Recurring concern

Unreliable patient observation arrangements

First to latest report 28 Mar 2013 — 24 Jun 2026

Reports that mention this concern: 139
Times this concern has been raised: 174
Stated actions linked to this concern: 328

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.

What is 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

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

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

Reports and published responses 139 reports

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

8 Aug2022
Avon
Concerns raised2
1. Failure to allocate the appropriate ECO observation level following falls risk assessment
2. Failure by staff to understand and implement the ECO Policy
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Bristol NHS Foundation Trust
Stated actions 3
1. Bristol NHS Foundation Trust
  Implement the revised Enhanced Care Observation and Meaningful Activities Policy with non-numbered observation categories and holistic patient-needs guidance.
2. Bristol NHS Foundation Trust
  Strengthen the Enhanced Care Observation policy with North Bristol NHS Trust partners.
3. Bristol NHS Foundation Trust
  Provide affected staff groups with support, education, training, ward signs, meaningful-activities resources and task kits after policy approval.
Respondent positions 1
1. Bristol NHS Foundation Trust
  The patient’s admission presentation did not trigger higher observation because he was calm, oriented, engaged, and able to follow instructions.
  Disputes the concern
AI-generated summary

Mr Gerwyn John REES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Gerwyn John REES, who was elderly and frail, was admitted to hospital after experiencing falls and was assessed as requiring low-risk enhanced care observations. He fell twice on 29 November 2020, fracturing his hip, and later died in January 2021 following surgery, as a result of general frailty and the hip injury. The principal concerns were the initial low-risk falls assessment, inadequate steps to prevent the fall, and an apparent lack of learning and investigative rigour following his death.

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 allocate the appropriate ECO observation level following falls risk assessment
Wider context from the report
“• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020 • However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death • The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2 • Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment • When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time) • I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES • The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy • Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question • For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe. ”
Source location
Mr Gerwyn John REES · Prevention of Future Deaths report
Page 3 · 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
Failure by staff to understand and implement the ECO Policy
Wider context from the report
“• I find it very difficult to see how Mr REES could properly have been allocated to level 2 ECO observations (“low risk”) at the time of his initial falls risk assessment on 29 November 2020 • However, notwithstanding that initial concern on my part, I am more concerned by the apparent absence of learning following Mr REES’s death • The Trust’s Root Cause Analysis (‘RCA’) investigation/report (co-authored by ████████ a Matron / Senior Nurse) does not identify any issue or concern in respect of that initial allocation to ECO level 2 • Further – during the inquest – when I questioned the nurse who had approved the initial “Level 2” allocation on Ward A413 ████████ she initially maintained that ECO Level 2 was appropriate for Mr REES at that time, before later conceding to me that he should have been allocated to Level 3 observations from the outset and that ECO Level 2 was not an appropriate categorisation for him at the time of his initial falls risk assessment • When I then questioned ████████ (RCA co-author) about this same point, she too initially gave evidence that ECO Level 2 was a reasonable categorisation for Mr REES during the initial falls risk assessment, applying “clinical judgement” (albeit that she later accepted – I think – that it had not been an appropriate categorisation at that time) • I struggle to see how, as a senior nurse with responsibility for investigating an incident such as this and disseminating learning as a result of it, Nurse ████████ can have suggested to me that ECO 2 was ever appropriate for Mr REES • The lack of criticism of Mr REES’s initial risk allocation to ECO level 2 in the RCA report, coupled with these aspects of the live evidence of Nurse ████████ and Matron ████████ (see above) suggest to me that there was a lack of investigative rigour in the RCA reporting process, and/or that the ECO Policy was (and is) not properly understood by the staff involved in authoring the RCA, or in implementing the policy • Whilst it is relatively commonplace to see circumstances in which policies or standard operating procedures have not been properly understood or implemented on a ward, in real time, it is more concerning still to see circumstances such as these; in which even after the Trust’s investigation and learning process have been completed there does not appear to be an appreciation of where mistakes have been made: this of course means that there has been a missed opportunity to learn from the death in question • For completeness, I do not think that I am wrong in my interpretation of the ECO Policy, but if I am, and if – following that policy properly – a patient with a background such as Mr REES could properly be described as at “low risk” and requiring only the protection that is afforded by ECO level 2, then I would be very concerned that the policy itself was not fit for purpose, or safe. ”
Source location
Mr Gerwyn John REES · Prevention of Future Deaths report
Page 4 · 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 the revised Enhanced Care Observation and Meaningful Activities Policy with non-numbered observation categories and holistic patient-needs guidance.

Verbatim wording from the response
“As a direct result of this case, we have reconsidered our Enhanced Care Observation (ECO) and Meaningful Activities Policy and are in the process of implementing a revised policy to take on board our learning from this case. It is expected that this updated policy will be in place by November 2022. The updated policy removes the levels of 1, 2, 3, and 4 for ECO, which sometimes causes confusion amongst practitioners and replaces the levels for all inpatients requiring observations with:”

Source location
Response from University Hospital Bristol and Weston
Page 2 · response
Published 30 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen the Enhanced Care Observation policy with North Bristol NHS Trust partners.

Verbatim wording from the response
“In addition, to provide equitable and consistent care for all our patients, we will look at strengthening the ECO policy along with our partners in North Bristol NHS Trust.”

Source location
Response from University Hospital Bristol and Weston
Page 2 · response
Published 30 September 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide affected staff groups with support, education, training, ward signs, meaningful-activities resources and task kits after policy approval.

Verbatim wording from the response
“Once the updated policy has been approved, key staff groups affected by the ECO policy will be provided support, education, and training in applying the policy in practice. This will include display signs in ward areas, a meaningful activities list and task kits, and additional training to the ECO team from the dementia, delirium and falls team.”

Source location
Response from University Hospital Bristol and Weston
Page 3 · response
Published 30 September 2022
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 patient’s admission presentation did not trigger higher observation because he was calm, oriented, engaged, and able to follow instructions.

Verbatim wording from the response
“We have reflected on the Root Cause Analysis carried out in this case with particular regard to the concerns you have raised. When assessing the falls risk for new patients admitted to hospital, we consider many aspects including their past medical history, reason for admission, and the presentation of the patient at that time. In Mr Rees’ case he was assessed on admission and assigned ECO level 2. At the time of presentation Mr Rees was found to be alert, orientated, not agitated, and calm. Mr Rees was able to hold a coherent conversation and was able to understand instructions to sit and wait for help to assist him to mobilise. Mr Rees was not putting himself at risk e.g., he was not attempting to mobilise on his own. We recognised that Mr Rees was an elderly gentleman with a history of previous falls and underlying mental health and medical health issues.”

Source location
Response from University Hospital Bristol and Weston
Page 2 · response
Published 30 September 2022
Open published response
1 Jul2022
Manchester City
Concerns raised1
1. Failure to complete patient observations as directed
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Shona Christine Michaela Campbell · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

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 patient observations as directed
Wider context from the report
“3. Patient observations were not being completed as directed and accurate records were not being kept. ”
Source location
Shona Christine Michaela Campbell · Prevention of Future Deaths report
Page 6 · concerns
Open source report
3 Apr2022
Bedfordshire and Luton
Concerns raised1
1. Failure to perform critical clinical observations
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mandy Jane DICKERSON · 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

Mandy Jane Dickerson attended the Urgent GP Care Centre on 26 April 2020 after several days of diarrhoea and vomiting, but was discharged without assessment by the medical team. She died at home on 30 April 2020 from sepsis. The principal concerns included a non-mandatory and unreliable sepsis template, inadequate recording and communication of key observations, and confusion about referral responsibilities when specialist assessment was requested.

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 perform critical clinical observations
Wider context from the report
“4. There was in my view a failure to record and then to convey key information to the medical registrar who consequently may have given advice which was ill-informed. The nurse practitioner told me, in oral evidence and in a statement provided at the eleventh hour the night before the Inquest, that the measurements had been performed but simply not recorded. However, the remainder of the note was particularly and contemporaneously detailed with these critical observations being conspicuous in their absence. I found that the observations had not been made. In addition, no record was made of the name of the medical registrar making investigation of this element difficult. ”
Source location
Mandy Jane DICKERSON · Prevention of Future Deaths report
Page 3 · concerns
Open source report
4 Mar2022
Liverpool and the Wirral
Concerns raised1
1. Failure to conduct five-minute observations at frequent but unpredictable times
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Mersey Care NHS Foundation Trust
Stated actions 6
1. Mersey Care NHS Foundation Trust
  Issue urgent instructions on using and recording intermittent supportive observations.
2. Mersey Care NHS Foundation Trust
  Standardize language and roll out recording observations at unpredictable times within five-, ten- or fifteen-minute windows.
3. Mersey Care NHS Foundation Trust
  Conduct local audits, spot checks and additional dip audits to verify accurate, random-time recording of supportive observations.
1. Mersey Care NHS Foundation Trust
  Complete annual supportive-observation competency assessments and observed practice checks for inpatient staff across Clock View and other Local Division wards.
2. Mersey Care NHS Foundation Trust
  Revise the Ward Assurance Audit, operate interim recording changes and conduct weekly audits with findings shared through safety and clinical meetings.
3. Mersey Care NHS Foundation Trust
  Introduce an electronic system supporting unpredictable-interval supportive observations.
AI-generated summary

Sarah-Louise Jennifer Doyle · 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

Sarah-Louise Jennifer Doyle, aged 19, was found hanging in her room while detained under the Mental Health Act and subject to five-minute observations. She was taken to hospital but died at 01:40 on 27 February 2022; concerns were raised that observations were recorded at predictable times and may not have been precise.

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 five-minute observations at frequent but unpredictable times
Wider context from the report
“On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations. The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations. ”
Source location
Sarah-Louise Jennifer Doyle · 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
Issue urgent instructions on using and recording intermittent supportive observations.

Verbatim wording from the response
“I can confirm that in relation to supportive observations the following actions are already either complete or well underway:”

Source location
2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 8 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Standardize language and roll out recording observations at unpredictable times within five-, ten- or fifteen-minute windows.

Verbatim wording from the response
“2. On March the 8th 2022 the Regulation 28 was discussed at the local division safety huddle with all inpatient Matrons present. An immediate action was for them to discuss with their”

Source location
2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 8 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct local audits, spot checks and additional dip audits to verify accurate, random-time recording of supportive observations.

Verbatim wording from the response
“4. A local audit has been developed with Inpatient Matrons to check and provide assurance that recording the actual time service users were checked is taking place, as opposed to rounding to the nearest 5-minute time window. As additional assurance, spot checks are being undertaken by the Senior Leadership Team and Inpatient Matron/Ward Manager group.”

Source location
2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 8 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Complete annual supportive-observation competency assessments and observed practice checks for inpatient staff across Clock View and other Local Division wards.

Verbatim wording from the response
“6. Inpatient staff are required to have yearly competence assessments regarding supportive observations. All of the staff on the wards in Clock View will have had their yearly competency updated on the supportive observation policy and will have been observed in practice carrying out at least 2 supportive observations checks by the end of April 2022. All of the other wards across Local Division will be completed by the end of May 2022.”

Source location
2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 8 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revise the Ward Assurance Audit, operate interim recording changes and conduct weekly audits with findings shared through safety and clinical meetings.

Verbatim wording from the response
“9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.”

Source location
2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 3 · response
Published 8 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce an electronic system supporting unpredictable-interval supportive observations.

Verbatim wording from the response
“9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.”

Source location
2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 3 · response
Published 8 March 2022
Open published response
28 Feb2022
East London
Concerns raised1
1. Failure to keep hourly observations by the 1:1 carer
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Vijaykumar Girishbhai Gadhavi · 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

Vijaykumar Girishbhai Gadhavi died from a drug overdose while an in-patient at Whipps Cross Hospital under enhanced one-to-one care. The report raised concerns about breaches of the Enhanced Care Policy, the absence of an alert or risk-management plan, inadequate recording of property and medication, insufficient family involvement, and a lack of evidence that learning from earlier self-harming incidents had been implemented.

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 keep hourly observations by the 1:1 carer
Wider context from the report
“5. There were multiple breaches of the Enhanced Care Policy. There was no risk assessment by the allocated nurse; no consideration of the need to break up the shift of the 1:1 carer and no hourly observations kept by the 1:1 carer. ”
Source location
Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Jan2022
South Wales Central
Concerns raised1
1. Failure to establish safe levels of observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Manon Edie Jones · 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

Manon Edie Jones, aged 16, died from ligaturing shortly after being admitted to a mental health unit following self-harm and a deterioration in her mental health. The report identified concerns that clinicians did not have access to relevant community and hospital records, that clinical records were not entered contemporaneously in a single record, and that this impaired assessment, observation decisions and safeguarding.

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 safe levels of observations
Wider context from the report
“(3) The absence of a single in and outpatient clinical record impaired the ability of the clinicians at the unit on admission to be able to assess Manon, fix a safe levels of observations, and safeguard her. ”
Source location
Manon Edie Jones · Prevention of Future Deaths report
Page 2 · concerns
Open source report
8 Dec2021
Nottinghamshire
Concerns raised1
1. Untested observation-level support plans
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Heathcotes Group
Stated actions 2
1. Heathcotes Group
  Implement individualised observation care plans defining observation levels, responsibilities, methods, escalation, reduction decisions, and supporting documentation.
2. Heathcotes Group
  Install privacy-conscious CCTV near bedroom doors to review observation practice following events.
AI-generated summary

Rebecca Begg · 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

Rebecca Begg died at Heathcotes, Moorgreen, in the early hours of 15 September 2020 after a self-harm incident, and was found unresponsive despite resuscitation. The report identified concerns about monitoring compliance with care plans, the lack of robust incident reviews, untested observation-level support plans, staff involvement in care planning, and communication and escalation arrangements with the NHS trust.

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
Untested observation-level support plans
Wider context from the report
“As yet untested ‘observation level’ support plans ”
Source location
Rebecca Begg · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement individualised observation care plans defining observation levels, responsibilities, methods, escalation, reduction decisions, and supporting documentation.

Verbatim wording from the response
“Several changes have been made in regards to compliance with care plans. An observation care plan has been formulated for each individual which includes information about that person, levels of observations they may require and why, when and who can implement the observations, how to undertake the observations and what process is followed to increase or decrease the observations. The decision to decrease observations is made by at least three members of the MDT (comprising of members of the Clinical team, Senior Operations team, the Registered Manager, Senior Compliance Managers. At least one person involved in the decision making is from the Clinical team and the”

Source location
2021-0416-Response-from-Heathcotes-Group_Published
Page 1 · response
Published 16 December 2021
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
Install privacy-conscious CCTV near bedroom doors to review observation practice following events.

Verbatim wording from the response
“review is documented and stored for future reference. The care plan is written in detail and provides staff with clear guidance on exactly what action to take. This process has been tested and used several times since being implemented. The whole process has been reviewed by the MDT and amended or adjusted as required. The observation changes have also been tested, as we are now able to review the CCTV following an event, which has been installed in proximity to bedroom doors (whilst ensuring privacy for those we support). Several audits have taken place to ensure staff are adhering to the observations in place and the frequency of them.”

Source location
2021-0416-Response-from-Heathcotes-Group_Published
Page 2 · response
Published 16 December 2021
Open published response
25 Nov2021
Manchester South
Concerns raised1
1. Lack of standardised observation charts and completion rules on mental health wards
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dr Malcolm Dixon · 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

Dr Malcolm Dixon became unwell in autumn 2019 with what was later diagnosed as a severe depressive illness and was admitted as an informal, voluntary patient to Priory Hospital, Altrincham. He died there on 29 December 2019 following an impulsive act undertaken in the context of severe mental illness. Concerns included inaccurate observation records, electronic care-record timestamps being overwritten, and the absence of professional documentation requirements for some unregistered 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
Lack of standardised observation charts and completion rules on mental health wards
Wider context from the report
“1. Given the particular importance of documented observations being taken at specific intervals on mental health wards, it is a matter of concern that standardised observation charts (together with accompanying standard rules as to how they should be completed) are not in use across these settings both in the NHS and private sectors; ”
Source location
Dr Malcolm Dixon · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Aug2021
West Yorkshire Eastern
Concerns raised1
1. Lack of guidance for assessing vulnerable patients for overnight checks
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Mid Yorkshire Teaching NHS Trust
Stated actions 2
1. Mid Yorkshire Teaching NHS Trust
  Implement a standard operating procedure requiring documented hourly or two-hourly overnight visual checks based on patient location and risk.
2. Mid Yorkshire Teaching NHS Trust
  Disseminate interim overnight-check guidance to nursing teams across the Trust pending standard operating procedure implementation.
Respondent positions 2
1. Mid Yorkshire Teaching NHS Trust
  The existing Standard Observations Policy cannot accommodate overnight patient-checking guidance because it focuses on vital observations and escalation.
  Unable to act
1. Mid Yorkshire Teaching NHS Trust
  The Trust will not reintroduce intentional rounding because it was discontinued after becoming a tick-box exercise rather than meaningful checking.
  Unable to act
AI-generated summary

Mary Ann LINCOLN · 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

Mary Ann LINCOLN was admitted to Pinderfields General Hospital on 18 May 2020 and was discovered deceased on the floor of her room on 21 May 2020, with an open fracture of the tibia and fibula. The concerns identified included inadequate overnight checks for vulnerable patients at risk of falls and weaknesses in the circulation and understanding of the bedrails policy.

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 guidance for assessing vulnerable patients for overnight checks
Wider context from the report
“(1) During evidence it became apparent that there is no guidance or policy with regard to checks on patients overnight (who are not subject to NEWS, turning etc). Mrs Lincoln was put in to bed at around 2130 and only checked once in the night despite being in hospital, having a history of falls and knowledge of the fact she needed the toilet overnight. Although she had previously used the call buzzer she was also known to mobilise herself. She was not discovered until 0630, and then only because someone noticed as they passed her door. She had lain on the floor for some time, with an open fracture. The hospital conducted a serious incident review in which it recommended the checks policy should be reviewed. It appears it was reviewed but no changes were made. Evidence had been heard that previous rounding checks were deemed inappropriate and therefore no further action was required. Therefore there is no policy or guidance with regard to people who are vulnerable, a falls risk and known to get up in the night (for any reason) to be further assessed for checks overnight. ”
Source location
Mary Ann LINCOLN · 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 a standard operating procedure requiring documented hourly or two-hourly overnight visual checks based on patient location and risk.

Verbatim wording from the response
“The SOP will include the following:”

Source location
2021-0275-Response-from-Mid-Yorkshire-Hospitals_Published-1
Page 3 · response
Published 19 August 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate interim overnight-check guidance to nursing teams across the Trust pending standard operating procedure implementation.

Verbatim wording from the response
“Regardless of this activity, it is accepted that staff at the Trust would benefit from written guidance around the frequency of checks expected to take place overnight ████████”

Source location
2021-0275-Response-from-Mid-Yorkshire-Hospitals_Published-1
Page 3 · response
Published 19 August 2021
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 existing Standard Observations Policy cannot accommodate overnight patient-checking guidance because it focuses on vital observations and escalation.

Verbatim wording from the response
“As part of the Trust’s Serious Incident investigation it was identified as an action that there was a need to review or develop guidance for nursing staff surrounding the frequency of patient checks during a night shift. One option considered at the time was whether this guidance should be included as part of the Standard Observations Policy already in operation at the Trust. However, following discussions with the Matron for Quality and Patient Safety, it was felt that the existing policy was not a suitable vehicle to include this type of guidance, as the policy’s focus is on vital observations and escalation.”

Source location
2021-0275-Response-from-Mid-Yorkshire-Hospitals_Published-1
Page 2 · response
Published 19 August 2021
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 Trust will not reintroduce intentional rounding because it was discontinued after becoming a tick-box exercise rather than meaningful checking.

Verbatim wording from the response
“Reintroduction of an “intentional rounding observation tool” was also considered but as this tool had previously been discontinued because it had become a “tick-box” exercise, it was considered inappropriate to reintroduce it when meaningful (albeit quick) checks should occur.”

Source location
2021-0275-Response-from-Mid-Yorkshire-Hospitals_Published-1
Page 2 · response
Published 19 August 2021
Open published response
20 Jul2021
Norfolk
Concerns raised1
1. Failure to carry out one-to-one observations in accordance with policy
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ben Buster KING · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

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 one-to-one observations in accordance with policy
Wider context from the report
“2. CCTV was shown at the inquest which revealed Ben King had been assaulted in the hours prior to his death and also that 1 to 1 observation was not carried out in accordance with the Observations Policy. CCTV is a reliable means of ensuring that staff comply with Policies and residents are treated with dignity. CCTV is not available in many if not all of the residential homes owned by JHL and JRCSL. ”
Source location
Ben Buster KING · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Failure to allocate the appropriate ECO observation level following falls risk assessment

Failure by staff to understand and implement the ECO Policy

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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 complete patient observations as directed

Concerns raised1

Failure to perform critical clinical observations

Concerns raised1

Failure to conduct five-minute observations at frequent but unpredictable times

Linked response

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

Concerns raised1

Failure to keep hourly observations by the 1:1 carer

Concerns raised1

Failure to establish safe levels of observations

Concerns raised1

Untested observation-level support plans

Linked response

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

Concerns raised1

Lack of standardised observation charts and completion rules on mental health wards

Concerns raised1

Lack of guidance for assessing vulnerable patients for overnight checks

Linked response

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Stated actions 3

Respondent positions 1

Stated actions 6

Stated actions 2

Stated actions 2

Respondent positions 2