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.

28 Feb2019
South London
Concerns raised1
1. Failure to implement the advised observation regime
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

Yong Keng Hong · 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

Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.

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 advised observation regime
Wider context from the report
“(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
Source location
Yong Keng Hong · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Dec2018
Norfolk
Concerns raised1
1. Failure to carry out nursing observations while patients await discharge
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

William Clifford ATHERTON · 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

William Clifford Atherton was admitted to hospital on 29 May 2017 with abdominal symptoms, urinary retention and poor kidney function. He was discharged despite worsening renal function and deterioration, and died after returning severely unwell with vomiting of faecal matter, a distended abdomen and severe pain; the reported cause was bowel obstruction. Concerns included the lack of senior medical review and nursing observations, failure to recognise warning signs and worsening blood results, and inconsistent early warning score documentation and escalation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to carry out nursing observations while patients await discharge
Wider context from the report
“That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it. ”
Source location
William Clifford ATHERTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Dec2018
South Yorkshire (Western)
Concerns raised1
1. Failure to take daily patient observations
This report raised 4 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
  Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.
  Stated by Brancaster Care Homes LimitedStated completed
2. Action
  Complete National Early Warning Score training for a registered nurse and provide the new observation policy.
  Stated by Brancaster Care Homes LimitedStated completed
Respondent positions 2
1. Position
  The omission of daily medical observations did not contribute to the death, which resulted from natural causes.
  Stated by Brancaster Care Homes LimitedDisputes the concern
1. Position
  Constant attention and assessment by care-home staff were considered reasonable care despite daily medical observations not being undertaken.
  Stated by Brancaster Care Homes LimitedExisting arrangements considered sufficient
AI-generated summary

John Duckenfield · 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

John Duckenfield was receiving intermediate care following a fall and was later admitted to Northern General Hospital, where he died on 21 January 2018. The inquest identified concerns about falsely asserted and unrecorded observations, failure to call a GP when requested, and inaccurate or misleading care-home records.

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 take daily patient observations
Wider context from the report
“During the inquest, evidence showed:- 1. ████████ falsely asserted he had taken observations of Mr Duckenfield in the presence of the family. Not only I, but safeguarding also, felt this assertion was dishonest. 2. He failed to record observations he said he carried out despite accepting a need to do so. 3. Falsely asserted he was never asked to call a GP 4. The care home manager, ████████ said observations should have been taken daily and recorded but were not. Surprisingly therefore, she asserted the care rendered was reasonable. 5. Records kept by the home were inaccurate and misleading. ”
Source location
John Duckenfield · 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 procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.

Verbatim wording from the response
“• I attach a procedure regarding observations (resident observation P52) and the recording of such (specific observations F13u and monthly observations F13l). The objective of this procedure is to: ◦ ensure that the residents are observed relevant to their condition/diagnosis; ◦ ensure that the observations are recorded; ◦ make sure relatives are fully aware of the observations and treatment required as a result of the observations; and ◦ ensure changes in baseline observations are reported to other professionals.”

Source location
2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019
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
Complete National Early Warning Score training for a registered nurse and provide the new observation policy.

Verbatim wording from the response
“My client notes the concerns in relation to Nurse Bogdan and your referral to his professional body. On 17 January 2019, Nurse ████████ successfully completed an observations training module on National Early Warning Score (NEWS2). I attach his certificate. NEWS2 is a guide used to quickly determine the degree of illness of a patient. It is based on the vital signs, respiratory rate, oxygen saturation, temperature, blood pressure and pulse. Nurse ████████ has also been issued with the new observation policy and signed to acknowledge his understanding and receipt of it.”

Source location
2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019
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
The omission of daily medical observations did not contribute to the death, which resulted from natural causes.

Verbatim wording from the response
“In light of the above, our client’s position is that Mr Duckenfield received reasonable care whilst he was at Pexton Grange despite the fact that daily observations were not carried out. He was receiving constant attention and assessment from the care home. It is also our client’s view that Mr Duckenfield died from natural causes and there was no evidence to suggest that omission to take daily medical observations contributed to the sad death.”

Source location
2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019
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
Constant attention and assessment by care-home staff were considered reasonable care despite daily medical observations not being undertaken.

Verbatim wording from the response
“assessments of Mr Duckenfield and ████████ (who was employed by the safeguarding team and interviewed ████████) told the court that this was one method of monitoring a patient – the other being the taking of their observations;”

Source location
2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019
Open published response
28 Nov2018
Manchester North
Concerns raised1
1. Failure to adhere to patient observation policy and protocol
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

John Lea · 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

John Lea was admitted to hospital for management of heart failure and was later found collapsed on the ward after the bay-tagging nurse temporarily left without arranging monitoring. Resuscitation was unsuccessful and his death was confirmed on 12 June 2017; the report considered a sudden cardiac-related event more likely than not. Concerns included incomplete risk assessments, poor communication, gaps in documentation, failure to escalate a change in oxygen saturations, incorrectly calculated NEWS scores, and failures to follow relevant policies and protocols.

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 adhere to patient observation policy and protocol
Wider context from the report
“6. Failure to adhere to Trust policy/protocol – prevention of falls, patient observation. ”
Source location
John Lea · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Nov2018
Southampton and New Forest
Concerns raised2
1. Insufficient staff training in implementing patient observation policies and prioritising vulnerable patients
2. Unclear applicability of patient observation policies to all in-patients
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Eleanor Valerie Fyfe BRABANT · 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

On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.

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 staff training in implementing patient observation policies and prioritising vulnerable patients
Wider context from the report
“5.1 It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable patients. ”
Source location
Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
Page 1 · 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
Unclear applicability of patient observation policies to all in-patients
Wider context from the report
“5.1 It is unclear from the evidence whether the changes made to policies for observations on patients at Antelope House since this death apply to all in-patients cared for by the Trust and what steps have been made to train staff in their implementation, particularly in relation to prioritising the most vulnerable patients. ”
Source location
Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report
Page 1 · concerns
Open source report
9 Oct2018
Liverpool and the Wirral
Concerns raised1
1. Failure to repeat observations hourly in accordance with the NEWS policy
This report raised 11 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

Tom Cribley · 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

Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

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 repeat observations hourly in accordance with the NEWS policy
Wider context from the report
“A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”
Source location
Tom Cribley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
13 Aug2018
Inner North London
Concerns raised1
1. Failure of allocated ward staff to remain awake and attentive
This report raised 9 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.
Respondent positions 1
1. Position
  The alleged sleeping incident was disputed because staff denied it and no contemporaneous reports or other evidence supported the allegation.
  Stated by Royal Free HospitalDisputes the concern
AI-generated summary

Flora Marion BABER · 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

Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.

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 of allocated ward staff to remain awake and attentive
Wider context from the report
“3. Family members told me that at one point, they found the member of staff allocated to Dr Baber’s bay sitting in a chair apparently asleep. ”
Source location
Flora Marion BABER · Prevention of Future Deaths report
Page 2 · 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
The alleged sleeping incident was disputed because staff denied it and no contemporaneous reports or other evidence supported the allegation.

Verbatim wording from the response
“8 West’s Ward Manager has reviewed all the staff rotas for the Saturdays during this patient’s admission and has spoken to all staff on shift. They all deny being asleep or being aware of a colleague sleeping.”

Source location
2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Page 4 · response
Published 24 January 2019
Open published response
8 Aug2018
South Yorkshire (Western)
Concerns raised1
1. Inappropriate patient observation regimes
This report raised 4 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
  Revise inpatient observation policy, remove ten-minute observations, and inform staff of the resulting safe-practice requirements.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated completed
2. Action
  Roll out bespoke suicide-prevention training and continue refining its content using feedback.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progress
3. Action
  Review and update clinical risk training to strengthen its focus on suicide-risk assessment.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated completed
AI-generated summary

Keith Dransfield · 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

Keith Dransfield died in Northern General Hospital on 30 September 2017 from cerebral hypoxia due to hanging, with psychiatric depression also recorded. The inquest identified concerns about an inappropriate observation regime, inadequate risk assessment, failure to routinely consult patient records, and insufficient staff training.

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
Inappropriate patient observation regimes
Wider context from the report
“During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”
Source location
Keith Dransfield · 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
Revise inpatient observation policy, remove ten-minute observations, and inform staff of the resulting safe-practice requirements.

Verbatim wording from the response
“• The Trust has reviewed and revised its Policy: Observation of Inpatients – Routine and Enhanced Observations of Patients. In light of national evidence, and in line with accepted best practice, observations at 10 minute intervals have been removed. The Trust has taken steps to ensure that all staff are aware of the new policy and the changes to practice that will be required to implement the policy safely.”

Source location
2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 3 · response
Published 30 October 2018
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
Roll out bespoke suicide-prevention training and continue refining its content using feedback.

Verbatim wording from the response
“• The Regulation 28 ruling states that Mr Dransfield was on an inappropriate level of observation at the time of his death. The Trust takes a thorough and proactive approach to the management of risk and, to support our staff in making clinical decisions about levels of risk, the Trust has initiated a programme of bespoke suicide prevention training. This programme of training has commenced, and the Trust has and will continue to review the course content in light of feedback received to improve, refocus and to ensure it is effective and fit for purpose.”

Source location
2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 3 · response
Published 30 October 2018
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 and update clinical risk training to strengthen its focus on suicide-risk assessment.

Verbatim wording from the response
“The content of our Clinical Risk Training has also been reviewed and updated with an enhanced focus on Suicide Risk Assessment.”

Source location
2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 4 · response
Published 30 October 2018
Open published response
8 Aug2018
Manchester North
Concerns raised1
1. Lack of a policy or protocol for observation and monitoring of service users
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop a simple observation protocol and recording system for monitoring service users when directed by medical practitioners.
  Stated by Persona Care And Support LimitedStated planned
AI-generated summary

Dr Donald Clegg · 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

Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.

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 a policy or protocol for observation and monitoring of service users
Wider context from the report
“6. There is no policy/protocol for the observation/monitoring of service users e.g. when directed to do so by a medical practitioner. Staff are left to interpret for themselves what this means. ”
Source location
Dr Donald Clegg · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a simple observation protocol and recording system for monitoring service users when directed by medical practitioners.

Verbatim wording from the response
“Having reviewed this area, we do not have an adequate system and protocol. This links closely to Point 4 (above). We will be developing a simple protocol for staff and an appropriate recording system for observations to sit alongside the training mentioned earlier. The new Compliance Manager will be tasked with this as an urgent action.”

Source location
2018-0269-Response-by-Persona
Page 4 · response
Published 25 October 2018
Open published response
8 May2018
London Inner (South)
Concerns raised1
1. Failure to conduct required ward 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 7
1. Action
  Issue an internal Blue Light Bulletin to registered nurses using the case to reinforce observation and recording practice standards.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
2. Action
  Direct ward managers to hold learning conversations with inpatient registered and non-registered nurses about observation practice.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
3. Action
  Review the Therapeutic Engagement and Observation Policy, focusing on practice-standard clarity and policy implementation.
  Stated by South London and Maudsley NHS Foundation TrustStated in progress
1. Action
  Deliver annual Learning the Lessons presentations on timely observation and recording to newly registered nurses, using the case as teaching material.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
2. Action
  Deliver annual Learning the Lessons presentations on timely observation and recording to nurses in training years one to three, using the case as teaching material.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
3. Action
  Develop a timeline for transforming mental health safety and engagement observations into the e-observation framework, beginning with scoping.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
4. Action
  Conduct six-monthly snap audits of compliance with observation standards, report results through quality governance meetings, and take necessary improvement steps.
  Stated by South London and Maudsley NHS Foundation TrustStated in progress
AI-generated summary

WILLIAM DICKENS · 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

WILLIAM DICKENS, who was assessed as at high risk of repeat self-harm, died on 10 May 2017 after being discovered hanging by a belt from the bed in his room at a mental health unit. The report raises concerns that required intermittent observations were not carried out, that observation-log entries were made after the event, and that defects in the logging process could create a risk of future deaths.

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 required ward patient observations
Wider context from the report
“(1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with. While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period. (2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died. No note had been made on the log to indicate that the entries were being made after the event. (3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe. (4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event. (5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future. ”
Source location
WILLIAM DICKENS · 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 an internal Blue Light Bulletin to registered nurses using the case to reinforce observation and recording practice standards.

Verbatim wording from the response
“1) The Director of Nursing to use the case as the basis of an internal safety alert ‘Blue Light Bulletin’ to be sent out to all registered nurses to reinforce the practice standards. To be completed by 6/07/18”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 1 · response
Published 1 July 2018
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
Direct ward managers to hold learning conversations with inpatient registered and non-registered nurses about observation practice.

Verbatim wording from the response
“2) All Ward Managers to be directed to have a learning conversation with inpatient registered and non-registered nurses about the practice. To be completed by 31/07/18”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 1 · response
Published 1 July 2018
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 the Therapeutic Engagement and Observation Policy, focusing on practice-standard clarity and policy implementation.

Verbatim wording from the response
“3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to the clarity of practice standards and the implementation of the policy.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 1 · response
Published 1 July 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver annual Learning the Lessons presentations on timely observation and recording to newly registered nurses, using the case as teaching material.

Verbatim wording from the response
“4) From September 2018 the cohort of newly registered nurses to receive a “Learning the Lessons” presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver annual Learning the Lessons presentations on timely observation and recording to nurses in training years one to three, using the case as teaching material.

Verbatim wording from the response
“5) From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a timeline for transforming mental health safety and engagement observations into the e-observation framework, beginning with scoping.

Verbatim wording from the response
“7) The Director of Nursing as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into the e-observation framework. This is a long term project that is complex to deliver, a time frame is difficult to reliably commit to, the aim will be scoping from January 2019.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct six-monthly snap audits of compliance with observation standards, report results through quality governance meetings, and take necessary improvement steps.

Verbatim wording from the response
“8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to implement the advised observation regime

Concerns raised1

Failure to carry out nursing observations while patients await discharge

Concerns raised1

Failure to take daily 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.2

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

Concerns raised1

Failure to adhere to patient observation policy and protocol

Concerns raised2

Insufficient staff training in implementing patient observation policies and prioritising vulnerable patients

Unclear applicability of patient observation policies to all in-patients

Concerns raised1

Failure to repeat observations hourly in accordance with the NEWS policy

Concerns raised1

Failure of allocated ward staff to remain awake and attentive

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

Concerns raised1

Inappropriate patient observation regimes

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

Lack of a policy or protocol for observation and monitoring of service users

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 conduct required ward 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.7

Actions described in response 2

Respondent positions 2

Respondent positions 1

Actions described in response 3

Actions described in response 1

Actions described in response 7