Recurring concern

Failure to maintain required continuous patient observation

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First reported 7 Apr 2014•Latest report 27 May 2026

Definition

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.

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
21

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
31

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

East London NHS Foundation Trust3
Care Quality Commission2
Department of Health and Social Care2
NHS England2
Northern Care Alliance NHS Foundation Trust2
Black Country Healthcare NHS Foundation Trust1
British Renal Society1
Essex Partnership University NHS Foundation Trust1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Langley Trust1
Mid and South Essex NHS Foundation Trust1
New Cross Hospital1
NHS Greater Manchester Integrated Care Board1
North London Mental Health Partnership1
North Manchester General Hospital1

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.

  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
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Data last updated 7 September 2026