Recurring concern

Unreliable patient observation arrangements

First to latest report 28 Mar 2013 — 24 Jun 2026

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

What this concern includes

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

What is not included
  • Condition-specific physiological or neurological monitoring
  • Management auditing of observations where frontline observation arrangements are otherwise reliable
  • Continuous eyesight or one-to-one observation where that dedicated control supplies a narrower parent

Reports and published responses 139 reports

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

  1. North London

    AI-generated summary

    Dale Owen Ricardo Scott Proverbs · 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

    Dale Owen Ricardo Scott Proverbs, a patient detained under the Mental Health Act and placed in seclusion at North London Clinic, collapsed after continuous observation was not maintained and died. The report identified concerns that Partnerships In Care’s observation policies were not followed and that the applicable level of observation could be insufficient to prevent another fatality in similar circumstances.

    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 observation levels for patients in seclusion under the current policy

    Wider context from the report

    “That there were, at the time of Mr Proverbs death, Partnership In Care Policies in place that created a higher standard of observation required for patients on seclusion than the Code of Practice for The Mental Heath Act 1983 prescribed. The Partnerships In Care Policies in place at the time of Mr Proverb’s death, if followed, are likely to have prevented his death. If the Code of Practice for the Mental Heath Act 1983 were to be followed by Partnerships In Care, which is now their policy, then the level of observation for patients in seclusion would not be enough to prevent another fatality were the circumstances to be the same as those surrounding Mr Proverbs death. ”

    Source location

    Dale Owen Ricardo Scott Proverbs · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Constant observation is not always appropriate because it may be unnecessarily restrictive; the Code therefore retains its existing overall observation requirement.

    Verbatim wording from the response

    “Your main concern is however that the levels of observation recommended in the MHA Code of Practice for patients in seclusion are not sufficient enough to prevent a death from occurring in similar circumstances.”

    Source location

    2015-0010-Response-by-Department-of-Health
    Page 2 · response
    Published 6 January 2015

    Open published response

  2. Manchester South

    AI-generated summary

    Elsie Mallalie u · 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

    Mrs Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her 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 accurately calculate and use patient observation scores

    Wider context from the report

    “4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10) ”

    Source location

    Elsie Mallalie u · 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

    Replace PARS with NEWS, train Trust staff in NEWS scoring, provide an escalation guide and maintain refresher training as needed.

    Verbatim wording from the response

    “With regards the failure to take observations during the night shift; this occurred because a member of the nursing staff unfortunately miscalculated the PARS score, which meant that Mrs Mallalieu did not have her observations taken as she would have done if scoring had been correct. Since Mrs Mallalieu’s treatment the PARS scoring system has been replaced by a different system called NEWS and Trust staff have been trained in the use of it. A quick reference NEWS escalation and response guide has also been made available to all staff. The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration.”

    Source location

    2014-0501-Response-by-Tameside-Hospital-NHS-Trust
    Page 3 · response
    Published 17 November 2014

    Open published response

  3. Exeter & Great Devon

    AI-generated summary

    Polly Elisabeth Jane CARPENTER · 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

    Polly Elisabeth Jane Carpenter, who had a history of psychotic depression and repeated suicide attempts, left an inpatient psychiatric unit on 5 May 2011 and deliberately sat on a railway track, where she was struck by a train and died. The concerns included weaknesses in recording risk assessments, observations and nurse allocation, limited staff awareness of current risk, and inadequate security of unit windows, which contributed to her absconding.

    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 formally record observation levels

    Wider context from the report

    “(4) The decision not to formally record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern. From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they may/may not have performed. This does not support the view that being in hospital means that a regular robust system of care and attention is given to patients who desperately need the help for which they have been admitted. It is hoped that provision of a permanent record, would allow a culture of individual responsibility to flourish in the minds of all the nursing staff, so patients are looked after in the fullest sense of the word. ”

    Source location

    Polly Elisabeth Jane CARPENTER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to record nurse allocation for observations

    Wider context from the report

    “(4) The decision not to formally record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern. From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they may/may not have performed. This does not support the view that being in hospital means that a regular robust system of care and attention is given to patients who desperately need the help for which they have been admitted. It is hoped that provision of a permanent record, would allow a culture of individual responsibility to flourish in the minds of all the nursing staff, so patients are looked after in the fullest sense of the word. ”

    Source location

    Polly Elisabeth Jane CARPENTER · 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

    Retain Level 1 and 2 observation forms, allocation charts and shift planners for two years, uploading records when an observation incident occurs.

    Verbatim wording from the response

    “• Level 1 and 2 (intermittent) observation forms (hard paper forms) are stored for two years, along with the allocation charts and the shift planners. They are only uploaded if an incident occurs during the period of observation. Therefore in the future should we need access to the observation chart records this will be able to be achieved. In the case of Polly, with the new policy in place the observation charts for the previous 24 hours would have been uploaded and all observation charts for the duration of her stay would have been stored.”

    Source location

    2014-0469-Response-by-Devon-Partnership-NHS-Trust
    Page 1 · response
    Published 28 October 2014

    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 revised observation documentation with comment fields and a registered-nurse review and RiO progress-note update each shift.

    Verbatim wording from the response

    “• Revised documentation has been developed and is being implemented which includes room on the form for comments; there are guidelines on what we would expect to see written on these forms. From this the registered nurse on every shift would review the completed forms and provide an update on RiO in the progress notes. Again guidance will be issued as to what we would expect to see written.”

    Source location

    2014-0469-Response-by-Devon-Partnership-NHS-Trust
    Page 1 · response
    Published 28 October 2014

    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 guidance on the information expected in completed observation documentation.

    Verbatim wording from the response

    “• Revised documentation has been developed and is being implemented which includes room on the form for comments; there are guidelines on what we would expect to see written on these forms. From this the registered nurse on every shift would review the completed forms and provide an update on RiO in the progress notes. Again guidance will be issued as to what we would expect to see written.”

    Source location

    2014-0469-Response-by-Devon-Partnership-NHS-Trust
    Page 1 · response
    Published 28 October 2014

    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

    Storing intermittent observation forms for two years, with uploading only after incidents, is considered sufficient to enable future access when needed.

    Verbatim wording from the response

    “• Level 1 and 2 (intermittent) observation forms (hard paper forms) are stored for two years, along with the allocation charts and the shift planners. They are only uploaded if an incident occurs during the period of observation. Therefore in the future should we need access to the observation chart records this will be able to be achieved. In the case of Polly, with the new policy in place the observation charts for the previous 24 hours would have been uploaded and all observation charts for the duration of her stay would have been stored.”

    Source location

    2014-0469-Response-by-Devon-Partnership-NHS-Trust
    Page 1 · response
    Published 28 October 2014

    Open published response

  4. Manchester South

    AI-generated summary

    Agnes Mary Hannan · 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

    Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life 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 carry out or record required nursing observations

    Wider context from the report

    “6. This patient needed very careful monitoring at all times and yet there was a period of 24 hours when no nursing observations were carried out or recorded. ”

    Source location

    Agnes Mary Hannan · 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

    Replace the PARS observation system with NEWS, train staff, and provide a NEWS escalation and response guide.

    Verbatim wording from the response

    “Response At the time of Mrs Hannan’s treatment the Trust used a PARS scoring system for recording nursing observations. That system is designed to track observations, determine the regularity of them and trigger escalation of care whenever required. Instructions for use of the PARS score system was provided to nurses through training and also by clear explanatory notes within each individual nursing observation chart. The insufficient observations in this case arise from failure to adhere to the Trust’s PARS system.”

    Source location

    2014-0573-Response-by-Tameside-Hospital-NHS-Trust
    Page 3 · response
    Published 27 October 2014

    Open published response

  5. Black Country

    AI-generated summary

    JAMES DWAYNE CLARKE · 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

    James Dwayne Clarke was involved in a motorcycle collision, became paraplegic and had a tracheotomy tube. After he was discharged home, carers failed to check him during parts of the night and did not notice that his tracheotomy tube had become blocked, resulting in his death. The principal concerns were that the standard of care was seriously lacking and that the carers had received theoretical but no practical training, potentially placing others receiving services at risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to carry out required overnight checks

    Wider context from the report

    “My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant, the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public. ”

    Source location

    JAMES DWAYNE CLARKE · 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

    Carry out an unannounced responsive inspection of the care provider against safeguarding, risk, welfare and complaints requirements.

    Verbatim wording from the response

    “In terms of actions that we have undertaken, in May 2011 we carried out a responsive inspection unannounced. This was the service’s first inspection under the Health and Social Care Act 2008. This would have focused on the issues considered relevant at the point of inspection and any information of concern that we held. We inspected against four of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These were:”

    Source location

    2014-0398-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 10 September 2014

    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

    Adopt the Health and Social Care Act 2008 fundamental standards, including requirements concerning personalised, safe and competent care.

    Verbatim wording from the response

    “In April 2015 CQC will adopt the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, known as the “fundamental standards”. The changes in the regulations have emerged from the Robert Francis recommendations that there should be very obvious standards below which care must not fall. Regulation 9 will ensure that people receive care and treatment that is personalised for them and meets their needs; Regulation 12 is intended to prevent people from receiving unsafe care and treatment, and prevent avoidable harm or risk of harm. These regulations in particular will require providers to ensure that care is planned and delivered in a way that makes it crystal clear to care staff what is required of them, and that staff are experienced, trained and competent in the areas where they are providing that care.”

    Source location

    2014-0398-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 10 September 2014

    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 inspection processes using longer team-based inspections, consistent key lines of enquiry and service ratings.

    Verbatim wording from the response

    “In implementing the new fundamental standards, our inspection processes have been developed. We will conduct longer, more in-depth inspections with a team approach designed to “get under the skin” of care services. We have key lines of enquiry which are explored and reported on consistently. Each care service will be rated either Outstanding, Good, Requires Improvement or Inadequate. We will continue to use our enforcement powers where services do not deliver safe services.”

    Source location

    2014-0398-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 10 September 2014

    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

    Ensure the coroner’s report is noted and informs the provider’s next ratings inspection, including examination of processes and training.

    Verbatim wording from the response

    “We will ensure that your report is noted and informs the next ratings inspection that takes place of Complete Care Services; although the information is now a little dated the issues are well worth a further examination of their processes and training provision.”

    Source location

    2014-0398-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 10 September 2014

    Open published response

  6. Leicester City and South Leicestershire

    AI-generated summary

    Gillian Crossley · 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

    Gillian Crossley underwent elective bowel surgery, was discharged home, re-admitted the following day in extremis with bowel necrosis and perforation, and died on 28 March 2013 despite further surgery. The concerns included inadequate documentation, inadequate observation and monitoring, failure to properly assess and plan her discharge, and inadequate communication between those responsible for her 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 observe and monitor in accordance with patients' needs

    Wider context from the report

    “I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry: (1) Inadequate documentation (2) Failure to observe and monitor in accordance with Mrs Crossley's needs (3) Failure to properly assess the fitness for discharge and properly plan that discharge (4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley ”

    Source location

    Gillian Crossley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Leicester City and South Leicestershire

    AI-generated summary

    Christopher John Royal · Prevention of Future Deaths report

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

    Report summary

    Christopher John Royal suffered a cardiac event on 25 January 2013 and was found collapsed in the en-suite bathroom of Baron’s Park Nursing Home; CPR was unsuccessful. Concerns included unreliable 15-minute observation records, inadequate emergency response and first-aid training, and the potential impact of lengthy staff shifts on 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 provide a designated and accountable system for carrying out and recording observations

    Wider context from the report

    “1) Mr. Royal was on 15 minute observations. The observations were not carried out by a designated member of staff; there was no system in place; the recorded observations were unreliable and inaccurate; recordings were not made by the staff who had actually observed Mr. Royal. Consideration should be given to a more robust, safe and accountable observation system, and proper training and auditing to ensure this is in place and operating effectively. ”

    Source location

    Christopher John Royal · 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

    Review the observation policy against the concerns identified.

    Verbatim wording from the response

    “In response to this we have;”

    Source location

    Royal-2014-0354-Response
    Page 2 · response
    Published 30 July 2014

    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 the revised observation policy to nursing staff.

    Verbatim wording from the response

    “In response to this we have;”

    Source location

    Royal-2014-0354-Response
    Page 2 · response
    Published 30 July 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement observation and allocation record sheets defining responsibilities and review requirements.

    Verbatim wording from the response

    “c) Created a new record sheet for nursing staff to complete at the commencement and conclusion of shift. The sheet clearly identifies who is responsible for carrying out certain requirements and it places an onus on the nursing staff to review the sheet and the observation requirements (paperwork) at timely intervals (see appendix B, implemented 1st August 2014).”

    Source location

    Royal-2014-0354-Response
    Page 2 · response
    Published 30 July 2014

    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 and allocation sheets through General Manager audits.

    Verbatim wording from the response

    “d) Completion of observation sheets and allocation sheets are being monitored by our General Manager for audit purposes and to ensure that the new regime is being implemented in an accurate and effective manner. This is an ongoing process.”

    Source location

    Royal-2014-0354-Response
    Page 2 · response
    Published 30 July 2014

    Open published response

  8. Exeter & Great Devon

    AI-generated summary

    Elaine JOBE · 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

    Elaine JOBE, an informal voluntary psychiatric patient aged 53, was found hanging in a bathroom at Ocean View on 2 February 2011 after being placed on general hourly observation. Resuscitation and transfer to hospital did not avert her death. Concerns included inadequate records of risk assessments and observations, staff training, and communication of patient status and monitoring responsibilities between shifts.

    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 records of observation levels and observing staff

    Wider context from the report

    “(1) Lack of record keeping Inadequate/lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments. (ii) Lack of information regarding the Levels of Observations and the persons actually making the observations. ”

    Source location

    Elaine JOBE · 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 policy-based recording and staff allocation for heightened observation levels, including electronic records and hourly allocation charts.

    Verbatim wording from the response

    “(ii) The Trust Inpatient Service Engagement and Safety Policy sets clear expectations on the recording of observation levels, both in terms of directly onto the electronic care record for any patient on heightened levels of observation and for allocating staff to carry out the observations.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 3 · response
    Published 14 July 2014

    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 monthly a random sample of patients on observation Levels 2–4 to verify recording in electronic records and staff allocation records.

    Verbatim wording from the response

    “4/ Random monthly audits of patients on Levels 2-4 to ensure recording of observation levels are embedded as per the policy in both the electronic patient record and on the staff allocation record”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 5 · response
    Published 14 July 2014

    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 policies, standards and guidance address the concerns; new standards are not required, though further assurance actions will be implemented.

    Verbatim wording from the response

    “The Trust has policies, standards and guidance in place for the areas of concern noted in the report. It is not seen as required to introduce new standards, but to ensure the embeddedness of those currently in place. The Trust has several assurance measures in place, but further actions as described below will be put in place to provide additional assurance.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 5 · response
    Published 14 July 2014

    Open published response

  9. Shropshire, Telford and Wrekin

    AI-generated summary

    Peter James FAREBROTHER · 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

    Peter James Farebrother was found deceased on 24 August 2013, hanging from a belt ligature attached to the en-suite shower door in his room at Pine Ward. Concerns included the delayed transfer to Pine Ward, failures in handover and observation assessment, the return of his belt, and the suitability of the shower door as a ligature attachment point. The inquest jury concluded that the risk of returning his belt and placing him on general observation was not fully recognised and that these factors combined 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 recognise continuing constant-watch status after transfer

    Wider context from the report

    “(2) The failure by the receiving staff on Pine Ward a) during the remainder of the evening shift or b) at any time during the night shift to recognise that Mr Farebrother had been on constant watch up to and including the transfer and that no assessment had taken place changing that status. ”

    Source location

    Peter James FAREBROTHER · 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

    Flawed basis for observation-level assessment following information breakdown

    Wider context from the report

    “(4) The assessment may well have resulted in a higher observation level and the basis on which it was made, consciously or subconsciously, may have been flawed by the earlier breakdown in information. ”

    Source location

    Peter James FAREBROTHER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester North

    AI-generated summary

    Miss Samiyo Sahra Shih Farah · 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

    Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.

    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 age-appropriate observation guidance for children and adolescents in specialist mental health units

    Wider context from the report

    “1) Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units. At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues. The care needs of young people are quite different to those of adults. ”

    Source location

    Miss Samiyo Sahra Shih Farah · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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

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Data last updated 7 September 2026