Recurring concern

Failure to maintain required continuous patient observation

First to latest report 7 Apr 2014 — 27 May 2026

Reports that mention this concern
21
Times this concern has been raised
22
Stated actions linked to this concern
31

What this concern includes

Includes failures of a dedicated continuous, within-eyesight, 1:1, or equivalent patient-observation process, regardless of whether the failure arises from staff conduct, unsuitable facilities, inadequate staffing, or use of an ineffective observation method.

What is not included
  • Excludes observation requirements that are not continuous or not a dedicated patient-safety observation process.
  • Excludes generic staffing, training, documentation, policy, or environmental deficiencies unless they directly cause failure of required continuous patient observation.
  • Excludes monitoring of non-patient subjects, such as weapons, equipment, records, or communications.
  • Excludes unrelated patient-location, contact, or assessment failures where continuous observation is not the required control.

Reports and published responses 21 reports

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

  1. Surrey

    AI-generated summary

    Joyce May DENNIS · 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

    Joyce May Dennis, a resident of Roseacre Care Home, became unwell on 9 September 2019 and deteriorated over the following days before being admitted to hospital with sepsis and the onset of a heart attack. She died at 15.30 on 13 September 2019. The principal concerns were inadequate monitoring and record-keeping, failure to investigate or escalate worsening symptoms, insufficient staff training about illness and sepsis in older people, poor liaison, and failure to record family concerns.

    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 continuous observation sufficient to enable prompt medical assistance

    Wider context from the report

    “1. There was a lack of continuous oversight, a lack of notes, a lack of review of those notes and no investigations at the Care Home. It has been underlined to me heavily throughout the proceedings that the care staff are not medically qualified. I accept that and would not expect them to be so in a residential care home setting. However, they had a duty of care for Joyce and that included keeping her under sufficient observation to allow for medical assistance to be called promptly as necessary. ”

    Source location

    Joyce May DENNIS · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  2. Buckinghamshire

    AI-generated summary

    Amanda Gibbens · 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

    Amanda Gibbens died on 13 July 2020 at Stoke Mandeville Hospital after suffering a cardiac arrest while detained under Section 2 of the Mental Health Act at Ruby Ward. The concerns included the use of a monitor rather than continuous direct observation during Level 3 observations and ineffective bedroom searches for prohibited items that could be used for self-harm.

    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 ensure Level 3 constant “within eyesight” observations are conducted by direct visual observation

    Wider context from the report

    “1. Using a monitor screen for Level 3 constant “within eyesight” enhanced observations. The jury found in this case that the deceased could not be seen at all times whist in the de-escalation area, because male healthcare staff moved from observing the female patient from their position in the doorway of the de-escalation room, to view via the monitor in the corridor, when the patient moved into the bathroom, to increase her privacy. Although the Observation policy has been updated since this death in July 2020, by the time of the inquest, the use of the monitor for performing L3 observations was not specifically addressed or prohibited. Although the head of nursing was clear that this should no longer be happening in practice, the current Matron of Ruby ward gave evidence that this was still happening, and although it was now being ‘discouraged’, it was not prohibited. ”

    Source location

    Amanda Gibbens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester North

    AI-generated summary

    Christopher Byron · 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 Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

    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

    Unclear Royal College of Nursing instructions on continuous observation during iron infusions

    Wider context from the report

    “1. In the most recent guidance from the Royal College of Nursing dated May 2019, “Iron Deficiency and Anaemia in Adults” the instruction to nurses is for them to “observe the patient for 30 minutes”. The Court heard evidence from the Divisional Director of Nursing for the Northern Care Alliance who told the Court, in his view this instruction to nurses is unclear. This instruction was felt to be open to interpretation as to whether this means nurses should physically remain with the patient constantly for 30 minutes. If this is what is meant then it was suggested the instruction could be made more specific. ”

    Source location

    Christopher Byron · 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

    Unclear instructions on continuous observation during iron infusions

    Wider context from the report

    “4. The Court heard the Trust Guideline ‘Patient Blood Management of Medical Patients’ indicated the patient was to be observed for 30 minutes during the administration of the iron infusion. Due to a lack of recording the nurse who administered the iron infusion on the 30th December 2017 could not be identified. The nurse on the 9th January 2017 gave evidence to the Court that this was the first time she had administered an iron infusion and she was advised by the Sister to “treat it as a blood transfusion” whereby his observations were taken before and immediately after commencement of the infusion and observations taken every 15 minutes. Hence Mr Byron was left alone during the administration of the iron infusion. The Court heard the policy was unclear as to whether it meant nurses had to remain with the patient constantly for 30 minutes. ”

    Source location

    Christopher Byron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester West

    AI-generated summary

    John Waite · 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 Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.

    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 constant visual observation after central venous catheter removal

    Wider context from the report

    “ii. The Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters in existence within the Salford Royal NHS Foundation Trust at the time of the death included the fact that pressure should be applied for approximately 5 minutes after removal of the catheter or until bleeding has stopped and a patient should lie flat or supine for 30 minutes after removal of the catheter (if medically safe to do so). The guidelines did not state that a patient requires visual observation for a period of time following the removal of the catheter. iii. Following the death of the Deceased the Salford Royal NHS Foundation Trust has taken action to address the concerns in relation to the Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters, together with the ongoing training of staff who undertake the removal of catheters and the management of rare complications. A quick reference guide has been issued to staff by the Hospital in relation to the removal of catheters at the Hospital. The guide requires the patient to remain supine for 30 minutes post removal of the catheter with further bed rest for 2 hours post removal and a visual inspection of the dressing every 5 minutes during the period of 1 hour following the removal. However, the guide does not require constant visual observation for a period of time following the removal of the catheter. The evidence at the Inquest was that, if there is haemorrhage following the removal of a catheter, blood loss could amount to 200mls every minute so that in the period of 5 minutes between each 5-minute inspection of the dressing, advised by the guidance, one litre of blood could be lost, which could lead to death. The evidence at the Inquest was that a period of constant visual observation is required for a period of up to one hour following the removal of a catheter to reduce the risk of blood loss rather than simply monitoring by inspecting the dressing every 5 minutes for that period of time. ”

    Source location

    John Waite · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Issue an advisory alert to NHS England highlighting haemorrhage-prevention precautions and post-procedure observation and supervision.

    Verbatim wording from the response

    “In the interim, immediate action has been taken to issue an advisory alert to bring this area of concern to the attention of NHS England and ask that they review their current practices, paying particular attention to precautions such as pressure being applied to the exit site for no less than 15 minutes and a period of bed rest post procedure of no less than an hour. The level of patient observation and supervision post procedure is highlighted as a particular area of concern in the alert.”

    Source location

    John-Waite-Response
    Page 2 · response
    Published 26 September 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 develop Trust-wide CVC documentation, guidance, checklists and electronic patient-record materials through a multidisciplinary task group.

    Verbatim wording from the response

    “There are a large range of CVC products available for different clinical indications. In considering our actions to address the specific issues identified in the prevention of future deaths notice, we focussed on the CVCs used for the purpose of renal replacement therapy; however, our actions relating to training, competencies and policies will incorporate all CVCs.”

    Source location

    John-Waite-Response2
    Page 2 · response
    Published 26 September 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

    Require pre-removal CVC bleeding-risk assessment and senior medical review of observation arrangements for patients identified as high risk.

    Verbatim wording from the response

    “We have introduced guidance for staff to undertake a risk assessment prior to removal of CVCs. If the patient is deemed to be at risk for a haemorrhage post removal, this will discuss the observation plan with the senior medical staff prior to line removal. This will include a review of the”

    Source location

    John-Waite-Response2
    Page 2 · response
    Published 26 September 2018

    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

    Universal one-hour direct observation after CVC removal would not assure prevention of haemorrhage and could create risks to other patients.

    Verbatim wording from the response

    “The CVC task and finish group has reviewed all clinical incidents reported relating to central venous CVCs since 2012–2018 and these average 100 per month. Over 10 years there have been 150 safety reports relating to CVCs of which only 2 relate to bleeding post removal. One Mr Watte’s case experienced a significant but non-fatal haemorrhage from a CVC line site forty-eight hours after its removal.”

    Source location

    John-Waite-Response2
    Page 2 · response
    Published 26 September 2018

    Open published response

  5. Black Country

    AI-generated summary

    Mr Reginald Frank Lewis · Prevention of Future Deaths report

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

    Report summary

    Mr Reginald Frank Lewis was admitted to hospital after a fall, later fell again while on Ward C19 and sustained a head injury causing an intracerebral bleed; he died on 17 January 2017. Concerns included inadequate communication of his confusion, falls risk and blindness during transfer, his being left unsupervised after family visitors left, and pressure to accept him into a ward already managing several patients requiring continuous observation.

    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 ward capacity for patients requiring continuous observation

    Wider context from the report

    “2. On ward c19, there were already six patients on the ward required to be observed 24 hours a day in two bays. Two bays were subsequently closed to diarrhoea and vomiting. ”

    Source location

    Mr Reginald Frank Lewis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. London Greater (East)

    AI-generated summary

    Joshua Knox-Hooke · 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

    Joshua Knox-Hooke, a 22-year-old man with psychosis and recent drug use, attended North Middlesex Hospital on 1 December 2014 after cutting his neck and wrist and saying he wanted to kill himself. He left before psychiatric assessment and was later found deceased, partly immersed in Danbury reservoir; the inquest concluded that he died from drowning. Concerns included failure to keep him within eyesight in accordance with hospital policy and wider issues around patients leaving before psychiatric assessment and the handling of the incident.

    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 keep patients presenting with current self-harm attempts and suspected drug use within eyesight at all times

    Wider context from the report

    “1. I was informed that the Trust policy in place in December 2014 required a patient presenting with a current attempt at self-harm and suspected drug use to be nursed in an observable area AND to be kept within eyesight at all times. The evidence revealed that Joshua was not kept within eyesight at all times. ”

    Source location

    Joshua Knox-Hooke · 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 standard operating procedure for escalating patients who cannot be deterred from leaving before assessment and immediately informing police.

    Verbatim wording from the response

    “Patients who are deemed to be high risk are admitted to the mental health room and are allocated a 1:1 nurse and security officer to observe the patient awaiting assessment. A video feed of the mental health room is also transmitted to the nurses’ station area (Majors) in the ED. The ED Matron is currently developing a standard operating procedure so that when patients want to leave the department, prior to assessment, and cannot be deterred from leaving, this is escalated to the nurse in charge and the Police immediately informed.”

    Source location

    Knox-Hooke-Response
    Page 2 · response
    Published 1 August 2016

    Open published response

  7. Brighton and Hove

    AI-generated summary

    Christine Valerie STREET · 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

    Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying 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 maintain required arm’s length observation

    Wider context from the report

    “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed. The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA. The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all. This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy. There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust. The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately. ”

    Source location

    Christine Valerie STREET · 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

    Correct staff understanding that the specialist care record applies to patients requiring constant observation, including neurological patients.

    Verbatim wording from the response

    “I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Hold L8AW nursing study days covering deprivation of liberty, falls prevention, one-to-one care, end-of-life care and documentation.

    Verbatim wording from the response

    “A series of study days has been held for the nurses on L8AW, to help them understand fully their responsibilities and obligations. Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year, who provides training both on specific neuro-competencies for nurses and also on more general nursing skills.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.

    Verbatim wording from the response

    “It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Inform bank staff about observation policy and documentation requirements for one-to-one care.

    Verbatim wording from the response

    “Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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

    Run refresher teaching for healthcare assistants on one-to-one care requirements.

    Verbatim wording from the response

    “Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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 every patient requiring constant observation and collate the findings for subsequent learning and action.

    Verbatim wording from the response

    “Furthermore an audit has been carried out very recently of every patient being specialised. The findings are now being collated and action will be taken, including if necessary revision of the current policy, in the light of any learning points that emerge from this audit.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    Open published response

  8. Manchester City

    AI-generated summary

    Milly ZEMMEL · 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

    Milly ZEMMEL, who was blind and aged 89, was admitted to hospital after becoming unwell and later suffered falls, including an unwitnessed fall on 1 March 2015 while experiencing acute confusion. She fractured her left femur, was not considered fit for surgery, and died on 3 March 2015. The principal concerns were failures in falls-risk assessment, escalation and handover after an earlier fall, appropriate supervision and observations, and the adequacy of the hospital’s internal investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to initiate appropriate one-to-one supervision and observations

    Wider context from the report

    “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was. Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death. ”

    Source location

    Milly ZEMMEL · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce Safety Huddles at the start of ward and departmental shifts to discuss incidents, safety issues and enhanced observation needs.

    Verbatim wording from the response

    “The Trust has piloted and now introduced a ‘Safety Huddle’ at the commencement of each ward and departmental shift which includes the discussion and handover of any recent incidents, as well as safety issues relating to patients. This includes a prompt for discussion of any patients who will require additional observation or enhanced supervision as part of their care. This allows nursing staff to report on any unexpected and significant events involving patients and helps them to proactively plan and agree how to resolve them. The policy is within Appendix 2 - Safety Huddle document.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    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

    Introduce the Enhanced Patient Observation Policy to guide safe supervision and observation of adult in-patients.

    Verbatim wording from the response

    “The Enhanced Patient Observation Policy was also introduced in February 2016 to ensure patient safety and to help provide the appropriate level of supervision and observation for adult in-patients. This policy provides advice and support to staff on the different requirements and needs of patients who require observation. This can be found in Appendix 6 - Enhanced Patient Observation Policy.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    Open published response

  9. Oxfordshire

    AI-generated summary

    Connor Sparrowhawk · 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

    Connor Sparrowhawk died on 4 July 2013 at STATT after drowning following an epileptic seizure while in the bath; the jury found that neglect contributed. The report raises concerns about whether sight or sound observations during bathing can effectively prevent drowning in patients with epilepsy, and whether RIO adequately captures and makes accessible patients’ epilepsy histories.

    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 maintain effective bathing observations for patients with epilepsy

    Wider context from the report

    “1) It appears that the current recommendation at the Trust is for patients with epilepsy to be able to choose to bath but to be the subject of sight/sound observations. There are obvious difficulties in respect of patient dignity with observations by sight. As far as observations by sound are concerned, it is envisaged that a member of staff will be sat outside the bathroom door while the patient takes a bath. I am concerned however that observations by sound alone may not prevent someone from drowning. A person can drown in seconds if they are rendered unconscious by an epileptic fit. It also seems to me that a member of staff in, for example, the corridor is likely to be distracted by other members of staff and patients and may also have an occasional requirement to obtain a drink or use the toilet etc. In reality, on a busy ward, particularly with a patient who has reasonably well controlled epilepsy, the concern is that close observation by sight/sound is unlikely to be maintained. I am concerned that this policy is simply setting the Trust up to fail. I understand that a decision was taken sometime after Connor's death to stop bathing. I also understand however that the CQC when they carried out one of their inspections was critical of this decision due to the fact that the CQC are not in favour of blanket bans of this nature. I am sending a copy of this letter to the CQC for them to comment on. My concern is therefore in relation to the effectiveness of bath time observations for patients with epilepsy. ”

    Source location

    Connor Sparrowhawk · 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

    Finalise and ratify the Trust-wide protocol for safe bathing and showering of people with epilepsy.

    Verbatim wording from the response

    “The Clinical Director for Learning Disability Services, ████████, has led this piece of work alongside members of the Epilepsy Clinical Area of Practice group within the division. Although a comprehensive Epilepsy Map and Toolkit have been developed which cover all areas of risk, a decision has been made to write a new protocol specifically for bathing. This has been drafted by ████████, Consultant Nurse, again in conjunction with a range of practitioners. The document is called Protocol for the Safe Bathing and Showering of People with Epilepsy and has just been through a consultation process among senior clinical staff members. As a result of this, suggestions have been made as to some additions that are required to make it applicable to every speciality across the Trust rather than just the Learning Disability Division.”

    Source location

    2015-0445-Response-by-Southern-Health-NHS-Trust
    Page 1 · response
    Published 2 November 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Collate results from epilepsy, bathing-risk and physical-health audits to inform further improvements.

    Verbatim wording from the response

    “Compliance with policies and guidelines and with record keeping standards is assessed on an ongoing basis through management supervision and the peer review process. Audits are also regularly performed with an Epilepsy audit, bathing risk audit and physical health audit having been undertaken in the learning disability division in the last quarter. The results of these are being collated and will inform further improvements that are required.”

    Source location

    2015-0445-Response-by-Southern-Health-NHS-Trust
    Page 2 · response
    Published 2 November 2015

    Open published response

  10. 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 conduct timely and continuous patient observations

    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

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

Back to top

Data last updated 7 September 2026