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.

27 Oct2025
Black Country
Concerns raised1
1. Lack of clarity regarding required intervals for observation checks
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
  Implement and communicate a clear 15-minute requirement for Level 2 intermittent observations through policy, training materials and intranet resources.
  Stated by Black Country Healthcare NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Trust policies, training and resources unambiguously require Level 2 intermittent observations within 15 minutes and contain no reference to 30 minutes.
  Stated by Black Country Healthcare NHS Foundation TrustDisputes the concern
AI-generated summary

Shannon Lee Jordan · 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

Shannon Lee Jordan was admitted to hospital after her mental health deteriorated and she reported plans to run in front of cars. While detained and subject to observations, she was found unresponsive after tying a ligature around her neck and was pronounced deceased on 1 March 2023. The principal concern was confusion about whether 15-minute observations could be completed within a 15-to-30-minute range, with no national standard for observation intervals.

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 regarding required intervals for observation checks
Wider context from the report
“2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes. 3. There is no national standard, and each Trust can implement its own time interval for observation checks to be completed. ”
Source location
Shannon Lee Jordan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement and communicate a clear 15-minute requirement for Level 2 intermittent observations through policy, training materials and intranet resources.

Verbatim wording from the response
“2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.”

Source location
Response from Black Country Healthcare NHS Foundation
Page 1 · response
Published 26 January 2026
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
Trust policies, training and resources unambiguously require Level 2 intermittent observations within 15 minutes and contain no reference to 30 minutes.

Verbatim wording from the response
“2. My concern is that despite a new Policy being implemented by the Trust, which specifies that 15-minute observations should be recorded via the electronic tablet at 15-minute intervals. There remains, some confusion and lack of clarity whether the 15-minute time interval can fall within a range of 15 to 30 minutes.”

Source location
Response from Black Country Healthcare NHS Foundation
Page 1 · response
Published 26 January 2026
Open published response
24 Oct2025
Essex
Concerns raised1
1. Failure to undertake Level 2 intermittent observations at the required frequency
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 6
1. Action
  Shift observation practice toward therapeutic engagement through updated guidance and training.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Re-undertake Observation and Engagement competencies for the staff member requiring renewed training.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
3. Action
  Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
1. Action
  Deliver focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Stephen John Neville · Prevention of Future Deaths report

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

Report summary

Stephen John Neville, aged 68, was an informal inpatient at Beech Ward for planned ECT after a history of severe treatment-resistant depression, anxiety, agitation, and repeated suicide attempts. He died by hanging while in hospital. The report identified concerns including failures in risk communication and assessment, abrupt medication changes, inadequate therapeutic observations and engagement, insufficient auditing and quality assurance, and failure to mitigate risks associated with an unlocked shower room.

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 Level 2 intermittent observations at the required frequency
Wider context from the report
“1. There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations. Members of support staff demonstrably misunderstood (and appear to still misunderstand) the nature and purpose of Level 2 ‘intermittent’ (4 to 5 times) hourly observations, apparently routinely conducting such observations every 15 minutes on the hour, the quarter past and so on. Whilst the observations, when made, recorded the location of the patient and (very occasionally) noted what the patient may be doing, nothing was recorded in respect of an interaction or therapeutic engagement, as required by Trust policy. Such a lack of understanding of the basic role of the support worker and/or nursing staff in undertaking such critically important roles disclosed an (on-going) deficit in training. 2. Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT. A purported weekly quality assurance check being undertaken by the Ward Manager in December 2021, which claimed “an audit score of 100%”, was entirely at odds with the evidence at inquest which revealed repeated and significant inadequacies in the nature and quality of the observations undertaken and recorded. 3. Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: “I have no audit tool …. I am not confident that the audits are accurate and complete now … there is no audit process in place to check the quality of observation and engagement documentation.” 4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” 5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
Source location
Stephen John Neville · 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
Shift observation practice toward therapeutic engagement through updated guidance and training.

Verbatim wording from the response
“Response: In line with the details set out in the Trust’s learning statement filed with the Court, with respect to the Trust’s approach to Observation and Engagement, the Trust continues to shift focus to Therapeutic engagement rather than observation alone. This aligns with the national working group the Trust participated in across 2024 and led to the development of the Mental Health / Learning Disability Nurse Director guidance document.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 1 · response
Published 5 November 2025
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-undertake Observation and Engagement competencies for the staff member requiring renewed training.

Verbatim wording from the response
“At this Inquest it was evident that one Health Care Assistant (HCA) did not understand the requirements of level 2 observation in relation to the random nature of level 2 observations. It is of that that they had been absent from work for a period of 9 months before the inquest. The Ward Manager is working with this staff member to re-undertake Observation and Engagement Competencies.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.

Verbatim wording from the response
“The Ward Manager has also undertaken a check of all staff Observation and Engagement competencies to ensure confidence in current staff practice. As part of this process the Ward Manager checked that all staff have completed Oxevision E-Observation training, which includes training on documenting o-benservations to ensure therapeutic engagement is captured. This ensures a focus on the quality of the therapeutic engagement and observation.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Deliver focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.

Verbatim wording from the response
“To further enhance Trust routine online training, the Ward Manager is providing a number of focused face to face training sessions with ward staff to further gain assurance around interpretation and understanding. This will include highlighting the importance of recording therapeutic engagement and space for reflection on learning. This is due to be completed by the end of December 2025.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.

Verbatim wording from the response
“As part of the Trustwide learning response, the learning from this inquest has been shared through the care unit quality and safety meeting to ensure shared learning across the wider care unit. This has also been shared with the Training team with a specific focus on Oxevision e-observation training to ensure this training robustly guides staff on engagement techniques and importance of the quality of recording of the engagement. This training was reviewed in February 2025 following the Trust’s recent review of the Oxevision SOP.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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 three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.

Verbatim wording from the response
“Building on this review, further enhancements were introduced following inquest-related reflections. In November 2025, three new Oxevision audits were implemented to strengthen oversight of observation and therapeutic engagement, incorporating both staff and patient feedback:”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 3 · response
Published 5 November 2025
Open published response
7 Aug2025
County Durham and Darlington
Concerns raised1
1. Failure to prevent erroneous reductions in the frequency of care rounds
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
  Deliver education to the ward team distinguishing care rounding from observation frequency and reinforcing required clinical justification and oversight.
  Stated by County Durham and Darlington NHS Foundation TrustStated completed
2. Action
  Conduct organisation-wide audits to identify incorrect care-rounding practices and regularly monitor that correct practices remain embedded.
  Stated by County Durham and Darlington NHS Foundation TrustStated completed
3. Action
  Provide remedial education to teams where similar care-rounding practices are identified.
  Stated by County Durham and Darlington NHS Foundation TrustStated completed
AI-generated summary

Victor Jackson HUTCHENS · 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

Victor Jackson HUTCHENS died at Darlington Memorial Hospital on 27 February 2025 as a result of an accidental fall causing a head injury. A week before his death, care rounds were mistakenly reduced from hourly to four-hourly, raising concern that the error could recur and cause or contribute to a future death, although the inquest found it could not be said on a balance of probabilities that the error 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 prevent erroneous reductions in the frequency of care rounds
Wider context from the report
“On 20 February 2025, a week before the deceased's death, the frequency of care rounds was reduced, in error, from hourly to four-hourly. The member of staff responsible for the error is unaware of how the error occurred. That being the case, there is a concern that the error could occur again and could cause or contribute to a future death. ”
Source location
Victor Jackson HUTCHENS · 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
Deliver education to the ward team distinguishing care rounding from observation frequency and reinforcing required clinical justification and oversight.

Verbatim wording from the response
“In response, we have undertaken a comprehensive education programme with the ward team to clarify the distinct purposes of care rounding and observation frequency, and to reinforce that neither should be reduced without appropriate clinical justification and oversight.”

Source location
Response from County Durham and Darlington NHS Foundation Trust
Page 1 · response
Published 13 August 2025
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 organisation-wide audits to identify incorrect care-rounding practices and regularly monitor that correct practices remain embedded.

Verbatim wording from the response
“We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas.”

Source location
Response from County Durham and Darlington NHS Foundation Trust
Page 1 · response
Published 13 August 2025
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 remedial education to teams where similar care-rounding practices are identified.

Verbatim wording from the response
“We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas.”

Source location
Response from County Durham and Darlington NHS Foundation Trust
Page 1 · response
Published 13 August 2025
Open published response
23 Jun2025
Inner North London
Concerns raised1
1. Failure to conduct patient observations in accordance with observation policy
This report raised 8 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
  Roll out a supportive-observation template requiring staff to check and record signs of life, and incorporate it into Trust policy.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Provide bank-shift induction covering ward procedures and observation requirements, while prioritizing trained regular bank staff.
  Stated by North London NHS Foundation TrustStated in progress
3. Action
  Monitor observation sheets daily and reconcile weekly CCTV and documentation reviews, with increased nurse-leader visibility.
  Stated by North London NHS Foundation TrustStated completed
AI-generated summary

Louise Elizabeth Amy Crane · 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

Louise Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action plan.

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 patient observations in accordance with observation policy
Wider context from the report
“5) Observations on Topaz Ward The Trust’s own internal investigation highlighted issues regarding the review of required observation levels. However, the evidence at inquest, in relation to the observation round at or about 11:30 on 19 September raised a further concern, albeit this did not cause / contribute to Ms Crane’s death in the particular circumstances. The evidence was that the support worker conducting this check did not see any part of Ms Crane, and on trying to open the door there was some resistance. As such, the assumption was made that Ms Crane was sat with her back to the door, and the support worker marked Ms Crane as being in her room and moved on to the next room. This raises the concern that observations being undertaken do not always comply with the Trust’s own observation policy and that there may be a staff training / knowledge gap in this regard. ”
Source location
Louise Elizabeth Amy Crane · 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
Roll out a supportive-observation template requiring staff to check and record signs of life, and incorporate it into Trust policy.

Verbatim wording from the response
“Observations on Topaz Ward We recognise that observations are an area that have presented challenges for the organisation but we are committed to getting this right; observations are central to ensuring patient safety on our wards. There is also a need for consideration of patients’ privacy and dignity and to ensure that they are conducted in a way which is not unnecessarily intrusive. Following a review of observations as part of the EMS and learning from the BLPI, a new template has been piloted on three wards. This specifically prompts staff undertaking observations to check for and record Signs of Life. Staff are expected to enter the patient’s room and check their level of alertness/breathing where this is not immediately apparent, for example, by looking for chest movement when a patient is sleeping.”

Source location
Response from North London NHS Foundation Trust
Page 7 · response
Published 14 July 2025
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 bank-shift induction covering ward procedures and observation requirements, while prioritizing trained regular bank staff.

Verbatim wording from the response
“Use of bank staff presents a challenge as they may not receive the same training as substantive staff. We are addressing this through the recruitment referred to earlier which will reduce our reliance on bank staff, and where we do use bank staff, wherever possible these will be from a regular pool of staff who are trained on Trust policies and procedures. We are also ensuring all staff working a bank shift receive an induction to the ward which includes how to carry out observations.”

Source location
Response from North London NHS Foundation Trust
Page 7 · response
Published 14 July 2025
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
Monitor observation sheets daily and reconcile weekly CCTV and documentation reviews, with increased nurse-leader visibility.

Verbatim wording from the response
“Observation sheets are now monitored daily by the Nurse in Charge, Ward Manager, Matron, and out of hours via the Senior Site Coordinators. In addition, the Division has initiated a weekly CCTV and documentation review and reconciling these. This is undertaken by the Ward Managers and Matrons to ensure that documentation is accurate and up to date. We have also increased visibility of Nurse Leaders (Ward Managers, Matrons and members of the Senior Leadership Team) to support this work. As of August, the role of the Matrons has changed so that they are now focussed on clinical, rather than operational duties, with an emphasis on improving nursing standards and the quality of care.”

Source location
Response from North London NHS Foundation Trust
Page 8 · response
Published 14 July 2025
Open published response
20 Jun2025
Inner North London
Concerns raised2
1. Lack of paediatric nursing observations
2. Failure to complete final nursing observations before discharge
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 20
1. Action
  Publish standards requiring emergency departments to use a specific paediatric early warning score with appropriate triggers and actions.
  Stated by Royal College of Emergency MedicineStated completed
2. Action
  Design and pilot a revised paediatric early warning score for emergency departments.
  Stated by Royal College of Emergency MedicineStated in progress
3. Action
  Provide vital-signs, escalation, local-induction and policy training to nurses and other clinical staff, including triage competency training.
  Stated by Whittington Health NHS TrustStated completed
1. Action
  Require complete triage vital-sign sets for children with medical complaints and escalate abnormal or repeat observations using PEWS and national guidance.
  Stated by Whittington Health NHS TrustStated completed
2. Action
  Conduct monthly, random manual and quarterly governance audits of vital-sign observation compliance, providing feedback and identifying training needs.
  Stated by Whittington Health NHS TrustStated completed
3. Action
  Embed PEWS and observation escalation in multidisciplinary simulation training for emergency and paediatric teams.
  Stated by Whittington Health NHS TrustStated completed
4. Action
  Deploy electronic vital-sign devices, upgrade the nurse-in-charge workstation and update the paediatric emergency digital medical record and assessment proforma.
  Stated by Whittington Health NHS TrustStated completed
5. Action
  Review paediatric emergency staffing against safer-nursing-care data and professional judgement, resulting in additional nursing staff, with ongoing safety-level monitoring.
  Stated by Whittington Health NHS TrustStated completed
6. Action
  Allocate paediatric emergency cubicles and patient cohorts to designated nurses to establish responsibility and continuity of care.
  Stated by Whittington Health NHS TrustStated completed
7. Action
  Monitor observation-compliance safety through clinical governance committees and report to the Patient Safety Group and Trust Board.
  Stated by Whittington Health NHS TrustStated in progress
8. Action
  Continue staff training and induction on complete observations and escalation, including the content in paediatric emergency simulation training.
  Stated by Whittington Health NHS TrustStated in progress
9. Action
  Continue advocating locally and nationally for active reduction of paediatric staffing rota gaps.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
10. Action
  Revise and update emergency-care standards to clarify observations as holistic care, including frequency determined by the child’s wellbeing.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
11. Action
  Collaborate with NHS England and RCPCH to develop a single national paediatric early warning system for England.
  Stated by Royal College of NursingStated in progress
12. Action
  Produce educational material supporting implementation of the System-wide Paediatric Observations Tracking Programme.
  Stated by Royal College of NursingStated completed
13. Action
  Collaborate with RCPCH to revise emergency care standards for children and young people, including requirements concerning observations.
  Stated by Royal College of NursingStated in progress
14. Action
  Require paediatric clerking documentation to specify the frequency of observations.
  Stated by Whittington Health NHS TrustStated completed
15. Action
  Require review of vital signs before paediatric discharge through the ED discharge checklist and audit its use regularly.
  Stated by Whittington Health NHS TrustStated completed
16. Action
  Disseminate the ED paediatric discharge checklist at emergency, surgical and paediatric inductions and thereafter at future medical inductions.
  Stated by Whittington Health NHS TrustStated planned
17. Action
  Conduct quarterly audits of paediatric discharge-checklist compliance and present results to the divisional quality meeting.
  Stated by Whittington Health NHS TrustStated planned
Respondent positions 1
1. Position
  Individual nursing practice and the reported concerns fall outside the organisation’s regulatory functions and authority.
  Stated by Royal College of NursingOutside remit
AI-generated summary

Finlay Joshua ROBERTS · 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

Finlay’s parents took him to Whittington Hospital the night before he died, during an extremely busy and understaffed night in the paediatric emergency department. The report describes failures to conduct serial nursing observations, complete appropriate tests, and obtain specialist advice before Finlay was discharged home. The principal concerns were that missing nursing observations may be a wider issue and that medical staff failed to recognise that the observations had not been carried out.

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 paediatric nursing observations
Wider context from the report
“The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff. However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks. I remain concerned on two counts: 1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual. 2. The medical staff at the Whittington did not recognise the lack of nursing observations. • Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent. • The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged. ”
Source location
Finlay Joshua ROBERTS · 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 complete final nursing observations before discharge
Wider context from the report
“The lack of serial nursing observations was a fundamental omission from Finlay’s care. I heard at inquest that there have been many improvements in the paediatric emergency department at the Whittington since his death, not least of which has been the addition of more nursing staff. However, a lack of paediatric nursing observations is a subject about which I wrote a PFD report on 13 March 2025 to a different hospital (the Royal Free) following the death of Billie Wicks. I remain concerned on two counts: 1. A lack of nursing observations may be a much wider issue than is recognised. In my experience there is nothing about the Whittington and the Royal Free that stands out as unusual. 2. The medical staff at the Whittington did not recognise the lack of nursing observations. • Observations were thought to be acceptable because they were not reported as otherwise, when in fact they were absent. • The discharging doctor decided that, if his final observations were normal Finlay could go home. Those observations were never carried out, but Finlay was nevertheless discharged. ”
Source location
Finlay Joshua ROBERTS · 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
Publish standards requiring emergency departments to use a specific paediatric early warning score with appropriate triggers and actions.

Verbatim wording from the response
“The standards that RCEM published in 2024 in Guidelines for the provision of Emergency Services include that “Emergency Departments must use a specific paediatric early warning score and ensure that appropriate triggers and actions are in place.” All Paediatric early warning scores dictate how often observations should be checked depending on the age of the child and initial observations.”

Source location
2025-0316 Response from Royal College of Emergency Medicine
Page 1 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Design and pilot a revised paediatric early warning score for emergency departments.

Verbatim wording from the response
“RCEM is involved in the design and piloting of a revised paediatric early warning score specifically intended for Emergency Departments.”

Source location
2025-0316 Response from Royal College of Emergency Medicine
Page 1 · response
Published 14 July 2025
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 vital-signs, escalation, local-induction and policy training to nurses and other clinical staff, including triage competency training.

Verbatim wording from the response
“• Training & Induction Enhancements: ◦ All new nurses now receive training on vital signs monitoring and escalation during induction and in-house triage training. This ensures that all new starters have a foundational understanding of the importance of recording and escalating abnormal observations from the outset. All clinical staff are also required to familiarise themselves with the department’s common presentation policies during their induction.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 1 · response
Published 14 July 2025
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 complete triage vital-sign sets for children with medical complaints and escalate abnormal or repeat observations using PEWS and national guidance.

Verbatim wording from the response
“◦ At triage a complete set of vital signs appropriate to their clinical presentation is required for every child presenting to the department with a medical complaint. This standard has been reinforced through the Emergency Department Triage Training Study Day, which all triage nurses attend. These triage observations will be as recommended by the Royal College of Emergency Medicine (RCEM)”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 2 · response
Published 14 July 2025
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 monthly, random manual and quarterly governance audits of vital-sign observation compliance, providing feedback and identifying training needs.

Verbatim wording from the response
“• Monthly and Manual Audits: ◦ Monthly audits of compliance with vital sign observations have been instituted with the support of the Information Requests Team, with outcomes reviewed by the paediatric emergency department senior team. These will be used to identify ongoing training needs and support continuous improvement with feedback to the team.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 2 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Embed PEWS and observation escalation in multidisciplinary simulation training for emergency and paediatric teams.

Verbatim wording from the response
“• Simulation Training with PEWS: ◦ Paediatric Early Warning Scores (PEWS) have been embedded into multidisciplinary simulation training. These simulations take place on alternative Thursdays, including the children’s and young people department which allows collaborative learning for acute Paediatrics.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 2 · response
Published 14 July 2025
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
Deploy electronic vital-sign devices, upgrade the nurse-in-charge workstation and update the paediatric emergency digital medical record and assessment proforma.

Verbatim wording from the response
“• Electronic Monitoring Enhancements: ◦ Four additional electronic devices have been deployed in the department to facilitate real-time recording and review of vital signs. Each Nursing staff member has access to an electronic device for inputting Vital signs.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 3 · response
Published 14 July 2025
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 paediatric emergency staffing against safer-nursing-care data and professional judgement, resulting in additional nursing staff, with ongoing safety-level monitoring.

Verbatim wording from the response
“◦ Staffing levels in the Paediatric Emergency department have been reviewed and aligned with SNCT (safer nursing care tool data), and professional judgement based on staff feedback. This review resulted in additional nursing staff. The staffing levels will continue to be reviewed and reported to the Board on a six monthly basis.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 4 · response
Published 14 July 2025
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
Allocate paediatric emergency cubicles and patient cohorts to designated nurses to establish responsibility and continuity of care.

Verbatim wording from the response
“◦ We have introduced the allocation of cubicles where nurses are assigned responsibility for specific cubicles and key assessments i.e. Triage and patient cohorts to ensure ownership and continuity of care.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 4 · response
Published 14 July 2025
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
Monitor observation-compliance safety through clinical governance committees and report to the Patient Safety Group and Trust Board.

Verbatim wording from the response
“• Ongoing monitoring of compliance by the senior nursing and medical team with oversight from the paediatric and emergency department clinical governance committees reporting into the Patient Safety Group on a 3 monthly basis. Patient Safety Group reports to Trust Board via the Quality Governance and Quality Assurance Committees.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 5 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue staff training and induction on complete observations and escalation, including the content in paediatric emergency simulation training.

Verbatim wording from the response
“• Ongoing training and induction for all staff in regard to the importance of complete observations and their escalation. This training will also be part of all simulation training in PED”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 5 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue advocating locally and nationally for active reduction of paediatric staffing rota gaps.

Verbatim wording from the response
“As we noted then, observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtained, and RCPCH recognises that challenges in adequately staffing emergency departments may be one reason. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact on paediatric staffing, and we continue to advocate at a local and national level for an active reduction in these gaps.”

Source location
2025-0316 Response from Royal College of Paediatrics and Child Health
Page 1 · response
Published 14 July 2025
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 and update emergency-care standards to clarify observations as holistic care, including frequency determined by the child’s wellbeing.

Verbatim wording from the response
“The RCPCH Facing the Future Standards for Emergency Care ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of audit, review and revision and update of these standards, to be published later in 2025. The revised version will set out that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations. This update has been led by an Intercollegiate Committee for Emergency Care, including representation from the Royal College of Nursing.”

Source location
2025-0316 Response from Royal College of Paediatrics and Child Health
Page 1 · response
Published 14 July 2025
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
Collaborate with NHS England and RCPCH to develop a single national paediatric early warning system for England.

Verbatim wording from the response
“The RCN has been collaborating with NHS England and the Royal College of Paediatric and Child Health (RCPCH) to develop a single national paediatric early warning system (PEWS) for England since 2018 and are supportive of equivalent processes across the UK. The RCN has produced supportive educational material to support the role out of this initiative System wide Paediatric Observations Tracking Programme. This work is aimed for implementation across the four-nations in the UK.”

Source location
2025-0316 Response from Royal College of Nursing
Page 2 · response
Published 14 July 2025
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
Produce educational material supporting implementation of the System-wide Paediatric Observations Tracking Programme.

Verbatim wording from the response
“The RCN has been collaborating with NHS England and the Royal College of Paediatric and Child Health (RCPCH) to develop a single national paediatric early warning system (PEWS) for England since 2018 and are supportive of equivalent processes across the UK. The RCN has produced supportive educational material to support the role out of this initiative System wide Paediatric Observations Tracking Programme. This work is aimed for implementation across the four-nations in the UK.”

Source location
2025-0316 Response from Royal College of Nursing
Page 2 · response
Published 14 July 2025
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
Collaborate with RCPCH to revise emergency care standards for children and young people, including requirements concerning observations.

Verbatim wording from the response
“The RCN is also collaborating with the RCPCH in the revision of the emergency care standards for children and young people which will specify that observations are part of holistic care and repetition is dependent on the child’s well-being, alongside clarification around frequency of observations.”

Source location
2025-0316 Response from Royal College of Nursing
Page 2 · response
Published 14 July 2025
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 paediatric clerking documentation to specify the frequency of observations.

Verbatim wording from the response
“We acknowledge that staff failed to identify that vital observations were incomplete and not repeated at the time of Finlay’s discharge. In response:”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 3 · response
Published 14 July 2025
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 review of vital signs before paediatric discharge through the ED discharge checklist and audit its use regularly.

Verbatim wording from the response
“◦ The ED paediatric discharge checklist now requires that there is a review of patient’s vital signs prior to discharge. This has been implemented since Finlay’s death and its use will be audited regularly.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 3 · response
Published 14 July 2025
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 the ED paediatric discharge checklist at emergency, surgical and paediatric inductions and thereafter at future medical inductions.

Verbatim wording from the response
“◦ The discharge checklist will be disseminated at ED and surgical induction in August and paediatric induction in September and at all future medical inductions thereafter.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 3 · response
Published 14 July 2025
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 quarterly audits of paediatric discharge-checklist compliance and present results to the divisional quality meeting.

Verbatim wording from the response
“◦ Audits will be conducted and will be presented at the division’s quality meeting on a quarterly basis.”

Source location
2025-0316 Response from Whittington Health NHS Trust
Page 3 · response
Published 14 July 2025
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
Individual nursing practice and the reported concerns fall outside the organisation’s regulatory functions and authority.

Verbatim wording from the response
“We are not the regulator for nurses in the UK, nor do we have any control over individual nursing practice in individual workplaces; therefore, we have no remit to address the concerns you have noted in respect of this death. However, the RCN offers a suite of learning resources to support nurses, students, nursing support workers, midwives, and health care professionals at all stages of their careers. We provide expert-led, quality-assured, evidence-based education for continuing professional development CPD and learning on a range of topics and subjects.”

Source location
2025-0316 Response from Royal College of Nursing
Page 1 · response
Published 14 July 2025
Open published response
26 May2025
Cumbria
Concerns raised2
1. Failure to provide additional monitoring for patients in side rooms that are not easily observed
2. Lack of frequent recorded observations for deteriorating patients
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 6
1. Action
  Complete an urgent assurance check of falls documentation and current AMU patient monitoring.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
2. Action
  Develop and implement a Trust-wide documented risk-benefit protocol for placing deteriorating patients in isolation.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
3. Action
  Reinforce at least hourly intentional rounding for patients receiving necessary side-room care through visual prompts.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated planned
1. Action
  Develop and pilot a two-zone ward layout with two registered nurses to improve visibility and responsiveness.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
2. Action
  Develop a cohort-based care model for admission-ward patients with elevated NEWS2 scores and assess it for wider rollout.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
3. Action
  Explore electronic-health-record dashboard options for real-time observation flagging and escalation alerts.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Four-hourly observations initially complied with NEWS2 policy because the recorded scores did not trigger increased monitoring, despite later missed observations and escalation failures.
  Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes the concern
AI-generated summary

Sarah Kathleen Hill · 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 Kathleen Hill was admitted for an elective ERCP to remove gallstones and developed worsening pancreatitis, perforation, multi-organ failure and cardiac arrest before dying in the early hours of 8 November 2024. Concerns included inadequate falls-risk assessment and reporting, insufficient documentation and monitoring, poor observability in a side room, and understaffing despite escalation.

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 additional monitoring for patients in side rooms that are not easily observed
Wider context from the report
“(4) Mrs Hill was placed in a side room where she was not easily observed without consideration given for the need for additional monitoring which led to her being left alone for extended periods of time. ”
Source location
Sarah Kathleen Hill · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of frequent recorded observations for deteriorating patients
Wider context from the report
“(3) There was a lack of frequent recorded observations necessitated by Mrs Hill's deteriorating condition. ”
Source location
Sarah Kathleen Hill · 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 an urgent assurance check of falls documentation and current AMU patient monitoring.

Verbatim wording from the response
“Immediate Assurance Check: An urgent assurance check on falls documentation and current patient monitoring on AMU is being completed to confirm improved compliance post-incident. Additionally, the ward has an established programme of work to undertake thematic reviews of falls related incidents (including collapses) on a quarterly basis to determine quality improvement plans and identify any new themes that ought to be shared with other teams or added to our Falls Trust Wide Improvement Plan.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 2 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and implement a Trust-wide documented risk-benefit protocol for placing deteriorating patients in isolation.

Verbatim wording from the response
“Side Room Risk Assessment: Working with the infection prevention team, using the hierarchy of risks alongside professional judgement, develop and implement a Trust wide documented risk-”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 4 · response
Published 17 June 2025
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
Reinforce at least hourly intentional rounding for patients receiving necessary side-room care through visual prompts.

Verbatim wording from the response
“Intentional Rounding: Where side room care is necessary, intentional rounding will be re-enforced at least hourly, and staff are reminded of this through visual prompts.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and pilot a two-zone ward layout with two registered nurses to improve visibility and responsiveness.

Verbatim wording from the response
“Ward Layout Improvements: A proposal to split the corridor where the single rooms are, into two zones with two registered nurses is being developed and will be piloted to improve nurse-patient ratios in this part of the ward.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a cohort-based care model for admission-ward patients with elevated NEWS2 scores and assess it for wider rollout.

Verbatim wording from the response
“Cohort Monitoring: A pilot of a cohort-based care model for patients on the admission ward with elevated NEW2 scores is under development and if successful will be rolled out to other acute admission wards. This will allow greater visibility of patient’s with a dedicated nurse for the area/room. Prioritise use of rooms 1-6 which are closer to the front of the ward and doctor hub room.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Explore electronic-health-record dashboard options for real-time observation flagging and escalation alerts.

Verbatim wording from the response
“• Deteriorating Patient Dashboard: Options are to be explored to enhance real-time flagging systems within the electronic health record, including escalation alerts visible to nurses and medical clinicians if observations fall below safe thresholds.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 4 · response
Published 17 June 2025
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
Four-hourly observations initially complied with NEWS2 policy because the recorded scores did not trigger increased monitoring, despite later missed observations and escalation failures.

Verbatim wording from the response
“Following Mrs Hill’s ERCP procedure on 5 November 2024, she was admitted to the AMU at 19:00 hours with a diagnosis of post-ERCP pancreatitis based on a significantly raised amylase level. Mrs Hill’s condition initially appeared stable, with a planned 4-hourly National Early Warning Score (NEWS 2) in response to the score of 0-1 due to temperature 38.2°C on 6 November 2024. In line with the Trust policy (4-6 hourly observations for the first 48 hours unless NEWS2 triggers a change/escalation), the vital signs monitoring remained at 4 hourly.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 3 · response
Published 17 June 2025
Open published response
18 Mar2025
Northumberland
Concerns raised2
1. Insufficient capacity for line-of-sight observation of patients at risk of falls
2. Failure to carry out falls observations in accordance with Trust falls policy
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 1
1. Action
  Highlight maintaining line-of-sight observation and calling for assistance when required in staff training.
  Stated by Northumbria Healthcare NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Existing acuity assessment, escalation, staffing support and monitoring processes are considered sufficient to manage changing numbers of patients at risk of falls.
  Stated by Northumbria Healthcare NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Renate MARK · 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

Renate MARK suffered an unwitnessed inpatient fall in hospital on 24 April 2024, sustaining a cervical spinal fracture and subdural haematoma, and died there on 25 April 2024 after receiving palliative care. Concerns included that she was assessed as a level 3 falls risk but was not under direct observation, that investigations relied on the incorrect belief that the fall was witnessed, and that too many patients at risk of falls were being monitored through peripheral vision. Further concern was raised about insufficient scrutiny of witness accounts during the Trust’s 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
Insufficient capacity for line-of-sight observation of patients at risk of falls
Wider context from the report
“(2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff's peripheral vision. The inquest heard that on 24 April 2024 8 patients were assessed as level 3 falls risk and 1 patient was assessed as level 4 falls risk. I am concerned as to the number of patients at risk of falls being observed in this way. I am further concerned that there is a misunderstanding of what is meant by peripheral vision and what constitutes a witnessed or unwitnessed fall. ”
Source location
Renate MARK · 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 carry out falls observations in accordance with Trust falls policy
Wider context from the report
“(1) The deceased was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. Witness statements served in advance of the inquest stated the fall was witnessed. It was however eventually accepted in evidence that the fall was in fact unwitnessed. The precise circumstances of the fall could not be determined. All of the investigations undertaken by the Trust relied upon the incorrect understanding that the fall was witnessed and observations were in line with Trust falls policy, when they were not. ”
Source location
Renate MARK · 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
Highlight maintaining line-of-sight observation and calling for assistance when required in staff training.

Verbatim wording from the response
“In relation to Mrs Mark’s fall, the nursing assistant was assigned to Pod 3 on Ward 9; there were 8 patients being nursed in single bedrooms each with an ensuite bathroom. Pod 3 has a circular design which would enable a member of staff to observe those 8 rooms, through windows and glass/open doors from the corridor. At the time of the incident, patients were asleep/settled, and it was only Mrs Mark that was awake requiring the toilet. As she required the toilet and was at risk of falling, in order to maintain her safety, the nursing assistant should have called for additional support from another colleague to ensure falls observations for the other patients were maintained whilst he attended to Mrs Mark's in the bathroom. This learning has been fed back to the Ward 9 Team and nursing assistant involved in the incident.”

Source location
Response from Northumbria NHS
Page 2 · response
Published 26 March 2025
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 acuity assessment, escalation, staffing support and monitoring processes are considered sufficient to manage changing numbers of patients at risk of falls.

Verbatim wording from the response
“The Trust is confident that robust processes are in place to assess acuity of care at ward level for all wards as detailed in Claire Simpson's statement dated 13 March 2025 (served with the court as part of the inquest process). The processes are led by Matrons and supported by Operational Managers and Operational Leads, who are responsive to increasing staffing in order to address any concerns raised regarding increased patient acuity. There is also a process in place supported by funding, where staff can request additional staffing i.e. Bank staff, in order to support high numbers of patients at risk of falls. Bank staff are a Trust employed workforce, who provide cover on a pre booked, as needed basis. They are trained to Trust standards for falls management.”

Source location
Response from Northumbria NHS
Page 2 · response
Published 26 March 2025
Open published response
13 Mar2025
Inner North London
Concerns raised1
1. Failure to perform hourly observations in the emergency department
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 3
1. Action
  Provide augmented medical and nursing staffing, including a 24/7 Emergency Department Assistant, using bank and agency cover pending establishment approval.
  Stated by Royal Free London NHS Foundation TrustStated in progress
2. Action
  Continue advocating locally and nationally for active reduction of paediatric rota gaps.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
3. Action
  Audit, review, revise and update emergency care standards, with publication planned for later 2025.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
AI-generated summary

Billie Diane WICKS · 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

Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.

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 hourly observations in the emergency department
Wider context from the report
“1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations. Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life. Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free. Although the circumstances were different, there is a theme. ”
Source location
Billie Diane WICKS · 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 augmented medical and nursing staffing, including a 24/7 Emergency Department Assistant, using bank and agency cover pending establishment approval.

Verbatim wording from the response
“• Nurse staffing on the night of Billie’s first attendance on 14th September 2024 was in line with the nursing establishment levels of safe staffing except for one Registered Nurse (RN) rota gap during the day shift prior to Billie’s attendance. In the interim the trust has approved additional staffing to medical and nursing shifts, filled by bank and agency staff to mitigate staffing to the levels described in the business case based on safe staffing skill mix assessment and the level of acuity / complexity of patients attending in the Royal Free Hospital emergency department.”

Source location
Response from Royal Free Hospitals
Page 2 · response
Published 17 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue advocating locally and nationally for active reduction of paediatric rota gaps.

Verbatim wording from the response
“From the information provided we do not know many observations (if any) Billie had during her five hour stay in ED. Observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtainable, however RCPCH recognises that challenges are significantly exacerbated by gaps in clinical rotas resulting in understaffed departments. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact paediatrics, and we continue to advocate at a local and national level for an active reduction in these gaps¹.”

Source location
Response from Royal College of Paediatrics and Child Health
Page 1 · response
Published 17 March 2025
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
Audit, review, revise and update emergency care standards, with publication planned for later 2025.

Verbatim wording from the response
“Standards apply to all persons up until the age of 18, regardless of where they are treated. These standards aim to ensure that urgent and emergency care is fully integrated to ensure children are seen by the right people, at the right place and in the right setting. We are currently in the process of audit, review and revision and update of our current standards, to be published later in 2025.”

Source location
Response from Royal College of Paediatrics and Child Health
Page 2 · response
Published 17 March 2025
Open published response
11 Mar2025
Sunderland
Concerns raised1
1. Failure to escalate non-compliance with Level 2 EICO observation requirements
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
  Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated completed
2. Action
  Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated planned
3. Action
  Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated planned
AI-generated summary

Mr Allan Taylor · Prevention of Future Deaths report

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

Report summary

Mr Allan Taylor was admitted to Sunderland Royal Hospital after an unwitnessed fall at home and later suffered a further unwitnessed fall in hospital, fracturing his right neck of femur. He died in theatre on 1 June 2024 after becoming hypotensive and suffering cardiac arrest during surgery. The report identified that required Level 2 observations were not provided because the side room was not within sight or sound of the nursing station, and the issue was not escalated; it noted that closer observation might have enabled assistance and possibly prevented the fall.

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 escalate non-compliance with Level 2 EICO observation requirements
Wider context from the report
“1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it. 2. The evidence was that this was not escalated to the Matron or Site Manager, which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations. 3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall. ”
Source location
Mr Allan Taylor · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.

Verbatim wording from the response
“Our internal investigation identified omissions in care regarding the level of observation in place for Mr Taylor and the lack of escalation of concerns. Actions were undertaken to address this issue; an urgent review of the existing Enhanced Interactive Care and Observation (EICO) guideline took place which has now been amended and renamed Enhanced Therapeutic Observation and Care (ETOC) for patients in line with recent national changes in guidance as recommended by NHS England. In addition to exploring best practice nationally, the review of the guideline also took into consideration how other local Trusts manage safe observation and care of patients.”

Source location
Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 11 March 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.

Verbatim wording from the response
“This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.”

Source location
Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 11 March 2025
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
Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.

Verbatim wording from the response
“This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.”

Source location
Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 11 March 2025
Open published response
11 Feb2025
Inner North London
Concerns raised1
1. Lack of patient observation on psychiatric wards
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 3
1. Action
  Issue a clinical-interest-based safety statement opposing use of patient-observation video technology to address staff shortages.
  Stated by Royal College of PsychiatristsStated completed
2. Action
  Advocate for research and safeguards concerning video technology in patient observation.
  Stated by Royal College of PsychiatristsStated in progress
3. Action
  Work with NHS England to provide advice on video technology in mental health inpatient care.
  Stated by Royal College of PsychiatristsStated completed
AI-generated summary

Nicholas J D’Ourou · 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

Nicholas J D’Ourou, who had been admitted to Highgate Acute Mental Health Centre as a voluntary patient, was found on 15 April 2024 with a ligature around his neck and died from asphyxiation. The report raises concerns about inconsistent practice and limited guidance for cross-titrating psychiatric medication, and about the lack of patient observation, including electronic monitoring, in psychiatric wards.

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 patient observation on psychiatric wards
Wider context from the report
“2. I heard evidence that the local psychiatric Trust had undertaken a trial of electronic patient observation (i.e. automated monitoring of respiratory rate, temperature) but that this had been discontinued, owing to patient complaints regarding invasion of privacy. The issue of privacy and electronic monitoring on psychiatric wards is clearly a complex issue. However, in circumstances such as Nicholas’ death, I am concerned that the lack of patient observation could result in future deaths. ”
Source location
Nicholas J D’Ourou · 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 a clinical-interest-based safety statement opposing use of patient-observation video technology to address staff shortages.

Verbatim wording from the response
“2. On the second point around the use of video technology when observing patients, we do believe that more needs to happen in the context of research to understand when such technology might have a positive impact and what safeguards are needed. For example, in a short statement we made in January this year we made clear such technology must always be based on what is in the clinical interests of the patient, never to be used to address things like staff shortages.”

Source location
Response from Royal College of Psychiatrists
Page 2 · response
Published 13 February 2025
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
Advocate for research and safeguards concerning video technology in patient observation.

Verbatim wording from the response
“2. On the second point around the use of video technology when observing patients, we do believe that more needs to happen in the context of research to understand when such technology might have a positive impact and what safeguards are needed. For example, in a short statement we made in January this year we made clear such technology must always be based on what is in the clinical interests of the patient, never to be used to address things like staff shortages.”

Source location
Response from Royal College of Psychiatrists
Page 2 · response
Published 13 February 2025
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
Work with NHS England to provide advice on video technology in mental health inpatient care.

Verbatim wording from the response
“That is why we have over the last year sought through work with NHS England to provide more advice in this area and were delighted earlier this year that they published principles which all trusts should use when considering this and other”

Source location
Response from Royal College of Psychiatrists
Page 2 · response
Published 13 February 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of clarity regarding required intervals for observation checks

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

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

Concerns raised1

Failure to undertake Level 2 intermittent 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.6

Concerns raised1

Failure to prevent erroneous reductions in the frequency of care rounds

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 conduct patient observations in accordance with observation policy

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 raised2

Lack of paediatric nursing observations

Failure to complete final nursing observations before discharge

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.20

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

Actions described in response 1

Respondent positions 1

Actions described in response 6

Actions described in response 3

Actions described in response 3

Actions described in response 20

Respondent positions 1