Recurring concern

Unreliable patient observation arrangements

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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.

15 Jul2021
Brighton and Hove
Concerns raised1
1. Failure to require staff compliance with therapeutic engagement and observation policy during night-time or presumed-sleeping 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 4
1. Action
  Strengthen internal monitoring of Policy compliance through weekly Ward Manager and monthly Matron reviews.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
2. Action
  Enhance therapeutic-observation training and competency assessment, including for agency and bank staff.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
3. Action
  Undertake a quality-improvement programme addressing observation competencies, individualised care, patient experience, and night-time observations including seclusion and physical observations.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
1. Action
  Consider technological aids to support patient safety and enhanced physical observation, including remote monitoring of respiration, movement and heart rate.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
AI-generated summary

Henry James Holcombe · 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

Henry James Holcombe’s death was investigated, and the inquest concluded that he died from natural causes. The report raised concerns about the ongoing failure to comply with therapeutic engagement and observation policies, including observations of patients described as asleep who were later found to have been dead for several hours.

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 require staff compliance with therapeutic engagement and observation policy during night-time or presumed-sleeping observations
Wider context from the report
“(1) The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 – page 5). Since 27.12.2019 to 5.3.2021 there have been three occasions when patients described as asleep over a series of observations, have actually been found to have been dead for several hours. Serious Incident reports have promised action but nothing effective has been produced. ”
Source location
Henry James Holcombe · 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
Strengthen internal monitoring of Policy compliance through weekly Ward Manager and monthly Matron reviews.

Verbatim wording from the response
“Specifically, in response to the findings of our investigation into Mr Holcombe's death, we have strengthened our internal monitoring arrangements to ensure the”

Source location
2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 1 · response
Published 3 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
Enhance therapeutic-observation training and competency assessment, including for agency and bank staff.

Verbatim wording from the response
“The Trust's actions, to date, in relation to this issue, have focused on staff training, competency and understanding of our Policy. This stipulates that: ‘If a member of staff is not able to observe the patient move or breath they must ensure the patient is conscious which will require entering the bedroom’ and staff competency and understanding of the Policy is assessed through competency checks. However, it is clear that further, sustained action is required to ensure that this requirement is fully understood and adhered to by all clinical staff.”

Source location
2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 1 · response
Published 3 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
Undertake a quality-improvement programme addressing observation competencies, individualised care, patient experience, and night-time observations including seclusion and physical observations.

Verbatim wording from the response
“Also, although Ms Hamilton-Deeley's concerns related particularly to safety at night, we have recognised that a systemic quality improvement approach is needed to ensure that therapeutic observations are of an appropriate standard. As a result, we are undertaking a robust programme of therapeutic observation Quality Improvement ('QI') work. The aim of this work is to improve the quality of therapeutic observations in terms of safety, effectiveness and experience; specifically, to ensure observations are therapeutic, individualised and skilled intervention that is responsive to a patient's needs, are least restrictive, and aimed at recovery. This QI work will give specific attention to:”

Source location
2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 2 · response
Published 3 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
Consider technological aids to support patient safety and enhanced physical observation, including remote monitoring of respiration, movement and heart rate.

Verbatim wording from the response
“Additionally, consideration is being given to the potential use of technological aids to support patient safety and enhanced physical observation, which includes an electronic system to remotely monitor a patient’s respiration, movement and heart rate and flags immediate changes to the patient’s physical presentation.”

Source location
2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 2 · response
Published 3 August 2021
Open published response
13 Jul2021
Inner South London
Concerns raised1
1. Failure to ensure adequate monitoring and observations for patients with severe pancreatitis
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.
Actions described in response 4
1. Action
  Provide enhanced nursing observation through the 24-hour Critical Care Outreach Team for patients managed outside critical care.
  Stated by Lewisham and Greenwich NHS TrustStated completed
2. Action
  Apply nationally derived critical-care admission criteria, with urgent intensive-care review within 60 minutes and admission or ward-management advice.
  Stated by Lewisham and Greenwich NHS TrustStated completed
3. Action
  Provide immediate critical-care doctor and outreach-nurse support, continuous trained staffing in the safest available area, and transfer to critical care when a bed becomes available.
  Stated by Lewisham and Greenwich NHS TrustStated completed
1. Action
  Use the SELACCN and SPRINT support agreement to facilitate transfer to the nearest available critical-care bed when local capacity is unavailable.
  Stated by Lewisham and Greenwich NHS TrustStated completed
Respondent positions 2
1. Position
  Patients not requiring critical care can receive adequate ward monitoring, cardiac monitoring where needed, and 24-hour enhanced nursing observation through CCOT.
  Stated by Lewisham and Greenwich NHS TrustExisting arrangements considered sufficient
1. Position
  Critical-care capacity constraints are addressed through immediate specialist support, safe interim care, and transfer arrangements to available local critical-care beds.
  Stated by Lewisham and Greenwich NHS TrustExisting arrangements considered sufficient
AI-generated summary

Abiodun Adisa ORITOGUN · 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 Abiodun Adisa Oritogun was admitted with severe acute pancreatitis, deteriorated on the ward, and died after collapsing while self-discharging; the inquest concluded that he died from complications of pancreatitis and ileus. Concerns included inadequate monitoring and escalation after his condition worsened, and uncertainty about whether patients with severe pancreatitis received an appropriate level of care and ITU referral.

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 ensure adequate monitoring and observations for patients with severe pancreatitis
Wider context from the report
“The coroner found that there were two concerns about medical care, namely 1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning. 2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year. Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level of care. ”
Source location
Abiodun Adisa ORITOGUN · 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 enhanced nursing observation through the 24-hour Critical Care Outreach Team for patients managed outside critical care.

Verbatim wording from the response
“Although Mr Oritogun was not referred to critical care for subsequent deterioration in his NEWS score, it is unlikely that his management would have changed through admission to ITU or HDU in the absence of organ failure. His nursing observation was enhanced through the provision of regular reviews by the Critical Care Outreach team (CCOT).”

Source location
Response from Lewisham and Greenwich NHS
Page 2 · response
Published 22 July 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
Apply nationally derived critical-care admission criteria, with urgent intensive-care review within 60 minutes and admission or ward-management advice.

Verbatim wording from the response
“Our criteria for admission to critical care (ITU or HDU) are the same as those adopted nationally. These criteria are derived from “Guidelines on admission to and discharge from Intensive Care and High Dependency Units” published by the Department of Health in March 1996; these guidelines are still applicable and current. The type of patients who require ITU care are unstable and have a requirement for multiple organ monitoring and/or support. Patients admitted to HDU are those requiring single organ support, or those who need observation and monitoring that cannot be safely provided on a general ward.”

Source location
Response from Lewisham and Greenwich NHS
Page 2 · response
Published 22 July 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
Provide immediate critical-care doctor and outreach-nurse support, continuous trained staffing in the safest available area, and transfer to critical care when a bed becomes available.

Verbatim wording from the response
“In the immediate response, we provide a critical care doctor (or airway trained anaesthetist) and a CCOT nurse to care for such patients wherever they may be, whether in the general wards, operating theatres, emergency department or elsewhere in the hospital.”

Source location
Response from Lewisham and Greenwich NHS
Page 3 · response
Published 22 July 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
Use the SELACCN and SPRINT support agreement to facilitate transfer to the nearest available critical-care bed when local capacity is unavailable.

Verbatim wording from the response
“As a secondary response, where an urgent bed is unlikely to become available within our own hospital critical care unit, we have a support agreement in place with the South-East London Adult Critical Care Network (SELACCN) and the Specialist Retrieval and Intensive Care Transfer service (SPRINT). The SPRINT team includes a critical care consultant, nurse and paramedic who can provide ITU and HDU level care in an ambulance, and operates its base from our own NHS Trust.”

Source location
Response from Lewisham and Greenwich NHS
Page 3 · response
Published 22 July 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
Patients not requiring critical care can receive adequate ward monitoring, cardiac monitoring where needed, and 24-hour enhanced nursing observation through CCOT.

Verbatim wording from the response
“Where patients with severe pancreatitis require such observation, monitoring or organ support, they would need to be referred by their team of ward doctors or responsible consultant surgeon to the critical care team. This would result in an urgent review by an intensive care doctor (within no longer than 60 minutes) and either admission to critical care or advice on further management being provided on how to continue a patient’s care and treatment on the general ward.”

Source location
Response from Lewisham and Greenwich NHS
Page 2 · response
Published 22 July 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
Critical-care capacity constraints are addressed through immediate specialist support, safe interim care, and transfer arrangements to available local critical-care beds.

Verbatim wording from the response
“In the immediate response, we provide a critical care doctor (or airway trained anaesthetist) and a CCOT nurse to care for such patients wherever they may be, whether in the general wards, operating theatres, emergency department or elsewhere in the hospital.”

Source location
Response from Lewisham and Greenwich NHS
Page 3 · response
Published 22 July 2021
Open published response
13 Jul2021
Gwent
Concerns raised1
1. Failure to perform patient observations at the required frequency
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 1
1. Action
  Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.
  Stated by Aneurin Bevan University LHBStated completed
AI-generated summary

Valmai Ann WEST · 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

Valmai West suffered falls on 11 and 16 January 2020, was admitted to hospital after fracturing her pubic ramus, and was later found unresponsive with an extensive subdural haemorrhage. She died at the Royal Gwent Hospital on 22 January 2020. The concern identified was that Emergency Department staffing levels may have contributed to observations not being performed in accordance with hospital protocol and NICE guidance, potentially putting future patients at risk.

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 patient observations at the required frequency
Wider context from the report
“During the course of the inquest, consideration was given to the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr ████████ Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ████████ assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department. Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk. ”
Source location
Valmai Ann WEST · 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
Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.

Verbatim wording from the response
“Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.”

Source location
2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 1 · response
Published 15 July 2021
Open published response
11 Jul2021
Mid Kent and Medway
Concerns raised2
1. Failure to carry out required observations following liver biopsy
2. Failure to record required observation levels in medical records
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 3
1. Action
  Develop a post-procedure handover form for use after every procedure.
  Stated by Medway NHS Foundation TrustStated completed
2. Action
  Require written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.
  Stated by Medway NHS Foundation TrustStated planned
3. Action
  Reiterate the post-procedure observation policy to nursing staff through recurring Big 4 ward messaging.
  Stated by Medway NHS Foundation TrustStated completed
AI-generated summary

Johanna Marie MORELAND · Prevention of Future Deaths report

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

Report summary

Johanna Marie Moreland died on 8 March 2021 at Medway Maritime Hospital following intra-abdominal haemorrhage after a liver biopsy, in the context of advanced hepatocellular carcinoma. Concerns included delays in receiving lumbar puncture results and starting antiviral treatment, and failure to follow or record required observations after the biopsy due to miscommunication between Trust staff.

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 required observations following liver biopsy
Wider context from the report
“(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records. ”
Source location
Johanna Marie MORELAND · Prevention of Future Deaths report
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
Failure to record required observation levels in medical records
Wider context from the report
“(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records. ”
Source location
Johanna Marie MORELAND · Prevention of Future Deaths report
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
Develop a post-procedure handover form for use after every procedure.

Verbatim wording from the response
“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location
2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 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
Require written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.

Verbatim wording from the response
“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location
2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 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
Reiterate the post-procedure observation policy to nursing staff through recurring Big 4 ward messaging.

Verbatim wording from the response
“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location
2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 2021
Open published response
8 Jul2021
Newcastle Upon Tyne and North Tyneside
Concerns raised1
1. Failure to provide observation at the level and frequency required by falls-risk assessment
This report raised 3 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
  Implement a ward observation chart specifying enhanced-observation levels and required frequencies.
  Stated by Northumbria Healthcare NHS Foundation TrustStated completed
2. Action
  Use AFLOAT across all hospital sites to set observation levels, with nurses documenting reasons for departing from its recommendation.
  Stated by Northumbria Healthcare NHS Foundation TrustStated completed
3. Action
  Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.
  Stated by Northumbria Healthcare NHS Foundation TrustStated in progress
1. Action
  Create electronic alerts notifying staff when scheduled patient observations are due.
  Stated by Northumbria Healthcare NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.
  Stated by Northumbria Healthcare NHS Foundation TrustExisting arrangements considered sufficient
1. Position
  AFLOAT determines observation levels rather than falls risk; falls risk is assessed separately under the Trust’s Falls Risk Assessment document.
  Stated by Northumbria Healthcare NHS Foundation TrustDisputes the concern
AI-generated summary

Benjamin Clark · 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

Benjamin Clark died in hospital on 17 January 2021 after a series of falls, including an unwitnessed fall on the ward, resulting in Acute on Chronic Subdural Haematomas. The concerns included an undocumented downgrading of his falls-risk assessment, unclear observation requirements, suboptimal record keeping, lack of observational charts, and insufficient written evidence of daily reassessment or reassessment after significant changes.

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 observation at the level and frequency required by falls-risk assessment
Wider context from the report
“2. Matron ████████ told me that at the time of the fall, Mr. Clark was under observation as though he was a Level 1 falls risk, despite being assessed as Level 2. Note keeping was suboptimal and there was a lack of clarity as to whether he should have been observed every 30 minutes or every 60 minutes. ”
Source location
Benjamin Clark · 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 a ward observation chart specifying enhanced-observation levels and required frequencies.

Verbatim wording from the response
“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 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
Use AFLOAT across all hospital sites to set observation levels, with nurses documenting reasons for departing from its recommendation.

Verbatim wording from the response
“The evidence provided to HM Assistant Coroner was that the AFLOAT tool was used in both hospitals and the AFLOAT assessment is kept on the ward. The AFLOAT assessment is a laminated chart, kept on all wards, which staff refer to for setting a level of observation, prior to adding onto NerveCentre. The evidence heard was that the AFLOAT tool had not been included within Mr Clark’s documentation. The evidence did not suggest that only NSECH used this tool in writing.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 3 · response
Published 9 July 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
Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.

Verbatim wording from the response
“4. Discussions are ongoing between the Matrons within NTGH in order to place the AFLOAT risk assessment and observation chart onto the electronic care record NerveCentre. The Trust can confirm that this will be done before the end of August 2021. Notwithstanding this, the documents are in use in paper form.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 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
Create electronic alerts notifying staff when scheduled patient observations are due.

Verbatim wording from the response
“5. Once the documentation is placed on NerveCentre, an electronic alert will be created for observations and will alert staff via a hand held electronic device that a particular patient observation is due, ensuring a more robust regime for observations. The level of observation set by a Registered Nurse is linked to the timed alert required for care rounding.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 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
Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.

Verbatim wording from the response
“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 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
AFLOAT determines observation levels rather than falls risk; falls risk is assessed separately under the Trust’s Falls Risk Assessment document.

Verbatim wording from the response
“As per paragraph 4, AFLOAT is in use in paper form. The Trust can confirm that AFLOAT is used by all hospital sites within the Trust to assist with setting the level of observation. However, the final decision is at the nurse’s professional judgement. The nurse should document their rationale if they do not agree with the AFLOAT recommendation.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 3 · response
Published 9 July 2021
Open published response
19 May2021
Manchester North
Concerns raised1
1. Failure to conduct agreed hourly welfare checks
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.

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

Liam Kenyon · 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

Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.

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Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to conduct agreed hourly welfare checks
Wider context from the report
“2. Having agreed with the support plan and this being confirmed in an email to staff, hourly checks were not conducted on Liam. ”
Source location
Liam Kenyon · Prevention of Future Deaths report
Page 1 · concerns
Open source report
30 Apr2021
East London
Concerns raised1
1. Failure to undertake required intermittent observations
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
  Require all inpatient nursing staff to complete and annually renew the observations competency checklist, with completion recorded and reported for oversight.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Review observation practice daily and through weekly night ward visits, discuss findings with Ward Matrons, and escalate compliance information through nursing leadership.
  Stated by East London NHS Foundation TrustStated in progress
3. Action
  Implement daily observation audits and a directorate data-reporting structure for reliable monitoring, governance review and local remedial action.
  Stated by East London NHS Foundation TrustStated in progress
1. Action
  Create an observations training module and ESR compliance record, deliver training annually, and report completion data for management and Board review.
  Stated by East London NHS Foundation TrustStated in progress
AI-generated summary

Rohan Dayal Singh · 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

Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to 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 undertake required intermittent observations
Wider context from the report
“2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated. ”
Source location
Rohan Dayal Singh · 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
Require all inpatient nursing staff to complete and annually renew the observations competency checklist, with completion recorded and reported for oversight.

Verbatim wording from the response
“One of the first steps being taken to address this problem is that all nursing staff (including new staff members and bank staff) working in Trust in-patient services must complete the observations competency checklist that forms part of the Trust’s Observation Policy by 30 June 2021. This is irrespective of whether they have completed the checklist in the past. Local Ward Matrons managing this process have been identified. They will send the staff records showing completed competency training to the Trust’s Learning and Development Team, who will upload the information on each Nurse’s ESR. The Matrons will then feed the information about compliance back to the Director of Nursing for senior oversight.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 3 · response
Published 5 May 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
Review observation practice daily and through weekly night ward visits, discuss findings with Ward Matrons, and escalate compliance information through nursing leadership.

Verbatim wording from the response
“Clinical Nurse Managers have already started reviewing nurses’ observation practice daily. They are also undertaking weekly night visits on the wards to observe compliance with the observation policy at night - as this has traditionally been overlooked.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 3 · response
Published 5 May 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
Implement daily observation audits and a directorate data-reporting structure for reliable monitoring, governance review and local remedial action.

Verbatim wording from the response
“A new system for auditing observations is being implemented. Templates for monitoring auditing observation practice were sent to the Borough Lead Nurses as of 30 May 2021 to be cascaded down to their respective teams. Ward Managers will complete the audits daily and report to Ward Matrons on the numbers of observations being undertaken properly and any patterns of failures or concerns.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 4 · response
Published 5 May 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
Create an observations training module and ESR compliance record, deliver training annually, and report completion data for management and Board review.

Verbatim wording from the response
“Nurse Observation Training Modules”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 4 · response
Published 5 May 2021
Open published response
4 Mar2021
Inner North London
Concerns raised1
1. Failure to implement specified monitoring of an intoxicated patient
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 7
1. Action
  Require formal observations and documentation for all patients, including those not receiving treatment, throughout attendance.
  Stated by Phoenix Hospital GroupStated completed
2. Action
  Re-audit formal observations quarterly to verify that the revised observation policy is followed for all patients.
  Stated by Phoenix Hospital GroupStated planned
3. Action
  Implement four-hourly ward observations with defined documentation, escalation tools, and clinical responsibilities from admission to discharge.
  Stated by Phoenix Hospital GroupStated completed
1. Action
  Implement a consultant-completed care plan for non-surgical patients, cancellations, and medical admissions, specifying observation frequency and discharge arrangements.
  Stated by Phoenix Hospital GroupStated completed
2. Action
  Establish a suspected-intoxication policy covering identification, monitoring, clinical intervention, escalation, transfer, and safeguarding.
  Stated by Phoenix Hospital GroupStated completed
3. Action
  Provide education and ongoing simulation on the suspected-intoxication policy for Weymouth and Phoenix Hospital Group staff.
  Stated by Phoenix Hospital GroupStated completed
4. Action
  Train ward staff through simulation on revised observation, transfer, deteriorating-patient, resuscitation, massive-transfusion, and intoxication policies.
  Stated by Phoenix Hospital GroupStated completed
Respondent positions 1
1. Position
  Formal observations were conducted on arrival and staff maintained visual observations, disputing that the patient received no observations.
  Stated by Phoenix Hospital GroupDisputes the concern
AI-generated summary

Paula Anne SPEIRS · 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

Paula Anne Speirs died following the ingestion of non-prescribed benzodiazepines before a planned procedure at Weymouth Street Hospital. The procedure was cancelled because staff considered her intoxicated, but she was allowed to sleep in a room without formal observations or specific monitoring instructions. The concerns included inadequate monitoring of an intoxicated patient and a lack of instructions to nursing staff on avoiding positional asphyxia.

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 implement specified monitoring of an intoxicated patient
Wider context from the report
“1. However, in spite of her intoxication at 7am (from what was at the time an unknown substance, initially presumed to be alcohol), no formal observations were ordered or undertaken. Her room was easily accessible, but nobody was specifically tasked with monitoring her. No instructions were given as to how frequently she should be checked, or what that checking should involve. 2. The nurses looking after Ms Speirs were not given any instructions on how to avoid positional asphyxia. When I asked them about this at inquest, they explained that they had not previously heard of positional asphyxia. I have encountered positional asphyxia most frequently in a custodial setting. Detainees in police cells are now subject to very clearly laid down procedures that attempt to reduce the risk of positional asphyxia and to reduce drink and drug related deaths. It seems to me an omission that there is not a similar regime in a hospital, where one would expect the medical care to be of a higher standard. ”
Source location
Paula Anne SPEIRS · 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
Require formal observations and documentation for all patients, including those not receiving treatment, throughout attendance.

Verbatim wording from the response
“The observation policy, in conjunction with the admission policy and departmental teaching, has modified operational procedures such that, moving forward, this patient would have had a full set of observations conducted and documented throughout their attendance at The Weymouth even though this does not occur routinely at other private or NHS hospitals. This information would then be passed on by the consultant to the patient’s GP for follow-up post-departure.”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 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
Re-audit formal observations quarterly to verify that the revised observation policy is followed for all patients.

Verbatim wording from the response
“It is our intention to re-audit on a quarterly basis to ensure our policy results in formal observations on all patients even if not having treatment.”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 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
Implement four-hourly ward observations with defined documentation, escalation tools, and clinical responsibilities from admission to discharge.

Verbatim wording from the response
“I enclose a copy of the ward observations, reporting and escalation policy which now formally states that all surgical and medical patients within The Weymouth will be observed at no less than 4-hour intervals from admission to discharge. It clearly outlines the documents which are present in specific locations that can be initiated by staff, such as neurological observations charts and the UK NEWS2 Charts which were already in use. The observation policy details the expectations that all clinical staff are required to follow regarding observation documentation including clear responsibilities amongst clinical staff.”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 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
Implement a consultant-completed care plan for non-surgical patients, cancellations, and medical admissions, specifying observation frequency and discharge arrangements.

Verbatim wording from the response
“I also enclose a formal care plan which has now been implemented and is to be in place for any non-surgical patient including cancellations of surgery or medical admissions. This is to be completed by the admitting Consultant. It clearly specifies the expectation from the Consultant on frequency of observation and a clear discharge pathway.”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 3 · response
Published 8 March 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
Establish a suspected-intoxication policy covering identification, monitoring, clinical intervention, escalation, transfer, and safeguarding.

Verbatim wording from the response
“We have also established a policy for the management of a suspected intoxicated patient, a copy of which is attached. This policy gives guidance on the management of a patient who attends in a state that appears intoxicated, including suspected or known, accidental or intentional overdose or poisoning of a known or unknown substance. The protocol includes conducting a rapid bedside toxicology saliva screen to detect and confirm the presence of cannabis, cocaine, opiates, amphetamines, benzodiazepines, methamphetamines and alcohol. This policy ensures the early identification of a suspected intoxicated patient, appropriate escalation, ongoing monitoring, clinical intervention, and process for escalation to facilities beyond The Weymouth’s capabilities. The policy ensures holistic and thorough management and considers safeguarding.”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 4 · response
Published 8 March 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
Provide education and ongoing simulation on the suspected-intoxication policy for Weymouth and Phoenix Hospital Group staff.

Verbatim wording from the response
“Education on this new policy, as well as ongoing simulations, has been undertaken for all Weymouth staff (and indeed all staff across Phoenix Hospital Group).”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 4 · response
Published 8 March 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
Train ward staff through simulation on revised observation, transfer, deteriorating-patient, resuscitation, massive-transfusion, and intoxication policies.

Verbatim wording from the response
“I also enclose copies of internal facilitator reports following Middlesex University simulation training in March 2021 as well as a report from internal simulation training conducted by the Clinical Governance and Risk Leads. During this training, ward staff received education on the revised Massive Transfusion Policy, Transfer Out Policy, Observation Policy, Deteriorating Patient and Resuscitation Policy and Suspected Intoxicated Patient Policy.”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 4 · response
Published 8 March 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
Formal observations were conducted on arrival and staff maintained visual observations, disputing that the patient received no observations.

Verbatim wording from the response
“████████, who was the lead Consultant responsible for her care, and Dr ████████, as her anaesthetist, examined her in the patient room and both undertook a lengthy consultation. Upon arrival to her room, a set of formal observations were conducted and documented in the patient’s notes. The nurses and RMO maintained visual observations for the duration of Ms Speirs stay.”

Source location
2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
Page 2 · response
Published 8 March 2021
Open published response
14 Dec2020
West Sussex
Concerns raised1
1. Failure to provide clear and consistent requirements for hourly observations of patients in their rooms
This report raised 6 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
  Refresh observation guidance and provide all staff with pocket reference cards supporting safe observation practice.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
2. Action
  Display easy-read observation guidance posters on all inpatient wards.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
3. Action
  Update mandatory observation training and competencies, requiring annual completion and induction completion before agency or bank staff shifts.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
1. Action
  Introduce a Trust-wide nursing competency framework and checklist requirements for documenting patient activity on observation charts.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  No policy changes were considered necessary because the incident resulted from staff failing to adhere to the existing Therapeutic Engagement and Observation Policy.
  Stated by Sussex Partnership NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Christopher Swain · 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

Christopher Swain, who was detained under Section 3 of the Mental Health Act 1983, was found unresponsive in his room at Langley Green Hospital on 22 September 2019 with a ligature around his neck and was confirmed deceased by paramedics. Concerns included inconsistent staff practices when conducting observations, uncertainty about when he was last seen alive, the absence of a formal mental health review, care plan and adequate risk assessment, inadequate record-keeping, no recorded therapeutic engagement, and failure to provide staff to accompany a sectioned patient to another hospital.

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 clear and consistent requirements for hourly observations of patients in their rooms
Wider context from the report
“a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff. b) Following the evidence the Jury concluded:- (a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health. (b) that the nursing and clinical records were not kept in accordance with the trust health and record policy. (c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay. Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case. c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at risk ”
Source location
Christopher Swain · 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
Refresh observation guidance and provide all staff with pocket reference cards supporting safe observation practice.

Verbatim wording from the response
“i. Guidance on observations was refreshed to support staff competency and implementation. All staff now have a pocket guide z card on conducting observations, this can be utilised as an aide memoire and reference guide.”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 6 January 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
Display easy-read observation guidance posters on all inpatient wards.

Verbatim wording from the response
“ii. An easy read poster guide on observations is also now available on all inpatient wards.”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 6 January 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
Update mandatory observation training and competencies, requiring annual completion and induction completion before agency or bank staff shifts.

Verbatim wording from the response
“iii. Training and competencies on completing observations has been updated. This training is mandatory and must be completed annually and at induction for all agency and bank staff before they are able to commence a shift. There has been evidence submitted of staff completion and ongoing adherence to the requirement for each staff member to complete the induction checklist which includes observations. As of December 2020 there is a 100% compliance for staff who have completed training in Therapeutic Engagement and Observation competency assessments at Langley Green Hospital.”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 6 January 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
Introduce a Trust-wide nursing competency framework and checklist requirements for documenting patient activity on observation charts.

Verbatim wording from the response
“A new competency framework has been developed and introduced Trust wide to strengthen our systems and processes which reinforces the requirement of stating on the observation chart, the activity of the patient rather than ticking to evidence their presence on the ward. Each member of the Trust inpatient Nursing Team has been required to individually complete the competency check list and such is now integral to the Bank and Agency staff induction checklists - Trust-wide. There is particular focus on this point included in the Eight Steps to Quality and Safety poster now present in the nursing offices across the Trust acute wards. The evidence of all Langley Green Hospital staff completion and ongoing adherence to the requirement for each staff member to complete the induction checklist, which includes observations, has already been submitted to the Court.”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 6 January 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
No policy changes were considered necessary because the incident resulted from staff failing to adhere to the existing Therapeutic Engagement and Observation Policy.

Verbatim wording from the response
“In light of the clinical care review conducted in the wake of Christopher’s death, the Trust reconsidered its Therapeutic Engagement and Observation Policy. I and my Clinical, Operational and Service Directors were satisfied that no changes to Policy were required. The issue that arose in Christopher’s care was quite clearly, a lack of adherence to Trust Policy by staff. To prevent reoccurrence of non-compliance with Trust Policy within Langley Green Hospital and elsewhere within the Trust, the following actions were taken across all inpatient services:”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 2 · response
Published 6 January 2021
Open published response
10 Dec2020
Sunderland
Concerns raised1
1. Lack of clarity about required observation frequency for residents at risk of falls
This report raised 6 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 3
1. Action
  Issue updated resident belongings, resident admission, and falls management policies across the Group, with staff read-and-sign confirmation and Alexandra View supervision sessions.
  Stated by Roseberry Care Centres GB LimitedStated completed
2. Action
  Introduce an Observation and Monitoring form, update the Falls Risk Assessment, and require at least hourly sensor-mat checks throughout each shift with daily senior-management monitoring at Alexandra View.
  Stated by Roseberry Care Centres GB LimitedStated planned
3. Action
  Repeat Prevention and Management of Falls training for Alexandra View staff.
  Stated by Roseberry Care Centres GB LimitedStated completed
AI-generated summary

Edward Mallaby · 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

Edward Mallaby died after a boxed television fell onto him in his room at Alexandra View Care Home, causing injuries, bedbound status and pneumonia. Concerns included the handling and secure storage of potentially hazardous personal property, failure or absence of alerts when he was out of bed, unclear observation arrangements, and the lack of a rapid learning exercise or deadline for policy and training review.

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 clarity about required observation frequency for residents at risk of falls
Wider context from the report
“4. Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations, or whether the door to his room was to be open or not. ”
Source location
Edward Mallaby · 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
Issue updated resident belongings, resident admission, and falls management policies across the Group, with staff read-and-sign confirmation and Alexandra View supervision sessions.

Verbatim wording from the response
“Please find enclosed updated policies in respect of:”

Source location
2020-0277-Response-from-Roseberry-Care-Centres-Redacted
Page 1 · response
Published 6 January 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
Introduce an Observation and Monitoring form, update the Falls Risk Assessment, and require at least hourly sensor-mat checks throughout each shift with daily senior-management monitoring at Alexandra View.

Verbatim wording from the response
“In addition, I have introduced an Observation and Monitoring form (also enclosed) to be used in accordance with the updated Management and Prevention of Falls policy and updated the Falls Risk Assessment to reference this new record (attached). At the time of Mr Mallaby’s accident, sensor mats were checked at each shift changeover and recorded on the handover by the person in charge. The introduction of this form will ensure sensor equipment is checked for its position and that it is in working order throughout the shift and a minimum of hourly. This amendment to policy and additional checking is being monitored daily at Alexandra View by on site senior management.”

Source location
2020-0277-Response-from-Roseberry-Care-Centres-Redacted
Page 2 · response
Published 6 January 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
Repeat Prevention and Management of Falls training for Alexandra View staff.

Verbatim wording from the response
“The staff at Alexandra View have also repeated their Prevention and Management of Falls training to refresh their knowledge; all staff successfully completed this by 7th January 2021.”

Source location
2020-0277-Response-from-Roseberry-Care-Centres-Redacted
Page 2 · response
Published 6 January 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to require staff compliance with therapeutic engagement and observation policy during night-time or presumed-sleeping observations

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 ensure adequate monitoring and observations for patients with severe pancreatitis

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

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

Concerns raised1

Failure to perform patient observations at the required 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.1

Concerns raised2

Failure to carry out required observations following liver biopsy

Failure to record required observation levels in medical records

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.3

Concerns raised1

Failure to provide observation at the level and frequency required by falls-risk assessment

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

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

Concerns raised1

Failure to conduct agreed hourly welfare checks

Actions described in response 4

Actions described in response 4

Respondent positions 2

Actions described in response 1

Actions described in response 3

Actions described in response 4

Respondent positions 2