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. Exeter & Greater Devon

    AI-generated summary

    Roger Clive DUGGAN · 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

    Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.

    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 staff responsibility for observing an agitated patient in the emergency department

    Wider context from the report

    “(2) Mr Duggan was brought to the Emergency Department of the Royal Devon & Exeter Hospital (Wonford) late on the evening of the 10th February 2013 in a state of heightened anxiety and agitation. Night Senior Nurse Mental Health Practitioner, ████████ was called to assess. I received Evidence that ████████ left the Deceased in cubicle 8 in Minors area (which was supervised) asking the staff nurse to sit with Mr Duggan while he spoke with the family. He was told that they would keep an eye on Mr Duggan. No one saw Mr Duggan leave the cubicle until the CCTV picked up his exit from the unit at 00.47 hours on 11th February 2013. It appears from Evidence that neither the Senior Nurse Mental Health Practitioner not night staff on the unit took responsibility for watching Mr Duggan. Mr Duggan was found Deceased in the River Exe at 14.30 hours 12th February 2013. ”

    Source location

    Roger Clive DUGGAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026