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 Dec2015
West Yorkshire (Western)
Concerns raised1
1. Failure to carry out required hourly nursing 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 1
1. Action
  Use Nerve Centre mobile observations to record patient observations, trigger escalation for raised NEWS scores, and monitor response trends.
  Stated by Calderdale and Huddersfield NHS Foundation TrustStated completed
AI-generated summary

Ruth Hilda Smith · 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

Ruth Hilda Smith died on 16 April 2014 at Huddersfield Royal Infirmary after developing a haemothorax following insertion of a central venous line, with sepsis, altered liver function and pneumonia also recorded as causes. Concerns included delays in medical review, inadequate nursing observations, and poor nursing and medical record keeping during the evening of 15 April and early hours of 16 April 2014.

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 hourly nursing observations
Wider context from the report
“Nursing Care At 22.05 Mrs Smith was found to have an elevated MEWS score and as a result a request was made for an FY 1 Doctor to review. Evidence was given by a senior charge nurse( who provided an overview of nursing care to Mrs Smith, but who was not directly involved in her care) that following this Mrs Smith should have undergone hourly observations. This did not happen. There was reference to observations being undertaken at 00.30 but these were not recorded. Further observations were incomplete The FY1 Doctor did not attend the ward until 00.30. There was no record within the notes to suggest that enquiries were undertaken between 22.30 and 00.30 to chase up the attendance of the FY 1 Doctor. I have the following concerns: 1. No attempts were made to ensure a doctor attended and reviewed Mrs. Smith between 22.30 and 00.30. 2. The level of nursing monitoring (hourly observations) taking place for much of the period between 22.30 on the 15th April and 03.25 on the 16th April. 3. The standard of the nursing record keeping. ”
Source location
Ruth Hilda Smith · 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
Use Nerve Centre mobile observations to record patient observations, trigger escalation for raised NEWS scores, and monitor response trends.

Verbatim wording from the response
“1. “Nerve Centre” – Nerve Centre is the use of mobile electronic observations and hospital at night software to improve patient safety and staff communication anywhere within our hospitals 24 hours a day, 7 days a week. All patient observations are recorded on an IPAD. The use of mobile technology also allows doctors and nurses to have all the tools and information at hand to be able to respond rapidly and effectively to deteriorating patients.”

Source location
Ruth-Smith-Response
Page 1 · response
Published 15 December 2015
Open published response
24 Nov2015
Blackpool and the Fylde
Concerns raised1
1. Failure to clearly require verbal engagement during patient 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 3
1. Action
  Review the observation policy and procedure using learning from serious incidents and national best practice.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated in progress
2. Action
  Develop and implement a revised observation policy and procedure by 31 March 2016.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated planned
3. Action
  Issue an internal patient safety alert reminding inpatient services of the current observation policy and procedure.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated completed
AI-generated summary

Piotr Grzegorz Kucharz · 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

Piotr Kucharz was admitted to a mental health hospital and later found unresponsive after using a cord as a ligature; he died in hospital on 12 October 2014. Concerns included the absence of an effective translation service and a lack of consistency and clarity among staff about what constituted an effective observation, including whether staff should enter a patient’s room and engage verbally.

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 clearly require verbal engagement during patient observations
Wider context from the report
“1. Piotr Kucharz was a Polish gentleman who commenced living in the United Kingdom in April 2014. At the time he sought to strangle himself with a cord he was an informal patient at the Conway Ward at Parkwood, a mental health facility in Blackpool. At his inquest, evidence was heard from a number of members of staff as regards what constitutes an effective observation. He was the subject of what were described as Safety and Security [SAS] and general observations, the completion of which was the responsibility of a number of members of care staff. The evidence heard from staff raised an area of concern because that evidence indicated quite clearly that there was a lack of consistency and clarity as regards what constitutes an effective observation. An independent expert witness indicated in a report that he completed prior to the inquest that he felt custom and practice was such that some staff were merely checking on the “whereabouts” of the patient. Some staff felt that they were expected to enter the room of the patient and to try to engage with him and to check the room environment for anything that may pose a risk to him. Others felt that whether they were expected to actually enter a patient’s room to conduct the observation could vary depending on the level of risk a particular patient presented, in other words that they felt they had an element of discretion as regards whether they entered the room. This evidence appeared to be in contrast to a Trust policy. In the case of Piotr Kucharz, as can be seen above he had limited understanding of English, and a number of staff gave evidence that he remained in his room throughout his time on the Conway Ward and did not wish to engage with them. Nevertheless, the author of the Trust’s Sudden Untoward Incident Review document agreed that there was no such discretion and that staff ought to enter the room to complete and effective observation. At the conclusion to the inquest I expressed the view that I was concerned that there is a risk of future deaths because staff remain unclear about what amounts to an effective observation, and more specifically whether there are circumstances which may allow them to refrain from verbally engaging with a patient, or from physically entering a patient’s room to check the environment, and that should that lack of consistency and clarity prevail, other patients may be placed at risk as a result of inadequate observations. For the avoidance of doubt, I confirm that I am of the opinion that the above concern remains valid despite the fact that further to Piotr Kucharz’s death the provision of mental health care for patient’s such as Piotr has moved from the Conway Ward at Parkwood to another facility within my jurisdiction at which members of staff who were working at the time of Piotr’s death continue to be employed in a similar capacity. ”
Source location
Piotr Grzegorz Kucharz · 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 the observation policy and procedure using learning from serious incidents and national best practice.

Verbatim wording from the response
“The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice. This review is currently underway and we will be developing and implementing a revised observation policy and procedure. The new observation policy and procedure will be implemented by 31 March 2016.”

Source location
2015-0465-Response
Page 2 · response
Published 24 November 2015
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 revised observation policy and procedure by 31 March 2016.

Verbatim wording from the response
“The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice. This review is currently underway and we will be developing and implementing a revised observation policy and procedure. The new observation policy and procedure will be implemented by 31 March 2016.”

Source location
2015-0465-Response
Page 2 · response
Published 24 November 2015
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
Issue an internal patient safety alert reminding inpatient services of the current observation policy and procedure.

Verbatim wording from the response
“In the interim, until this new policy and procedure is developed and implemented, an internal patient safety alert has been issued to remind staff of the current policy and procedure. This alert was sent to all inpatient services across the Trust.”

Source location
2015-0465-Response
Page 2 · response
Published 24 November 2015
Open published response
6 Nov2015
Brighton and Hove
Concerns raised1
1. Failure to implement the Observation Policy as part of risk assessment and management
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.

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

Mr Brian James SHILLINGLAW · 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

The supplied text does not provide the circumstances or date of Mr Brian James SHILLINGLAW’s death. The principal concerns relate to the creation, updating and use of care plans and risk assessments, communication and coordination among staff, observation policy, and recording and communicating Deprivation of Liberty Safeguarding status.

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 the Observation Policy as part of risk assessment and management
Wider context from the report
“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”
Source location
Mr Brian James SHILLINGLAW · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Jul2015
Avon
Concerns raised1
1. Failure to appropriately set patient observation levels at admission
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 1
1. Action
  Review the Observation Policy against revised NICE guidance on observation levels and reflect the guidance in policy and practice.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated planned
AI-generated summary

Simon Peter REYNOLDS · 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

Simon Peter REYNOLDS was admitted to Mason Unit at Southmead Hospital on 10 November 2014 after being detained under section 136 of the Mental Health Act. While left alone in his room, he forced a fist-sized ball of paper into his throat, causing him to choke; he later died in hospital on 21 November 2014. Concerns included the absence of a documented admission risk assessment, no computerised admission note by the nurse in charge, and the need to consider guidance or training on observation levels, suicide and self-harm risk assessment, risk management, and communication of 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 appropriately set patient observation levels at admission
Wider context from the report
“(3) I would also ask that you consider whether guidance or training ought to be provided to staff on how to set patient observation levels when being admitted onto Mason Unit; what factors to take into account when assessing a service users risk of suicide or self-harm and how to manage that risk appropriately and how to appropriately communicate that risk to other staff. ”
Source location
Simon Peter REYNOLDS · 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 the Observation Policy against revised NICE guidance on observation levels and reflect the guidance in policy and practice.

Verbatim wording from the response
“• Reviewing our Observation Policy to take account of revised guidance from the National Institute for Health and Care Excellence - “NICE NG10 Violence and aggression: short-term management in mental health, health and community settings”. This guidance includes definitions on the levels of observations which need to be reflected in our policy and practice.”

Source location
2015-0296-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 24 July 2015
Open published response
29 May2015
Avon
Concerns raised2
1. Failure to manage and balance hourly checks with 10-minute observations
2. Lack of policy for responding when a patient or service user is not found during a 10-minute observation period
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

Alison Jane DRAPER · 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

Alison Jane Draper, who had a history of mental health problems and previous attempts to self-harm, was found ligatured in her bedroom while on 10-minute observations at Juniper Ward. She sustained an unsurvivable hypoxic brain injury and died from her injuries. Concerns included the absence of a policy for when a patient is not found during a 10-minute observation and how staff should balance hourly checks for multiple patients with 10-minute observations.

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 manage and balance hourly checks with 10-minute observations
Wider context from the report
“2. I would also request that you consider the hourly check as detailed above. It appears in this case that one member of staff was asked to check 19 patients, two of whom were on 10 minute observations. Please consider whether guidance be given as to how to manage and balance the hourly checks with those on 10 minute observations. ”
Source location
Alison Jane DRAPER · 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 policy for responding when a patient or service user is not found during a 10-minute observation period
Wider context from the report
“1. I heard evidence that there is no policy in relation to what staff should do if a patient/service user is not found within the 10 minute observation period. I would ask that you consider whether guidance should be issued as to the steps that staff should take. ”
Source location
Alison Jane DRAPER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 May2015
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
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
  Issue guidance requiring medical practitioners to provide custody sergeants with verbal consultation updates.
  Stated by Staffordshire PoliceStated completed
2. Action
  Review Force Policy to incorporate the verbal medical consultation update requirement.
  Stated by Staffordshire PoliceStated in progress
3. Action
  Review Detention and Custody Authorised Professional Practice to consider guidance on medical practitioner–custody sergeant consultation, observation levels and detailed medical records.
  Stated by College of Policing and DCC Nick EphgraveStated in progress
AI-generated summary

Name not published · 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

The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.

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 verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels
Wider context from the report
“1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee’s custody medical record. ”
Source location
Name not published · 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 guidance requiring medical practitioners to provide custody sergeants with verbal consultation updates.

Verbatim wording from the response
“1. Guidance has been issued to all custody trained staff and our medical services provider, Nestor Primcare, to ensure that a verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of a detained person by such a medical practitioner within the custody environment. This will be captured within Force Policy which is being reviewed currently, and tested through the monthly QA process already in place.”

Source location
2015-0138-Response-by-Staffordshire-Police
Page 1 · response
Published 15 April 2015
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 Force Policy to incorporate the verbal medical consultation update requirement.

Verbatim wording from the response
“1. Guidance has been issued to all custody trained staff and our medical services provider, Nestor Primcare, to ensure that a verbal update is given by the medical practitioner to the appropriate Custody Sergeant following any consultation of a detained person by such a medical practitioner within the custody environment. This will be captured within Force Policy which is being reviewed currently, and tested through the monthly QA process already in place.”

Source location
2015-0138-Response-by-Staffordshire-Police
Page 1 · response
Published 15 April 2015
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 Detention and Custody Authorised Professional Practice to consider guidance on medical practitioner–custody sergeant consultation, observation levels and detailed medical records.

Verbatim wording from the response
“1. That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainees custody medical record.”

Source location
2015-0138-Response-by-College-of-Policing
Page 1 · response
Published 15 April 2015
Open published response
21 Apr2015
Brighton and Hove
Concerns raised1
1. Failure to conduct observations and therapeutic engagement in accordance with policy
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.

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

Bruce LONGDEN · 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

Bruce LONGDEN’s death was investigated by an inquest, but the circumstances of the death are referred to separately in the Record of Inquest. The substantive concerns included failures to follow Sussex Partnership Trust protocols, poor communication between trusts, inadequate understanding of his mental health condition and terminology, and delayed reporting of his absconsion to Sussex Police.

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 observations and therapeutic engagement in accordance with policy
Wider context from the report
“(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :- a) Transfer of Sussex Partnership Trust patients to the acute hospital and b) Observations and Therapeutic Engagement policy These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond. 2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust 3)Poor communication within Brighton & Sussex University Hospital Trust particularly: • Failure to appreciate the significance of Mr Bruce Longden’s mental health condition • Failure to understand the terminology used by the mental health liaison team • Failure of the Mental Health Team to adhere to commonly understood terminology • Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost ”
Source location
Bruce LONGDEN · Prevention of Future Deaths report
Page 1 · concerns
Open source report
30 Mar2015
County Durham and Darlington
Concerns raised1
1. Failure to provide structured monitoring or formal observations during delayed 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 1
1. Action
  Implement discharge-time observations, apply the Early Warning Score protocol when necessary, and record the results in Symphony, with routine audit of record completeness.
  Stated by County Durham and Darlington NHS Foundation TrustStated planned
AI-generated summary

Andrea Jane Thirkell · 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

Andrea Jane Thirkell had an unwitnessed fall at a nursing home and was taken to hospital, where she was deemed fit for discharge but remained in the department for several hours without structured monitoring or observation. She returned to the nursing home, was found unresponsive, and was later diagnosed at hospital with a serious head injury before dying later that day. Concerns related to the lack of formal monitoring during delayed discharge and the absence of formal guidance for late-night discharges, which could result in inconsistent or potentially erroneous decisions.

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 structured monitoring or formal observations during delayed discharge
Wider context from the report
“(1) Although considered to be medically fit for discharge at 19.25 hours she did not leave the department until 23.03 and during that time she was not subject to any structured form of monitoring or observation although nursing staff may have seen her during that time. Evidence was given that since this incident staff have been reminded that patients should be subject to formal observations if there is a delay in discharge. Although I was told this I am unclear as to whether there is a formal trust policy in place in this regard. ”
Source location
Andrea Jane Thirkell · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement discharge-time observations, apply the Early Warning Score protocol when necessary, and record the results in Symphony, with routine audit of record completeness.

Verbatim wording from the response
“The issue you have raised was discussed at the Emergency Department senior staff meeting at the University Hospital North Durham which convened on 23 April 2015 and was subsequently discussed and agreed by the Emergency Department at Darlington Memorial Hospital. The consensus of opinion was that at the time of leaving the department it would have been sensible for a member of the team to have undertaken a set of observations on the patient, to act upon these if necessary as per the Early Warning Score (EWS) protocol and then to record these in the allotted field on Symphony (the Emergency Department electronic notes system). In addition there is also a field in Symphony, under the transport Data Entry Protocol (DEP), which the team member is able to utilise to record the name of the person to whom the patient is returning.”

Source location
Thirkell-R2015-0124
Page 2 · response
Published 30 March 2015
Open published response
23 Mar2015
South Yorkshire (Western)
Concerns raised1
1. Incomplete handover causing unsafe changes to detainee observations
This report raised 28 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Document and standardise custody handover requirements, including transfer of risk-assessment information.
  Stated by South Yorkshire PoliceStated completed
2. Action
  Regularly train current and new custody staff on the standardised handover process.
  Stated by South Yorkshire PoliceStated planned
AI-generated summary

Neil Budziszewski · 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

Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.

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
Incomplete handover causing unsafe changes to detainee observations
Wider context from the report
“(26) The handover from the night custody sergeant to the morning custody sergeant was incomplete. Whilst CCTV makes plain that Mr Budziszewski was described as an alcoholic, there was no reference to the retching episode or the change in observations. In consequence of this latter point Mr Budziszewski was inadvertently changed back from 30 minute checks to 60 minutes without any consideration of needs. ”
Source location
Neil Budziszewski · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Document and standardise custody handover requirements, including transfer of risk-assessment information.

Verbatim wording from the response
“The process for handovers is now documented and is consistent across the force. The process is that the sergeant handing over will summarise to the incoming sergeant personal information about the detainee, details of the offence and the stage of the investigation and any specific risk factors. The focus of the handover is to be around the risk assessment which has been completed. Appendix C shows a completed copy of the handover Sergeants are expected to complete. As this is a live copy, third party data has been redacted out to ensure compliance with the Data Protection Act.”

Source location
2015-0109-Response-by-South-Yorkshire-Police
Page 5 · response
Published 23 March 2015
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
Regularly train current and new custody staff on the standardised handover process.

Verbatim wording from the response
“Unfortunately this was an example of extremely poor recording keeping. That cannot be defended however it is certainly below the expectations of South Yorkshire Police. The custody staff involved have all been spoken to following the inquest and advised of this issue and told of the expectations upon them. It is also anticipated that the new handover process should ensure this does not happen going forward and this process will be regularly trained to custody staff, current and new.”

Source location
2015-0109-Response-by-South-Yorkshire-Police
Page 8 · response
Published 23 March 2015
Open published response
9 Mar2015
Berkshire
Concerns raised1
1. Inconsistent methods for performing four-hourly patient observations
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.

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

Darren Linfoot · 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

Darren Linfoot was found unresponsive in his room at Broadmoor Hospital on 18 December 2011 and was declared deceased at Frimley Park Hospital. A post-mortem examination found lobar pneumonia as the cause of death, with dihydrocodeine toxicity contributing. Concerns included inadequate auditing of some potent medications, inconsistent four-hourly patient observations, and inconsistent understanding of the radio nurse’s duties.

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
Inconsistent methods for performing four-hourly patient observations
Wider context from the report
“(2) The evidence revealed that the methods of performing regular four hourly observations of patients by nursing staff was not fully understood and nurses have contrasting methods of how they conducted these observations. It is suggested that a consistent method is identified and appropriate training is provided. ”
Source location
Darren Linfoot · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to carry out required hourly nursing 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.1

Concerns raised1

Failure to clearly require verbal engagement during patient 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.3

Concerns raised1

Failure to implement the Observation Policy as part of risk assessment and management

Concerns raised1

Failure to appropriately set patient observation levels at admission

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 manage and balance hourly checks with 10-minute observations

Lack of policy for responding when a patient or service user is not found during a 10-minute observation period

Concerns raised1

Lack of verbal consultation between medical practitioners and custody sergeants about detainee concerns and observation levels

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 observations and therapeutic engagement in accordance with policy

Concerns raised1

Failure to provide structured monitoring or formal observations during delayed 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.1

Concerns raised1

Incomplete handover causing unsafe changes to detainee 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.2

Concerns raised1

Inconsistent methods for performing four-hourly patient observations

Actions described in response 1

Actions described in response 3

Actions described in response 1

Actions described in response 3

Actions described in response 1

Actions described in response 2