summary

Kenneth George Willard 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

Kenneth George Willard KING had bilateral leg wounds requiring community nursing care, with delays in some visits and subsequent infection. He was admitted to hospital with cellulitis of both legs and died on 12 November 2023 from septic shock due to bilateral leg cellulitis. Concerns included the absence of a formal structure for physiological observations in community patients and delays in implementing staff training and restrictions on untrained bank staff.

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
Reliance on subjective clinician judgment for decisions to perform physiological observations
Wider context from the report
“1. Evidence was heard that there is no formal structure in place as to when or with regard to the frequency of carrying out physiological observations on patients in the community. Observations are required to be taken if the attending clinician has any concerns about the patient's wellbeing or a deterioration in their condition, or at the request of a senior clinician or GP. No specific questions are asked of the patient, such as if they are feeling unwell, have pain or localised heat, the attending practitioner relies on general conversation carried out at their attendance to help form a view as to whether observations are required to be taken. It was accepted in evidence that the decision to perform observations relies on the clinical judgment of the relevant clinician, which is a subjective decision which may be exercised incorrectly and at variance with other clinicians. Different clinicians carry out visits in the community and so have no overall view of a patient's presentation and any deterioration. Written records are available but evidence was heard that in this case, on the last visit, the record of the previous attendance was looked at and no history prior to that. Evidence was heard that Health Care Practitioners may have limited clinical training and rely on instructions and advice from trained nurses. In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. ”
Source location
Kenneth George Willard KING · Prevention of Future Deaths report
Page 2 · concerns
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 formal structure for the timing and frequency of physiological observations in the community
Wider context from the report
“1. Evidence was heard that there is no formal structure in place as to when or with regard to the frequency of carrying out physiological observations on patients in the community. Observations are required to be taken if the attending clinician has any concerns about the patient's wellbeing or a deterioration in their condition, or at the request of a senior clinician or GP. No specific questions are asked of the patient, such as if they are feeling unwell, have pain or localised heat, the attending practitioner relies on general conversation carried out at their attendance to help form a view as to whether observations are required to be taken. It was accepted in evidence that the decision to perform observations relies on the clinical judgment of the relevant clinician, which is a subjective decision which may be exercised incorrectly and at variance with other clinicians. Different clinicians carry out visits in the community and so have no overall view of a patient's presentation and any deterioration. Written records are available but evidence was heard that in this case, on the last visit, the record of the previous attendance was looked at and no history prior to that. Evidence was heard that Health Care Practitioners may have limited clinical training and rely on instructions and advice from trained nurses. In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. ”
Source location
Kenneth George Willard KING · 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
Mandate physiological observations during every initial community patient visit and disseminate the updated clinical guidance.

Verbatim wording from the response
“In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. Trust guidance was updated and disseminated to all clinical staff to mandate the completion of physiological observations on every initial patient visit with immediate effect. A community patient escalation plan has been published and cascaded to support staff in identifying patients at risk of deterioration and the escalation actions that are required which includes the completion of physiological observations.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
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
Publish and cascade a community patient escalation plan covering deterioration identification, escalation actions and physiological observations.

Verbatim wording from the response
“In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. Trust guidance was updated and disseminated to all clinical staff to mandate the completion of physiological observations on every initial patient visit with immediate effect. A community patient escalation plan has been published and cascaded to support staff in identifying patients at risk of deterioration and the escalation actions that are required which includes the completion of physiological observations.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
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
Create a community patient assessment guide containing exploratory questions to identify changes in condition and required further action.

Verbatim wording from the response
“A community patient assessment guide is being created which will provide exploratory questions that community staff can use to ascertain any changes in the patient’s condition and identify if any further action is required. Both of these documents and how to use them will be included in the Deteriorating Patient training.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
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
Include the assessment guide and escalation plan in Deteriorating Patient training.

Verbatim wording from the response
“In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. Trust guidance was updated and disseminated to all clinical staff to mandate the completion of physiological observations on every initial patient visit with immediate effect. A community patient escalation plan has been published and cascaded to support staff in identifying patients at risk of deterioration and the escalation actions that are required which includes the completion of physiological observations.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
Open published response
18 Nov2024
Norfolk
Concerns raised1
1. Failure to carry out observations every two hours
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Conduct a joint night-shift walkaround to check every resident after handover.
  Stated by The Manor Care HomeStated completed
2. Action
  Schedule welfare observations at 9pm, 11pm, 1am, 3am and 5am.
  Stated by The Manor Care HomeStated completed
3. Action
  Assign each night-shift staff member a home section and responsibility for observing no more than 12 residents.
  Stated by The Manor Care HomeStated completed
1. Action
  Require staff to visually observe each assigned resident at least every two hours before rejoining colleagues for personal care.
  Stated by The Manor Care HomeStated completed
2. Action
  Record welfare checks electronically and have the Home Manager audit five residents’ previous-night observation timeliness daily.
  Stated by The Manor Care HomeStated completed
AI-generated summary

John Edward RILEY · 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 Edward RILEY, who had severely limited mobility and lived in a residential home, was found on the floor with the bed frame under his neck on 8 February 2024 and was declared dead at the scene. The inquest recorded the medical cause of death as a neck fracture following a fall. Concerns were raised that required two-hourly observations were sometimes carried out late, including after action had been taken to reduce delays.

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 carry out observations every two hours
Wider context from the report
“Evidence was heard that observations were sometimes not carried out every two hours as required. In January 2024 observations were at on occasions and on one prior occasion to 8 February 2024 in February 2024. Evidence were heard that some action has been taken by Manor House Residential Home to reduce late observations. Evidence was also heard that some observations are still being carried out outside of the two hour period. ”
Source location
John Edward RILEY · 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
Conduct a joint night-shift walkaround to check every resident after handover.

Verbatim wording from the response
“1. Following the handover to the night staff at 7pm, each pair of care staff goes to their assigned areas. They undertake a walk around together whereby they check each resident.”

Source location
Response from Manor House Care Home
Page 3 · response
Published 20 November 2024
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
Schedule welfare observations at 9pm, 11pm, 1am, 3am and 5am.

Verbatim wording from the response
“3. The two hourly welfare observations commence at 9pm and are undertaken thereafter at 11pm, 1am, 3am and 5am before the day staff commence their shift at 7am.”

Source location
Response from Manor House Care Home
Page 3 · response
Published 20 November 2024
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
Assign each night-shift staff member a home section and responsibility for observing no more than 12 residents.

Verbatim wording from the response
“4. For the purpose of the two hourly welfare observations, the home is divided into four sections. Each staff member on duty is assigned a section for the duration of their shift. The home has a maximum capacity of 48 residents and so each staff member is assigned the duty of undertaking the welfare observations for a maximum of 12 residents.”

Source location
Response from Manor House Care Home
Page 3 · response
Published 20 November 2024
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
Require staff to visually observe each assigned resident at least every two hours before rejoining colleagues for personal care.

Verbatim wording from the response
“5. Each staff member on duty is required to undertake a visual observation of each of their 12 residents at least every two hours. The individual members of care staff then re-join their partner upon completion of their respective observations to attend to those residents requiring personal care in a priority order.”

Source location
Response from Manor House Care Home
Page 3 · response
Published 20 November 2024
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
Record welfare checks electronically and have the Home Manager audit five residents’ previous-night observation timeliness daily.

Verbatim wording from the response
“7. Welfare checks are recorded electronically via a handheld device onto the resident's social care record. The timeliness of the welfare observations undertaken the previous night is reviewed for five different residents daily by the Home Manager. This random, daily auditing process ensures that the timeliness of the welfare observations is monitored daily, which further ensures compliance.”

Source location
Response from Manor House Care Home
Page 3 · response
Published 20 November 2024
Open published response
25 Oct2024
Nottinghamshire
Concerns raised1
1. Failure to consult a supervising officer on ACCT observation levels
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Responsibility for delivering suicide and self-harm risk management and the ACCT process at HMP Ranby sits with the Head of Safety.
  Stated by HM Prison and Probation ServiceRedirects responsibility
AI-generated summary

Mark Stephen Beresford · 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

Mark Stephen Beresford died at Bassetlaw District General Hospital on 7 July 2023 after applying a ligature while detained at HMP Ranby, having been discovered unresponsive and resuscitated. The jury found that he was suffering significant mental ill health and identified failings in the assessment and management of his mental health and self-harm risk, ACCT observations, completion of an action plan, response to his cell bell, and staffing. The report also raises concerns about prison leadership’s understanding and assessment of risk and its lack of candour and reflection during the inquest.

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 consult a supervising officer on ACCT observation levels
Wider context from the report
“I heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances. The supervising officer involved in the decision to close Mark’s ACCT on the morning of 3 July 2023, gave evidence that there was no likelihood Mark would commit further ACCTs of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents and the officer did not consult a supervising officer as required by PSI 64/2011. It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances. Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and/or the coroner. He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added: “I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.” When it was pointed out to him that that was not supported by either of the witnesses involved – who were both very clear that there had been no consultation - he apologised and suggested he had misunderstood. I am troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken. The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death. Mark was housed on HB3 North. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period. The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3S only. Every other prison witness asked about this agreed that there should be an officer covering each side of HB3 over lunch. Curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none. Although, he did later apologise for his difficulty answering other questions asked of him, explaining that he does not usually work in safer custody. 1. That, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby. 2. That there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody. ”
Source location
Mark Stephen Beresford · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Responsibility for delivering suicide and self-harm risk management and the ACCT process at HMP Ranby sits with the Head of Safety.

Verbatim wording from the response
“As you will also be aware responsibility for the delivery of the management of those prisoners at risk of suicide and self-harm and the effective management of the ACCT process at HMP Ranby sits with the Head of Safety.”

Source location
Response from HMPPS
Page 2 · response
Published 31 October 2024
Open published response
25 Oct2024
East London
Concerns raised1
1. Failure to undertake clinical observations at the expected frequency
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Provide live observation-frequency dashboards and monthly compliance reports to senior clinical staff.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completed
2. Action
  Conduct ward accreditation, deteriorating-patient audits and NEWS escalation audits to monitor observation and escalation compliance.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completed
Respondent positions 1
1. Position
  BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Chloe Every · 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

Chloe Every died in hospital on 14 May 2019 after complications from a hypoxic cardiac arrest sustained during her admission. The report identified concerns including morphine use without recorded justification, an enema undertaken without informed consent while she was unconscious, inadequate clinical observations, missing records, and failures in incident reporting and governance.

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 undertake clinical observations at the expected frequency
Wider context from the report
“3. The regularity of Chloe’s clinical observations fell well below the expected level. The lapses included a period of over 10 hours in which no observations were undertaken. ”
Source location
Chloe Every · 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
Provide live observation-frequency dashboards and monthly compliance reports to senior clinical staff.

Verbatim wording from the response
“There is live data in the format of a dashboard showing compliance with expected observation frequency available to senior staff within clinical areas (ward managers, matrons, practice development nurses and clinical group directors). Additional monthly performance reports have been sent to the same staffing groups since December 2023. Vital signs recording and actions form part of the Ward Accreditation Framework process and clinical areas work with the VitalPac team to continue to improve the timings of observations.”

Source location
Response from Barking, Havering and Redbridge NHS Foundation Trust
Page 3 · response
Published 31 October 2024
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
Conduct ward accreditation, deteriorating-patient audits and NEWS escalation audits to monitor observation and escalation compliance.

Verbatim wording from the response
“The wards areas in the Trust are subject to assessment utilising the Ward Accreditation Framework (WAF) which monitors metrics related to patient care and safety, as well as how the wards are operated. Audits are completed annually by subject matter experts and any areas in which the ward falls below 70% compliance is addressed with an action plan. The WAF framework assesses the nursing staff knowledge of the escalation process for deteriorating patients. The Ward Accreditation assessments started in 2020 and since then all wards in the Trust have completed and have achieved a minimum of a bronze standard for ward accreditation with many at Silver and working towards gold.”

Source location
Response from Barking, Havering and Redbridge NHS Foundation Trust
Page 3 · response
Published 31 October 2024
Open published response
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
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.

Verbatim wording from the response
“NHSE have informed us that BHRUT is preparing a response to address your concerns in full. This is entirely appropriate due to the nature of the concerns raised and as a direct recipient of this report. I look forward to their response with interest and do not wish to duplicate it. However, I will highlight some points from the information shared with us, of the actions taken to improve matters in relation to the care of patients with learning disabilities since Chloe’s death in 2019:”

Source location
Response from DHSC
Page 1 · response
Published 31 October 2024
Open published response
22 Oct2024
Birmingham and Solihull
Concerns raised1
1. Lack of enhanced nursing observations for patients requiring them
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Conduct a nursing workforce review addressing ward geography, staffing and enhanced-care capacity.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated planned
2. Action
  Re-embed the Enhanced Care policy and discuss enhanced-care risks in ward safety huddles.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
3. Action
  Use the Safer Nursing Care Tool within the wider acuity and dependency review to identify staffing needs.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated in progress
1. Action
  Request additional clinical-bank staffing case by case and assess staffing requirements shift by shift.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Identify patients at risk, communicate risks before the morning touchpoint, and implement additional safety measures where mitigation cannot be assured.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
3. Action
  Share ward geography information with assessment-area nursing leaders and request risk-aware side-room allocations.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
AI-generated summary

Robert TAYLOR · 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

Robert TAYLOR, who had prostate cancer, chronic liver disease and later high grade acute myeloid leukaemia, fell in hospital on 11 June 2024 after enhanced nursing observations had been identified as necessary but not put in place. He sustained traumatic subdural and subarachnoid haemorrhages and died on 21 June 2024. Concerns were raised about the lack of enhanced observations and the quality of the Trust’s post-death 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
Lack of enhanced nursing observations for patients requiring them
Wider context from the report
“1. The central issue in this case relating to the fall on 11/06/24 was the lack of enhanced nursing observations. The Nursing witness was unable to say what steps, if any, had been taken to try to put enhanced observations in place. The investigation report stated that enhanced observations had been identified as needed but did not expand on what actions were taken, if any, to obtain enhanced observation nor what actions had been taken after the death to ensure enhanced observations for patients that require them. This raises a concern for future deaths. ”
Source location
Robert TAYLOR · 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
Conduct a nursing workforce review addressing ward geography, staffing and enhanced-care capacity.

Verbatim wording from the response
“There will be a nursing workforce review to cover the points above. It is accepted that this point should have been more explicit within the report and details of the actions set out below should have been included.”

Source location
Response-from-University-Hospitals-Birmingham-NHS
Page 2 · response
Published 24 October 2024
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
Re-embed the Enhanced Care policy and discuss enhanced-care risks in ward safety huddles.

Verbatim wording from the response
“• The Enhanced Care policy has been re-embedded into the ward and risks are discussed in the ward huddle following shift handovers.”

Source location
Response-from-University-Hospitals-Birmingham-NHS
Page 2 · response
Published 24 October 2024
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
Use the Safer Nursing Care Tool within the wider acuity and dependency review to identify staffing needs.

Verbatim wording from the response
“• Acuity was noted to be a contributing factor within this case. There is currently a SNCT (Safer Nursing Care Tool) to review acuity levels as part of the wider Trust review of acuity and dependency. Whilst this work progresses increased staffing needs will be identified on a case-by-case basis as per the UHB enhanced care policy. Staff will be requested through UHB clinical bank services in a timely manner and explored on a shift-by-shift basis.”

Source location
Response-from-University-Hospitals-Birmingham-NHS
Page 2 · response
Published 24 October 2024
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
Request additional clinical-bank staffing case by case and assess staffing requirements shift by shift.

Verbatim wording from the response
“• Acuity was noted to be a contributing factor within this case. There is currently a SNCT (Safer Nursing Care Tool) to review acuity levels as part of the wider Trust review of acuity and dependency. Whilst this work progresses increased staffing needs will be identified on a case-by-case basis as per the UHB enhanced care policy. Staff will be requested through UHB clinical bank services in a timely manner and explored on a shift-by-shift basis.”

Source location
Response-from-University-Hospitals-Birmingham-NHS
Page 2 · response
Published 24 October 2024
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
Identify patients at risk, communicate risks before the morning touchpoint, and implement additional safety measures where mitigation cannot be assured.

Verbatim wording from the response
“• The nurse in charge currently identifies and discusses patients at risk of falls, as well as those requiring enhanced observations, with the Matron, prior to the 0800-touchpoint meeting. Since the inquest we have made changes in how this information is communicated. There is a more risk focused approach being taken and a focus on vulnerable patients in higher risk environments. If a ward area is unable to provide assurance that a risk is being mitigated, then additional safety measures to ameliorate the risk are put into place. Examples include: ○ Discussion in the morning safety huddle regarding risk of falls and patients for whom there is concern. ○ Reorganisation of workload to mitigate and reduce risk ○ Movement of patients into more appropriately positioned side rooms where possible.”

Source location
Response-from-University-Hospitals-Birmingham-NHS
Page 2 · response
Published 24 October 2024
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
Share ward geography information with assessment-area nursing leaders and request risk-aware side-room allocations.

Verbatim wording from the response
“• We have recognised that the current layout of ward 19 can be challenging when nursing patients who are at risk of falls because of having only two 6 bedded bays and 13 side rooms positioned in a T shape within the ward. In addition, only 4 side rooms have partial views (if the door is open), the other 9 have no visibility. We have spoken to the senior nursing team in charge of the assessment area regarding environmental challenges and provided a visual map of side rooms, so they are aware of the physical layout of the ward. We have asked the assessment areas when allocating patients to be mindful of ward geography and communicate any concerns and risks that patients may have such that plans can be put in place to support enhanced care and risk of falls.”

Source location
Response-from-University-Hospitals-Birmingham-NHS
Page 2 · response
Published 24 October 2024
Open published response
14 Oct2024
Surrey
Concerns raised1
1. Failure to provide sufficiently frequent direct night-time visual observations
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Align frequency-of-monitoring policy and clinical guidelines with national best practice through wider consultation and critique.
  Stated by The Children's TrustStated in progress
2. Action
  Review and audit video surveillance, wearable sensors, and other monitoring tools to ensure appropriate use alongside direct checks.
  Stated by The Children's TrustStated completed
3. Action
  Implement and embed a shift handover protocol communicating required supervision and observations and recording the preceding shift’s clinical observations.
  Stated by The Children's TrustStated completed
1. Action
  Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
  Stated by The Children's TrustStated completed
2. Action
  Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
  Stated by Care Quality CommissionStated completed
3. Action
  Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.
  Stated by Care Quality CommissionStated completed
Respondent positions 3
1. Position
  Strengthened monitoring policies, audits and governance arrangements were considered sufficient to address risks concerning night-time observations and safe care.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
1. Position
  The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
  Stated by Department of Health and Social CareRedirects responsibility
2. Position
  Some concerns about Mia’s care are better addressed by Tadworth Children’s Trust and the Care Quality Commission.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Mia Louise Gauci-Lamport · 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

Mia Louise Gauci-Lamport, who had treatment-resistant epilepsy and required full-time residential care, was found cyanotic and unresponsive at around 06.32 hours on 11 September 2023 after not being visually checked when a carer entered her room. Resuscitation was unsuccessful. The report raised concerns about inadequate night-time monitoring, incomplete medical records and insufficient clinical oversight and governance.

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 provide sufficiently frequent direct night-time visual observations
Wider context from the report
“1. Lack of appropriate monitoring of Mia during the night: Mia’s underlying illness caused seizures which were multifocal, complex and variable from tonic-clonic, myoclonic to cluster and absence seizures. Her care plan stipulated that carers should enter her room every 15 minutes to undertake visual observations throughout the night to ensure Mia was in a safe position, was breathing and not at risk of asphyxiation. However, this did not take place as frequently as specified. Moreover, it was common practice amongst some carers to review images from a video monitor placed over Mia’s cot rather than direct visualisation despite it being recognised that the monitor was insufficiently sensitive to reassure the carer that Mia was breathing, seizure free and safe from asphyxiation. ”
Source location
Mia Louise Gauci-Lamport · 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
Align frequency-of-monitoring policy and clinical guidelines with national best practice through wider consultation and critique.

Verbatim wording from the response
“A comprehensive review of our monitoring protocols and individualised care planning process has been undertaken which has led to several critical actions being identified, all of which are now overseen by robust internal governance:”

Source location
Response from The Children's Trust
Page 2 · response
Published 14 October 2024
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
Review and audit video surveillance, wearable sensors, and other monitoring tools to ensure appropriate use alongside direct checks.

Verbatim wording from the response
“○ Monitoring Tools: A review of monitoring tools, including video surveillance and wearable sensors, has been completed. We continually ensure that these tools are appropriate for each child's needs and used correctly to provide effective oversight without replacing appropriate checks. This initial action is complete and is now continuously reviewed and audited in line with evidence-based practice.”

Source location
Response from The Children's Trust
Page 3 · response
Published 14 October 2024
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 and embed a shift handover protocol communicating required supervision and observations and recording the preceding shift’s clinical observations.

Verbatim wording from the response
“○ Shift Handover Protocol: A revised Shift Handover Protocol has been introduced to ensure that the level of supervision and observation required for each child is understood and clearly communicated during shift changes. Additionally, the last set of clinical observations from the prior shift are recorded and discussed at handover, ensuring a seamless transition and continuity of care. This protocol has been embedded across The Children’s Trust and is subject to continuous review and audit to ensure compliance.”

Source location
Response from The Children's Trust
Page 3 · response
Published 14 October 2024
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
Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.

Verbatim wording from the response
“○ Frequency of Monitoring and PEWS Practice Audits: We have implemented new Frequency of Monitoring Practice audits overnight, conducted by Clinical Site Managers. This ensures continued compliance with the monitoring and observations policies. These audits are complemented by monthly quality walks to ensure the consistent implementation of care plans and protocols. This additional assurance mechanism is built into roles and responsibilities and findings from these audits feed into the broader clinical governance framework.”

Source location
Response from The Children's Trust
Page 3 · response
Published 14 October 2024
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
Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.

Verbatim wording from the response
“In December 2023 CQC had received key information and started to plan for an inspection in February. On February 20th to 21st 2024 the CQC undertook a comprehensive inspection of TCT as part of our regulatory response to the notification of Mia’s sad death. The inspection looked at all five key questions of whether TCT is Safe, Effective, Caring, Responsive and Well-led. (Please see attached PDF). CQC do not provide ratings for children’s homes that are registered with Ofsted, as per our policy.”

Source location
Response from CQC
Page 3 · response
Published 14 October 2024
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
Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.

Verbatim wording from the response
“In July 2024 following the coroner’s inquest and information from the independent investigator report, CQC requested monthly updates from TCT regarding the providers audits of frequency of monitoring of children and their Paediatric Early Warning System (PEWS). The audits and actions taken, provided CQC with assurance the leadership team continued to take positive action to address any gaps in practice that the audits identified.”

Source location
Response from CQC
Page 4 · response
Published 14 October 2024
Open published response
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
Strengthened monitoring policies, audits and governance arrangements were considered sufficient to address risks concerning night-time observations and safe care.

Verbatim wording from the response
“Since the sad death of Connor Wellsted in 2022 and Mia’s death, CQC have undertaken three subsequent inspections which have demonstrated that TCT have taken the appropriate actions to ensure the governance processes around night time observations have been strengthened. CQC is assured with regard to its own regulatory functions, by the actions taken by TCT. Specifically this includes to strengthening the frequency of monitoring policy and increased their audits of the implementation of this policy.”

Source location
Response from CQC
Page 6 · response
Published 14 October 2024
Open published response
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
The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.

Verbatim wording from the response
“Mia was in a residential care bed, which is commissioned instead by the Local Authority. The commissioning body, in this case the LA, has the responsibility for oversight of the quality of the service. NHSE have provided assurance that their regional team has been working with system and other partners on responding to risks and concerns in a joint approach at this provider, which will be set out in their response. In case of interest, NHSE’s guidance on specialised services can be found here: NHS commissioning » Specialised services.”

Source location
Response from DHSC
Page 2 · response
Published 14 October 2024
Open published response
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
Some concerns about Mia’s care are better addressed by Tadworth Children’s Trust and the Care Quality Commission.

Verbatim wording from the response
“Your Report raises multiple concerns in relation to the medical care and appropriate monitoring of Mia, including concerns regarding the access to clinical consultant care and a lack of adherence to her care plan within the residential care setting at Tadworth Children’s Trust (TCT). Noting you have also sent your Report to TCT and CQC, some of the concerns you raise may be better addressed by those organisations. In this response, I have addressed the matters of concern where NHS England are able to contribute and provide some assurance.”

Source location
Response from NHS England
Page 1 · response
Published 14 October 2024
Open published response
10 Oct2024
Milton Keynes
Concerns raised1
1. Failure of high-level intermittent observations to maintain patient safety
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Implement systems and processes supporting adherence to the observation and therapeutic engagement policy, with monitoring of staff understanding, training and compliance.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Discuss the inquest themes and the importance of observation-policy adherence with staff through supervision, group sessions and ward meetings.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Embed oversight of staff training uptake for observations and therapeutic engagements.
  Stated by Central and North West London NHS Foundation TrustStated completed
1. Action
  Realign the Nurse in Charge role to prioritise high-level observations, ensure seamless handovers and enable faster escalation when patients cannot be located.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Embed and optimise the Brigid app for real-time observation recording, rationale and frequency documentation, and random-check prompts.
  Stated by Central and North West London NHS Foundation TrustStated completed
3. Action
  Strengthen observation governance through shift-level checks, daily multidisciplinary reviews of highest-risk patients and allocated senior nursing support.
  Stated by Central and North West London NHS Foundation TrustStated completed
4. Action
  Revise the observation audit schedule to monitor weekly improvement under senior practice development nurse leadership.
  Stated by Central and North West London NHS Foundation TrustStated completed
5. Action
  Participate in a Trust-wide quality-improvement project to improve patient observation quality through May 2026.
  Stated by Central and North West London NHS Foundation TrustStated in progress
AI-generated summary

Florence Elizabeth Catherine STEWART · 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

Florence Elizabeth Catherine Stewart, who had been admitted to the Campbell Centre as a voluntary patient following detention under section 136 of the Mental Health Act, suffered a hypoxic brain injury after hanging herself and died at Milton Keynes University Hospital on 23 January 2024. The concerns identified were the failure of high-level intermittent observations to prevent her suicide and an oxygen bottle running out during resuscitation.

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 of high-level intermittent observations to maintain patient safety
Wider context from the report
“Firstly that the system of high level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. Secondly, that the Oxygen bottle used during resuscitation ran out of oxygen. ”
Source location
Florence Elizabeth Catherine STEWART · Prevention of Future Deaths report
Page 1 · 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 systems and processes supporting adherence to the observation and therapeutic engagement policy, with monitoring of staff understanding, training and compliance.

Verbatim wording from the response
“The Divisional Directors have provided assurance that the Campbell Centre management team has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement and have introduced measures to monitor understanding, training, and compliance. They have advised that there have been meetings with all staff to emphasise the importance of adherence to the Policy.”

Source location
Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024
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
Discuss the inquest themes and the importance of observation-policy adherence with staff through supervision, group sessions and ward meetings.

Verbatim wording from the response
“The Divisional Directors have provided assurance that the Campbell Centre management team has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement and have introduced measures to monitor understanding, training, and compliance. They have advised that there have been meetings with all staff to emphasise the importance of adherence to the Policy.”

Source location
Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024
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
Embed oversight of staff training uptake for observations and therapeutic engagements.

Verbatim wording from the response
“The specific themes from Ms Stewart’s inquest have been discussed in group supervision, individual supervision and ward meetings. The Campbell Centre management team has strengthened how temporary and new staff members are inducted to ensure that they can better identify their patients' needs. They have also embedded a system to oversee staff uptake of training in the use of observations and therapeutic engagements.”

Source location
Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024
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
Realign the Nurse in Charge role to prioritise high-level observations, ensure seamless handovers and enable faster escalation when patients cannot be located.

Verbatim wording from the response
“The Nurse in Charge role has been realigned to ensure that the observation system is delivered to prioritise patients requiring high-level intermittent observations and oversee a seamless handover of care when alternating staff members. This includes faster escalation”

Source location
Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024
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
Embed and optimise the Brigid app for real-time observation recording, rationale and frequency documentation, and random-check prompts.

Verbatim wording from the response
“The Trust has fully embedded the use of the Brigid app, a hand-held device that allows staff to remain with the patient and enter real-time updates of observation records, automatically updating the Trust's clinical record system. This has been optimised since the inquest and enables staff to document the rationale and frequency of observations, including prompts for random checks.”

Source location
Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024
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
Strengthen observation governance through shift-level checks, daily multidisciplinary reviews of highest-risk patients and allocated senior nursing support.

Verbatim wording from the response
“The Campbell Centre management team has refined its governance processes to ensure that changes have been embedded. This includes several checks carried out during each shift by a duty senior nurse to ensure that observations are completed on time, a daily review by the MDT on those patients at most risk of harm, and senior nursing input allocated to support this.”

Source location
Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024
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
Revise the observation audit schedule to monitor weekly improvement under senior practice development nurse leadership.

Verbatim wording from the response
“A system of audit schedules has been revised to check for weekly improvement, this is led by a senior practice development nurse.”

Source location
Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024
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
Participate in a Trust-wide quality-improvement project to improve patient observation quality through May 2026.

Verbatim wording from the response
“The Campbell Centre is part of a Trust-wide Quality improvement project looking to improve patient observation quality. The project commenced in November 2024 and is due to continue until May 2026.”

Source location
Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024
Open published response
18 Jul2024
Inner North London
Concerns raised1
1. Failure to complete safe and supportive observations
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Increase staffing on each shift by one unregistered Band 3 member and add a weekday Band 4 Life Skills Recovery Worker.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Recruit to eliminate registered vacancies, review unregistered workforce skills, and maintain safer staffing rota approval and monitoring.
  Stated by East London NHS Foundation TrustStated in progress
1. Action
  Use escalation protocols to guide staff when resources are insufficient to meet care needs.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Introduce observation relay boards to reduce missed observations and improve clinical-information handover.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Continue reviewing escalation protocols to support task prioritisation, rapid resource deployment and reporting of compromised care.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Anna Vivien Elliott · 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

Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety plans.

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 complete safe and supportive observations
Wider context from the report
“Concern 3 In Anna’s case, safe ad supportive observations were missed. This is, at least, in part due to high acuity on the unit as a whole on the night of Anna’s death, a support worker undertaking those observations being called away to an emergency and her colleagues reporting being unaware that she had left the ward. I heard evidence about steps that have been put in place to prevent observations being missed but the data provided by the Trust appeared to show that missed observations are rising and not decreasing. However, the data provided was out of date and the PFD witness was unable to interpret what was provided. I heard evidence about a strong focus on safety, openness and honesty following Anna’s death. I am therefore unclear whether the data reflects a true rise in missed observations or whether it is the result of more honest reporting of missed observations by staff on the ground. ”
Source location
Anna Vivien Elliott · 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
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.

Verbatim wording from the response
“19. The Trust is currently developing a new E-observations (e-obs) platform which has in-built prompts to ensure staff capture the location of a patient, what they observe and their interactions with a patient. Daily spot checks will be undertaken by the clinical nurse manager or the most senior nurse on shift out of hours. It is hoped that this will be in place in the coming six months.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
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
Increase staffing on each shift by one unregistered Band 3 member and add a weekday Band 4 Life Skills Recovery Worker.

Verbatim wording from the response
“Staffing/ resource availability | Staff establishment reviews were undertaken in 22/23 and 23/24. Correct and agreed investments have gone into teams, increasing staff on each shift by one unregistered Band 3. Additional investment has been made for a Band 4 Life Skills Recovery Worker on Mondays to Fridays 9am to 5pm to increase the delivery of activities and opportunities for meaningful engagement.”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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
Recruit to eliminate registered vacancies, review unregistered workforce skills, and maintain safer staffing rota approval and monitoring.

Verbatim wording from the response
“A proactive recruitment campaign has been ongoing with services moving to zero registered vacancies and a review of the unregistered workforce (correct band and skill). Staffing rotas for the wards have been reviewed and updated to reflect safer staffing requirements; senior approval of rotas is required six weeks in advance of the current period and quarterly rota monitoring meetings are in place.”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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
Use escalation protocols to guide staff when resources are insufficient to meet care needs.

Verbatim wording from the response
“Escalation protocols have been developed for use to guide staff when there are not sufficient resources in place to meet care needs.”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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
Introduce observation relay boards to reduce missed observations and improve clinical-information handover.

Verbatim wording from the response
“A Trust-wide Quality Improvement programme which involved all inpatient teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Continue reviewing escalation protocols to support task prioritisation, rapid resource deployment and reporting of compromised care.

Verbatim wording from the response
“Staffing/resource availability Continue to review escalation protocols to senior staff on site in response to changes in acuity or demand or if there are staff shortages on a shift. This is to include:”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
Open published response
10 Jul2024
Inner North London
Concerns raised1
1. Failure to conduct required observations
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 18
1. Action
  Increase each ward shift by one unregistered Band 3 staff member and add a weekday Band 4 Life Skills Recovery Worker.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Review and update ward rotas for safer staffing, with advance senior approval and quarterly monitoring.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Implement the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
  Stated by East London NHS Foundation TrustStated completed
1. Action
  Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Implement observation board relay to reduce missed observations and improve handover between staff.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Implement twilight shifts that add staffing during reduced activity periods and provide therapeutic activities.
  Stated by East London NHS Foundation TrustStated completed
4. Action
  Implement zonal observations to support continuous patient engagement and monitoring across wards.
  Stated by East London NHS Foundation TrustStated completed
5. Action
  Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
  Stated by East London NHS Foundation TrustStated completed
6. Action
  Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
  Stated by East London NHS Foundation TrustStated completed
7. Action
  Conduct senior-staff night visits with spot-check audits and observation of practice.
  Stated by East London NHS Foundation TrustStated completed
8. Action
  Continue reviewing escalation protocols for acuity, demand and staffing shortages, including task allocation, rapid resource deployment and reporting compromised care.
  Stated by East London NHS Foundation TrustStated planned
9. Action
  Review and relaunch use of the Standard Observation Measurement tool and its outputs to influence practice.
  Stated by East London NHS Foundation TrustStated planned
10. Action
  Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
  Stated by East London NHS Foundation TrustStated planned
11. Action
  Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
  Stated by East London NHS Foundation TrustStated in progress
12. Action
  Review the Human Factors Analysis findings and suggested improvements through senior leadership.
  Stated by East London NHS Foundation TrustStated planned
13. Action
  Develop a learning system linking internal incident and improvement learning with national observation-practice work.
  Stated by East London NHS Foundation TrustStated planned
14. Action
  Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
  Stated by East London NHS Foundation TrustStated planned
15. Action
  Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Mahamoud Hussain Ali · 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

Mahamoud Hussain Ali fell twice in the street on 19 August 2020 and was later detained under the Mental Health Act and transferred to Lea Ward. On 21 August 2020 he was found unresponsive and died in hospital on 26 August 2020. The principal concern was that required 15-minute observations were not conducted or were falsely recorded, and that subsequent Trust action had not been sufficient to ensure observations were conducted and recorded as required.

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 conduct required observations
Wider context from the report
“(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep. East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable. Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted. One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained. Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation. The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022. I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…” Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done.” Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur. ”
Source location
Mahamoud Hussain Ali · 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
Increase each ward shift by one unregistered Band 3 staff member and add a weekday Band 4 Life Skills Recovery Worker.

Verbatim wording from the response
“Overarching theme | Therapeutic engagement and observation improvement work undertaken Staffing/resource availability | Staff establishment reviews were undertaken in 22/23 and 23/24. Correct and agreed investments have gone into teams, increasing staff on each shift by one unregistered Band 3. Additional investment has been made for a Band 4 Life Skills Recovery Worker on Mondays to Fridays 9am to 5pm to increase the delivery of activities and opportunities for meaningful engagement.”

Source location
Response from ELFT
Page 2 · response
Published 31 July 2024
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
Review and update ward rotas for safer staffing, with advance senior approval and quarterly monitoring.

Verbatim wording from the response
“Staffing rotas for the wards have been reviewed and updated to reflect safer staffing requirements; senior approval of rotas is required six weeks in advance of the current period and quarterly rota monitoring meetings are in place.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
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 the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.

Verbatim wording from the response
“Staff competency | The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
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
Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.

Verbatim wording from the response
“Safety discussion sessions are facilitated weekly in directorates for all inpatient staff to review observation data, reflect on gaps in practice and disseminate learning.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
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 observation board relay to reduce missed observations and improve handover between staff.

Verbatim wording from the response
“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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 twilight shifts that add staffing during reduced activity periods and provide therapeutic activities.

Verbatim wording from the response
“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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 zonal observations to support continuous patient engagement and monitoring across wards.

Verbatim wording from the response
“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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
Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.

Verbatim wording from the response
“Standards of professional practice | Expected standards of practice have been communicated to staff, with frequent updates on improvement work since 2021 to date. In 2023, this specifically addressed accountability and responsibility for accurately documenting observations. It included the importance of honesty in documentation and gave guidelines for staff to follow for occasions when observations were missed. The Trust-wide Quality Improvement programme described above has introduced the observation relay board to reduce incidents of observations being left or not handed over.”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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
Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.

Verbatim wording from the response
“Audit and monitoring The Standard Observation Measurement (SOM) Tool was developed for oversight of rates of completion of all observations. Individual ward teams and directorates can access and use their data to drive continued improvement.”

Source location
Response from ELFT
Page 5 · response
Published 31 July 2024
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
Conduct senior-staff night visits with spot-check audits and observation of practice.

Verbatim wording from the response
“Night visits are undertaken by senior staff in directorates to monitor practice through spot check audits and observing work as it happens.”

Source location
Response from ELFT
Page 5 · response
Published 31 July 2024
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
Continue reviewing escalation protocols for acuity, demand and staffing shortages, including task allocation, rapid resource deployment and reporting compromised care.

Verbatim wording from the response
“Staffing/resource availability Continue to review escalation protocols to senior staff on site in response to changes in acuity or demand or if there are staff shortages on a shift. This is to include:”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Review and relaunch use of the Standard Observation Measurement tool and its outputs to influence practice.

Verbatim wording from the response
“Professional practice Review and relaunch use of SOM tool and outputs to impact on practice.”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.

Verbatim wording from the response
“Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.

Verbatim wording from the response
“Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Review the Human Factors Analysis findings and suggested improvements through senior leadership.

Verbatim wording from the response
“Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Develop a learning system linking internal incident and improvement learning with national observation-practice work.

Verbatim wording from the response
“Learning system To develop a learning system that includes learning from incidents and improvement work internally, but that also links in with national work in relation to observations practice.”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
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
Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.

Verbatim wording from the response
“To design an internal governance process for the review of reported cases of missed observations and learning that arises from this, that will report into the Patient Safety and Quality Assurance committees.”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
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
Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.

Verbatim wording from the response
“Standardised processes To develop a consistent approach to supporting staff to learn from incidents involving poor observations practice through reflection, personal accountability and, if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to establish a plan for close overnight observation

Concerns raised2

Reliance on subjective clinician judgment for decisions to perform physiological observations

Lack of a formal structure for the timing and frequency of physiological observations in the community

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to carry out observations every two hours

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to consult a supervising officer on ACCT observation levels

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to undertake clinical observations at the expected frequency

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of enhanced nursing observations for patients requiring them

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Failure to provide sufficiently frequent direct night-time visual observations

Actions described in response 4

Actions described in response 5

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 6