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. Essex

    AI-generated summary

    Aaron James DEELEY · 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

    Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.

    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

    Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation

    Wider context from the report

    “While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”

    Source location

    Aaron James DEELEY · Prevention of Future Deaths report
    Page 3 · concerns

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    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 joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.

    Verbatim wording from the response

    “As set out in evidence by EPUT during the course of this Inquest; a patient is placed on a section 5(2) MHA by the Acute Trust, there is a requirement for the mental health liaison team at EPUT to be informed to ensure that appropriate mental health support is in place.”

    Source location

    Response from Essex Partnership NHS
    Page 2 · response
    Published 26 June 2024

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    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 EPUT input and support to MSE’s ratification of its acute-hospital mental health admission and treatment policy.

    Verbatim wording from the response

    “In support of the collaborative approach that both Trusts are taking forward, the service matron has confirmed MSE leads that EPUT will be supportive of an active role in the ratification of this policy. Further, the EPUT Mental Health Liaison Service Operational Policy has been updated to include the support and advice to acute providers regarding risk management of patient’s presenting as requiring assessment under the Mental Health Act 2007. A Standard Operating Procedure (SOP) was presented at the Liaison Services steering group on the 30th July 2024, final copy for comments has been circulated for comments by 5th August 2024; the Policy is now due for final ratification.”

    Source location

    Response from Essex Partnership NHS
    Page 3 · response
    Published 26 June 2024

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    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

    Improve the enhanced supervision policy with practical guidance for safely supporting patients awaiting Mental Health Act assessment.

    Verbatim wording from the response

    “A key management tool for staff caring for acute patients with mental health needs is our ‘MSEPO-21228 Policy for Enhanced Supervision and Engagement’. We have therefore made several improvements to this policy to provide more practical guidance and support for staff during this important time while patients await assessment. We have also delivered training to nursing colleagues in relation to the updated policy and refreshers on record keeping standards so that staff are appropriately skilled in how to complete the supervision paperwork correctly.”

    Source location

    Response from Mid and South Essex NHS
    Page 2 · response
    Published 26 June 2024

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    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 nursing training on the updated supervision policy and record-keeping standards for supervision documentation.

    Verbatim wording from the response

    “A key management tool for staff caring for acute patients with mental health needs is our ‘MSEPO-21228 Policy for Enhanced Supervision and Engagement’. We have therefore made several improvements to this policy to provide more practical guidance and support for staff during this important time while patients await assessment. We have also delivered training to nursing colleagues in relation to the updated policy and refreshers on record keeping standards so that staff are appropriately skilled in how to complete the supervision paperwork correctly.”

    Source location

    Response from Mid and South Essex NHS
    Page 2 · response
    Published 26 June 2024

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    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

    Rewrite enhanced-supervision criteria to clarify when patients awaiting assessment should receive enhanced supervision.

    Verbatim wording from the response

    “Section 5 of our Policy for Enhanced Supervision and Engagement has been re-written in collaboration with the Mental Health Lead Nurse to clearly set out the criteria that should be met for a patient to trigger for enhanced supervision.”

    Source location

    Response from Mid and South Essex NHS
    Page 4 · response
    Published 26 June 2024

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    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Acute Trust is responsible for responding to concerns about the regime and policy for one-to-one observation pending Mental Health Act assessment.

    Verbatim wording from the response

    “With respect to the Learned Coroner, the answer to this particular concern will be for the Acute Trust to respond to. However, by way of completeness, the planned updates to the Mental Health Liaison Service Operational Policy will include provisions around support and advice to Acute providers regarding care planning and risk management.”

    Source location

    Response from Essex Partnership NHS
    Page 4 · response
    Published 26 June 2024

    Open published response

  2. Avon

    AI-generated summary

    Harry Roland Ian Vass · 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

    Harry Roland Ian Vass attended Southmead Hospital on 26 December 2022 with agitation, paranoid thoughts and recent cocaine use, and was later admitted to the Mason Unit. He became unresponsive after vomiting, low oxygen saturations, a high temperature and discolouration of his extremities, and died after transfer back to the emergency department. Concerns included inadequate physical and non-contact observations, and a lack of awareness among mental health nursing staff that acute behavioural disturbance is a medical emergency.

    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 adequate physical-health observations for highly agitated patients

    Wider context from the report

    “• Due to Harry’s level of agitation, he did not undergo the level of observations that would and should have happened either in the emergency department or once on the Mason Unit which may have assisted in assessing his physical health. • It was clear that none of the mental health nursing staff were aware of ABD and the fact it is a medical emergency. • The decision as to whether a person has ABD is important, Dr Delaney said that” this group are vulnerable to cardiac arrest”, that “deaths are multifactorial”, that “normally in the background a body is maintaining safe limits for e.g. pulse rate, blood pressure, temperature, but with acute disturbance in behaviour the body loses control of these safe parameters.” ”

    Source location

    Harry Roland Ian Vass · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Leicester City and South Leicestershire

    AI-generated summary

    Ash BANNISTER · 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

    Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to complete scheduled 7am support-plan checks

    Wider context from the report

    “Ash’s support plan stipulated that Ash was to be checked on every morning at 7am. Ash was not checked upon at 7am on the morning of her death, this is a breach of Ash’s support plan. There was nothing documented in any of the records disclosed to the Court to explain why the support plan was deviated from on this occasion. I was told by care home workers that they would not expect to check on a teenager at 7am at the weekend in a normal family home. The residential care home where Ash was living was not a normal family home but a therapeutic home for children with complex needs. The evidence from the Operations Manager at United Children’s Services who run the home was that Ash should have been checked on at 7am. Ash’s support plan was incorrectly deviated from without any documentation, explanation or justification as to why. This should not have happened. ”

    Source location

    Ash BANNISTER · Prevention of Future Deaths report
    Page 3 · 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

    Ash showed no behaviours or indicators requiring early-hours checks on 7 August 2021.

    Verbatim wording from the response

    “Ash often faced significant struggles with falling to sleep. Staff knew from living with and talking to Ash that Ash often couldn't fall sleep until the early hours of the morning. It was therefore usual for Ash to be allowed time to rest and to be first woken by staff for medication between 8.30am and 9am. As you heard at inquest, staff try insofar as possible to recreate a safe family home environment. Our staff consider the best interests of our young people, including whether or not they have been able to rest, and there were no presenting concerns or indications that Ash was at any heightened risk of harming themselves on the morning of 7 August 2021. Ash had complex needs, including self-harming when triggered, and was under the care of CAMHS for mental health support.”

    Source location

    Response from United Childrens Services
    Page 5 · response
    Published 30 April 2024

    Open published response

  4. Somerset

    AI-generated summary

    Cariss Lucy Stone · 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

    Cariss Lucy Stone was detained in a Psychiatric Intensive Care Unit and self-harmed on multiple occasions, including by attaching a ligature around her neck. During an interval in observations, she applied a ligature with fatal effect, and the healthcare assistant who found her did not have a ligature cutter. The concerns identified were possible inadequate understanding and training regarding observation requirements, including for agency staff, and the lack of routine access to ligature cutters for staff conducting 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

    Lack of adequate staff training and understanding of the level two observations policy

    Wider context from the report

    “(1) The Trust’s current policy for level two observations requires staff to observe a patient not less than five times an hour at random intervals which shall not be more than 15 minutes apart. A possible training issue was revealed during the inquest. Some members of staff who gave evidence at the hearing and in particular one senior member of staff did not appear to have a clear understanding of the policy and there was concern that agency staff might not receive adequate training ”

    Source location

    Cariss Lucy Stone · Prevention of Future Deaths report
    Page 1 · concerns

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    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 policy with clearer level 2 guidance, irregular intervals, multidisciplinary decisions and dedicated staffing for high-frequency observations.

    Verbatim wording from the response

    “Since this reported incident involving Miss Stone in 2019, Somerset NHS Foundation Trust Policy on Observation while maintaining Safety and Engagement has undergone a number of revisions to reflect changes in practice and to incorporate learning from patient safety incidents. The most recent version was published in May 2024 and builds upon existing policy and practice with the aim of providing greater clarity and improved clinical governance around practice of observation.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 1 · response
    Published 29 April 2024

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require and monitor competence assessment, supervised observation rounds and suicide-prevention training for all staff undertaking observations, including bank and agency staff.

    Verbatim wording from the response

    “All staff, who undertake observations, are required to complete an assessment of competence, which will be assessed by a competent Registered Mental Health nurse and who has a minimum of 1 year post registration experience. This is the sole requirement for staff who are employed on the Trust’s bank or via a nursing agency.”

    Source location

    Response from Somerset NHS Foundation Trust
    Page 3 · response
    Published 29 April 2024

    Open published response

  5. East Sussex

    AI-generated summary

    Stephen COSTER · 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 Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure by healthcare staff to carry out adequate observations

    Wider context from the report

    “b. A failure by healthcare staff to carry out adequate observations and to properly assess Stephen Coster’s condition as well as a failure to escalate his case. ”

    Source location

    Stephen COSTER · Prevention of Future Deaths report
    Page 2 · concerns

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    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 an agreed system clarifying prison welfare checks, healthcare clinical observations, required check levels and clinically appropriate inpatient transfers.

    Verbatim wording from the response

    “The prison has also conducted a further review, together with healthcare, to consider how best to manage the care and monitoring of unwell prisoners. An agreed system is now in place which clarifies that prison staff are responsible for welfare checks and medical staff are responsible for clinical observations. Healthcare staff inform prison staff of the need for checks on a particular prisoner and what level of check is required. Where healthcare feel it is clinically appropriate, a move to the inpatient unit at the prison will be facilitated so that healthcare staff are present to undertake all observations.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 20 March 2024

    Open published response

  6. Surrey

    AI-generated summary

    Larry Stephen SPRIGGS · 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

    Larry Stephen Spriggs died after falling from the window of his room at Farnham Road Hospital on 27 May 2021. The inquest identified concerns about the assessment and management of inpatient risk, the use of anti-anxiety medication, communication between staff, and the implementation and management of intermittent observations. The death was recorded as contributed to by neglect and caused or more than minimally contributed to by failures in implementing intermittent 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

    Inadequate arrangements for managing and implementing intermittent observation

    Wider context from the report

    “The adequacy of arrangements in place at Farnham Road Hospital to assess and manage inpatients risk. Use (or non-use) of anti-anxiety medication in relation to the support of Mr. SPRIGGS' symptoms. Passage of information between staff concerning patients care and treatment. The adequacy of arrangements to manage and implement the intermittent observation regime at Farnham Road Hospital. Processes for the management of incidents at Farnham Road Hospital such as those on the 27th May 2021 when Mr. SPRIGGS fell from the window of his room. ”

    Source location

    Larry Stephen SPRIGGS · 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

    Use twice-daily electronic SBAR updates and structured staff handovers, including daily safety reporting, to communicate safety-critical information.

    Verbatim wording from the response

    “Measures have been introduced to improve the passage of information between staff across our inpatient wards. It is acknowledged that embedding change takes time and we are committed to continually improving our processes to ensure effective and timely communication of information.”

    Source location

    Response from Surrey and Boarders Partnership NHS Foundation Trust
    Page 3 · response
    Published 26 February 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Apply observation competency checks, prompt sheets, nurse-in-charge oversight and monthly supportive-observation audits on Victoria Ward.

    Verbatim wording from the response

    “Observation competency checklists are completed at staff induction for all substantive and temporary staff working on Victoria Ward. An observation prompt sheet is provided to staff completing observations. The responsibility for overseeing observations lies with the nurse in charge. From June 2023, Victoria Ward introduced the Supportive Observations Audit Tool. This provides a quality assurance process for not only the policy compliance around supportive observations, but also in the wider context of MDT overview, clinical rationale, care planning and the views of the person. Audits of ten people in the care of the Victoria Ward are carried out on a monthly basis.”

    Source location

    Response from Surrey and Boarders Partnership NHS Foundation Trust
    Page 3 · response
    Published 26 February 2024

    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

    Test and evaluate the digital supportive-observation and therapeutic-engagement recording solution before deciding on wider rollout.

    Verbatim wording from the response

    “In addition, and in co-production with the Victoria Ward clinical team and the Quality Improvement team, a digital solution has been developed for the recording of supportive observations and therapeutic engagement. It is intended that this will be tested and evaluated for its impact on safety prior to a decision about wider roll out across the organisation as part of the current Inpatient Improvement Plan.”

    Source location

    Response from Surrey and Boarders Partnership NHS Foundation Trust
    Page 3 · response
    Published 26 February 2024

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    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 recommendations from the national therapeutic-observation and engagement review.

    Verbatim wording from the response

    “There is a national observation improvement programme underway and the Trust is leading one of the work streams around workforce and training. The programme is led by the National Mental Health and Learning Disability Nurses Directors Forum who are reviewing therapeutic observations and engagement practice. The Trust is part of the Project Board and will be implementing recommendations from the review alongside other mental health trusts.”

    Source location

    Response from Surrey and Boarders Partnership NHS Foundation Trust
    Page 4 · response
    Published 26 February 2024

    Open published response

  7. Essex

    AI-generated summary

    MORGAN-ROSE HART · 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

    Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to use Oxevision only as an adjunct to face-to-face observations

    Wider context from the report

    “(6) Staff entries in patient observations sheets should have given rise to a concern that some staff may have been using Oxevision not just as an adjunct to face-to-face observations, but instead of them. This remains a concern. ”

    Source location

    MORGAN-ROSE HART · 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

    Review and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.

    Verbatim wording from the response

    “A clinical review of the SOPs for Oxevission and Oxevission Observations to align terminology and produce updated versions of the SOPs has been implemented. This includes ensuring the continuity of terminology in the SOP and all communications mirroring system based terms and wording.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 28 December 2023

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.

    Verbatim wording from the response

    “All clinical staff are being retrained or trained in the use of Oxevission and observations. In line with the Oxevission SOP and the Therapeutic engagement and supportive observation policy.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 28 December 2023

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    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 Oxevision use through ward spot checks, DATIX review and maintained training records.

    Verbatim wording from the response

    “DATIX data reflects that staff are using Oxevission in adherence to policy and responding to alerts which has resulted in no harm. The Inpatient Leadership team continue to spot check ward practice and review DATIX data.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 28 December 2023

    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

    Circulate and reinforce the Therapeutic Engagement and Supportive Observation policy across all wards.

    Verbatim wording from the response

    “The review of the Therapeutic Engagement and Supportive Observation policy has been completed and circulated to all staff.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 6 · response
    Published 28 December 2023

    Open published response

  8. Plymouth, Torbay and South Devon

    AI-generated summary

    Paul Perrott · 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

    Paul Perrott, an inpatient detained under the Mental Health Act, died on 31 July 2020 after attempting to hang himself on Ashcombe Ward. Concerns included inadequate recording of his 15-minute observations, unclear responsibility for checking observation charts, insufficient staff awareness of his recent and historical suicide risk, and a focus on immediate rather than historical and contextual risks.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of clarity over responsibility for feedback on observation chart problems

    Wider context from the report

    “(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect . ”

    Source location

    Paul Perrott · 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

    Conduct monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.

    Verbatim wording from the response

    “Policy states that observation audits to check completion of observations are completed monthly by senior nurse managers. This process is in place through the quality review of clinical records and the results of those audits are submitted to the governance manager, feedback to staff and ward governance meetings. The audit performance is then reviewed monthly with ward managers at inpatient governance meetings. Engagement and observation competency checklists are completed for all new staff and these are reviewed and stored by ward managers with the senior nurse manager’s administrator monitoring compliance for wards.”

    Source location

    Response from Devon Partnership NHS Trust
    Page 2 · response
    Published 19 December 2023

    Open published response

  9. Norfolk

    AI-generated summary

    Geoffrey Alan WHATLING · 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

    Geoffrey Alan Whatling entered Amberley Hall Care Home for rehabilitation and later became unwell, with deteriorating NEWS2 scores leading to hospital admission on 10 April 2023. He died on 26 April 2023, with the medical cause of death recorded as infective exacerbation of chronic obstructive pulmonary disease, with frailty and old age. Concerns included incomplete food and fluid records, failures to call emergency services when required, inadequate observation frequency, and gaps in care-record documentation and follow-up.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to take observations hourly

    Wider context from the report

    “4. Mr Whatling’s observations were not taken hourly as required. ”

    Source location

    Geoffrey Alan WHATLING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Cornwall and Isles of Scilly

    AI-generated summary

    Valerie Ann Simmons · 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

    Valerie Ann Simmons developed a large left-thigh haematoma after receiving Fragmin while receiving anticoagulation therapy, was later admitted to hospital, deteriorated and died on 11 January 2023. Concerns included the absence of recorded observations after a change in her presentation and the need for further training on the risks of hypovolaemia in an anticoagulated patient.

    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 observations following changes in patient presentation

    Wider context from the report

    “Where there was a change in a patient’s presentation, it would be expected that a set of observations would be undertaken and recorded in a patient’s notes; ”

    Source location

    Valerie Ann Simmons · 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

    Amend the INR point-of-care-testing SOP and training video to cover anticoagulant-related bleeding complications and prompt observations after clinical deterioration.

    Verbatim wording from the response

    “members of the community nursing team who have been specifically trained and assessed as competent in the use of the INR POCT device, and who can demonstrate an understanding of the role of INR testing including a basic interpretation of the INR result. Practitioners must demonstrate competence and be signed off before performing this role. However, on review of the SOP and training video, conducted in response to the Regulation 28 report, we have identified that it does not include awareness on the tendency of patients taking anticoagulants to have bleeding complications such as haematomas, or how to manage the side effects/consequences for example hypovolaemia. (A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within a soft tissue and display as a purple-coloured bruise.”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 3 · response
    Published 31 October 2023

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    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

    Obtain investment for additional CASP training capacity and deliver three to four extra sessions annually for registered community nurses.

    Verbatim wording from the response

    “On review of training for community nursing, we have identified that the community assessment of sick patient training, (CASP) is a mandatory training requirement for the acute care at home and home first teams only. As a result of learning from this incident, the group has recommended that CASP would be an advantageous course to be added to the registered community nurse’s mandatory training, particularly as the acuity of patients in the community is increasing.”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 3 · response
    Published 31 October 2023

    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 share a learning-from-experience poster with community nursing teams on observations, deterioration recognition and documentation.

    Verbatim wording from the response

    “We recognise that policy updates and training changes can take time. To reassure the family, as part of our meetings, we have undertaken learning from experience to develop a poster which will be shared across all community nursing teams demonstrating the importance of recognising the signs of a deteriorating patient and highlighting the importance of taking and recording basic observations when there is change in clinical presentation.”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 4 · response
    Published 31 October 2023

    Open published response

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