Recurring concern

Failure to promptly enter and assess patients when welfare concerns arise

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First reported 18 Mar 2022•Latest report 22 Aug 2022

Definition

What this concern includes

Includes failures to enter promptly and assess a patient after a welfare concern, non-response, suspected non-respiration or comparable urgent indication, including delays caused by uncertainty about staff safety, room-entry expectations or the need to obtain additional assistance.

Not included

  • Excludes routine welfare checks or observations where no urgent concern, non-response or immediate need to establish the patient's condition is identified.
  • Excludes failures to provide treatment, CPR or ambulance response after prompt entry and assessment have occurred.
  • Excludes generic staffing, training, communication or emergency-response deficiencies that do not directly cause delayed entry and immediate welfare assessment.
  • Excludes environmental access failures where staff are willing and authorised to enter but a physical access problem, rather than the entry-and-assessment process, prevents access.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2022–2022

First to latest report issue date

Stated actions
1

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 Trust1
Norfolk and Suffolk NHS Foundation Trust1

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. Norfolk

    AI-generated summary

    Eliot HARRIS · 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

    Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.

    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 immediate staff entry to a patient’s room when welfare concerns arise

    Wider context from the report

    “5) Staff were reluctant to enter Eliot’s room following concern for his wellbeing. The evidence did not reveal what is now in place to ensure staff enter a patient’s room immediately if there are concerns for a patient’s welfare (having considered their (staff’s) own safety) ”

    Source location

    Eliot HARRIS · 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

    Strengthen the therapeutic-observations policy guidance on entering rooms during immediate welfare concerns and seeking help for staff safety.

    Verbatim wording from the response

    “Supporting people, during times of risk and harm, as soon as it is safe to do so is important part of providing good care. Through our physical interventions training we promote consideration of safety, accompanied with message to seek support. Alongside this consideration of safety, human factors can influence people’s thinking when experiencing unfamiliar or intense situations. We are therefore seeking insights from other mental health Trusts as to any actions and programmes that they apply. In addition, the Safety Day includes a session on the Therapeutic Observation policy which includes a discussion on entering a room when there are immediate concerns for the patient’s welfare and how seek help if there are potential concerns for their own safety. This message has been strengthened within the Therapeutic Observations ‘Policy on a Page’”

    Source location

    Response form Norfolk and Suffolk Foundation Trust
    Page 3 · response
    Published 3 October 2022

    Open published response

  2. Inner North London

    AI-generated summary

    Gary OTTWAY · 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

    Gary Ottway, aged 41, died after being found in cardiac arrest while detained alone in a seclusion room under constant nursing observation during a severe mental health episode. The report raised concerns about whether observation was constant or effective, delays in entering the room and obtaining emergency equipment, gaps in available medical training and resources, and ineffective chest compressions. The inquest determined that he died from natural causes involving two heart conditions.

    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 nursing staff to enter the seclusion room without a doctor present during an emergency

    Wider context from the report

    “5. The junior doctor was the last person to attend the resuscitation and told me he did so after the rapid response team, yet no one had entered the seclusion room by the time he arrived. It may be that there was a (perhaps unconscious) reluctance to enter the room without a doctor, despite the presence of the rapid response (nursing) team. But by the time the junior doctor got to the door (and immediately identified that Mr Ottway was not breathing, at least six and a half to seven minutes had elapsed since the first two nurses saw no evidence of respiration. This was well outside the three to four minute window of opportunity for resuscitation without inevitable brain damage or death. ”

    Source location

    Gary OTTWAY · Prevention of Future Deaths report
    Page 3 · 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

    Failure to enter a seclusion room promptly when non-respiration is suspected

    Wider context from the report

    “When the senior duty nurse and the nurse undertaking continuous observation noted that they could not see evidence of respiration, they did not immediately enter the seclusion room where Mr Ottway lay, because they deemed that unsafe following his earlier violent behaviour. ”

    Source location

    Gary OTTWAY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026