Recurring concern

Failure to maintain adequate visibility for patient monitoring

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First reported 22 Oct 2015•Latest report 7 Jul 2023

Definition

What this concern includes

Includes failures of dedicated environmental or operational arrangements intended to preserve staff visibility of patients during monitoring, including privacy arrangements, observation windows, workstation positioning and comparable visibility controls.

Not included

Excludes failures to perform observations at the required frequency or level when visibility itself is not deficient.
Excludes generic staffing, training, documentation or monitoring failures unless they directly impair a dedicated patient-visibility control.
Excludes non-patient surveillance systems, such as public-place, pool or general CCTV monitoring.
Excludes ward security, door locking or absconding controls where the issue is access control rather than staff visibility of patients.
Excludes generic lighting, layout or maintenance deficiencies unless they are specifically linked to preserving visibility for patient monitoring.

Reports: 6
Individual concerns: 7
Date range: 2015–2023
Stated actions: 7

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.

Ashford and St Peter'S Hospitals NHS Foundation Trust1

Barts Health NHS Trust1

Coventry and Warwickshire Partnership NHS Trust1

Department of Health and Social Care1

Devon Partnership NHS Trust1

Nottinghamshire Healthcare NHS Foundation Trust1

Royal London Hospital1

University Hospitals of Derby and Burton 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.

7 Jul2023
Nottinghamshire
Concerns raised1
1. Unsafe clinical observations through cell door hatches
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.
Actions described in response 1
1. Action
  Ratify and disseminate an escalation flow chart covering access problems and emergency response.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
AI-generated summary

Christopher Howard SMITH · 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 Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

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
Unsafe clinical observations through cell door hatches
Wider context from the report
“1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment. Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths. There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe. There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place. ”
Source location
Christopher Howard SMITH · 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
Ratify and disseminate an escalation flow chart covering access problems and emergency response.

Verbatim wording from the response
“• Escalation flow chart has been developed to assist staff and provide scenarios / context of when this might apply and what to do if unable to access an unwell patient. This has been ratified and disseminated to staff.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 2 · response
Published 6 November 2023
Open published response
2 Dec2020
East London
Concerns raised1
1. Failure to position dialysis patients within a clear line of sight from the nurses station
This report raised 3 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

Ivan Merryfield O’Neill · 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

Ivan Merryfield O’Neill bled to death during a dialysis appointment after a venous needle became dislodged from his arteriovenous fistula. Concerns included his restlessness and frailty, his position outside a clear line of sight from the nurses’ station, and an alarm that did not promptly alert staff to the bleed.

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 position dialysis patients within a clear line of sight from the nurses station
Wider context from the report
“3. Mr O’Neill was placed in a position which was outside of a clear line of sight from the nurses station. ”
Source location
Ivan Merryfield O’Neill · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Aug2019
Staffordshire South
Concerns raised1
1. Failure to maintain best possible visibility from Nurses’ Stations
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
  Remove the Ward 5 nursing station desk and provide staff with a mobile desk to improve patient visibility.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completed
2. Action
  Review all nursing station desks at Queen’s Hospital Burton to confirm correct positioning and visibility.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completed
AI-generated summary

Maureen Veronica Martin · 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

Maureen Martin was admitted to Queens Hospital with cardiac problems and fell on the ward while attempting to mobilise by herself. She sustained a severe head injury that was not suitable for surgery and died in hospital five days later. A concern was raised that the Nurses’ Station desk was facing the wrong way at the time of her fall, potentially reducing visibility.

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 best possible visibility from Nurses’ Stations
Wider context from the report
“Her son pointed out that at the time of her fall, the desk for the Nurses’ Station on the ward was facing the wrong way. Possibly this was linked to some temporary decoration works. When Mrs Martin’s son mentioned this, the desk was repositioned appropriately. I would be grateful if you could check that the desks at Nurses’ Stations in Queens Hospital are properly positioned and, if they do temporarily have to be moved, that the best possible visibility is maintained. ”
Source location
Maureen Veronica Martin · 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
Remove the Ward 5 nursing station desk and provide staff with a mobile desk to improve patient visibility.

Verbatim wording from the response
“1. Mrs Martin’s fall on Ward 5 was the subject of an internal investigation which concluded that the nursing station was indeed moved and it was found not to promote visibility of the patients as the nurse, if sat at the station, was facing the incorrect way. The action that arose out of this investigation was to remove the nursing station desk on that Ward and provide the staff with a “desk on wheels” so that this can be wheeled with the staff as they walk around the Bays.”

Source location
2019-0220-Response-by-University-Hospitals-of-Derby-and-Burton-NHS-Trust
Page 1 · response
Published 13 September 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
Review all nursing station desks at Queen’s Hospital Burton to confirm correct positioning and visibility.

Verbatim wording from the response
“2. A walkaround review has also been undertaken of all of the nursing stations/desks at Queen’s Hospital Burton to see if they are positioned in the correct places. I would like to assure you that they are all in the correct places and are facing the correct way. Indeed, most of the nursing desks are on wheels to allow nurses to complete their paperwork whilst they are in the Bays caring for patients; this encourages more visibility of the nursing staff and allows more time for the nurses to be with patients.”

Source location
2019-0220-Response-by-University-Hospitals-of-Derby-and-Burton-NHS-Trust
Page 2 · response
Published 13 September 2019
Open published response
5 Apr2019
Surrey
Concerns raised1
1. Failure of radiography-room layout and communication arrangements to enable recognition of breathing difficulties
This report raised 10 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

Mrs Alice Doris Dixon · 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

Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.

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 radiography-room layout and communication arrangements to enable recognition of breathing difficulties
Wider context from the report
“11. The way the room was set up it was difficult for the radiographer to realise that Mrs Dixon was having breathing difficulties during the scan as he was only able to see the top of her head and it was hard for him to hear over the sound of the scanner through the intercom in the scanner itself. ”
Source location
Mrs Alice Doris Dixon · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Apr2017
Coventry
Concerns raised1
1. Failure to reliably assess patients' breathing through the door window
This report raised 5 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

Joleen Linton · 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

Joleen Linton died on 3 August 2016 in her room on Spencer Ward, Caludon Centre, after being admitted as an informal patient following an overdose of prescribed drugs. She was discovered deceased at 0800 hours after hourly observations, with concerns about the practicality and reliability of observations, inaccurate recording of her position, reluctance to enter patients’ rooms, and a lack of clarity in the relevant policy.

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 reliably assess patients' breathing through the door window
Wider context from the report
“(2) Evidence indicated that in consequence of lighting, distance and obstructions it was not practical to reliably assess, through the door window, whether a patient was breathing; ”
Source location
Joleen Linton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Oct2015
Exeter and Greater Devon
Concerns raised2
1. Failure of door privacy arrangements to prevent concealment of patient self-harm attempts
2. Failure of door privacy arrangements to maintain staff visibility of patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Discontinue covering bedroom observation windows with towels or similar items across inpatient areas.
  Stated by Devon Partnership NHS TrustStated completed
2. Action
  Publish and distribute a trust-wide safety briefing requiring immediate action to prevent bedroom-window coverings from obstructing patient observation.
  Stated by Devon Partnership NHS TrustStated completed
3. Action
  Issue a further local alert to inpatient units and obtain formal ward responses confirming review and appropriate action.
  Stated by Devon Partnership NHS TrustStated planned
1. Action
  Develop and complete a Respect and Dignity Audit requiring teams to consider safe ways to maintain privacy.
  Stated by Devon Partnership NHS TrustStated in progress
AI-generated summary

Diane Knight · 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

Diane Knight, who had a significant history of mental illness and previous attempts to end her life by drug overdose, died by hanging on 3 February 2015 while a voluntary patient at Ocean View Ward, North Devon District Hospital. A towel placed over her room door and window concealed a belt end secured against the door jamb, and concerns were raised that this practice could conceal self-harm attempts and prevent staff from properly monitoring patients.

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 door privacy arrangements to prevent concealment of patient self-harm attempts
Wider context from the report
“(1) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life such as here with a belt end being trapped by the door against the door jamb. (2) The continuation of this practice may prevent staff being properly able to monitor the patients on the Unit, therefore this practice should be reviewed. (3) An alternative method for preserving patient privacy should be considered that would not allow a patient to conceal an attempt to cause themselves harm. ”
Source location
Diane Knight · 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
Failure of door privacy arrangements to maintain staff visibility of patients
Wider context from the report
“(1) The continued practice of putting a towel over the door could hide an attempt by a patient to harm themselves or end their life such as here with a belt end being trapped by the door against the door jamb. (2) The continuation of this practice may prevent staff being properly able to monitor the patients on the Unit, therefore this practice should be reviewed. (3) An alternative method for preserving patient privacy should be considered that would not allow a patient to conceal an attempt to cause themselves harm. ”
Source location
Diane Knight · 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
Discontinue covering bedroom observation windows with towels or similar items across inpatient areas.

Verbatim wording from the response
“(1) The practice of patients obscuring/covering the glass windows in their bedroom doors will be discontinued across all inpatient areas within Devon Partnership NHS Trust. A patient safety alert will be issued highlighting the risks and the actions required to be taken to eradicate this risk.”

Source location
Diane-Knight-Response
Page 1 · response
Published 22 October 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
Publish and distribute a trust-wide safety briefing requiring immediate action to prevent bedroom-window coverings from obstructing patient observation.

Verbatim wording from the response
“A trust wide safety briefing has been produced and was published on our Trust intranet, this is accessible to all staff and is one of the ways in which we publish and share learning across our services. This briefing was also included in our ‘on-line news’ which is sent out by email to all staff.”

Source location
Diane-Knight-Response
Page 2 · response
Published 22 October 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
Issue a further local alert to inpatient units and obtain formal ward responses confirming review and appropriate action.

Verbatim wording from the response
“We plan to issue a further local alert to all inpatient units which will be sent using our alerts process; this requires a formal response from each ward confirming that the alert has been reviewed and appropriate action taken. This is going to be sent once the RCA report has been agreed so any further actions from the commissioner’s review can be included. This is due to be completed by the end of January 2016 (following agreement of the report by the commissioner).”

Source location
Diane-Knight-Response
Page 2 · response
Published 22 October 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
Develop and complete a Respect and Dignity Audit requiring teams to consider safe ways to maintain privacy.

Verbatim wording from the response
“We are in the process of developing our Respect and Dignity Audit; we will be including a specific requirement for teams to consider how they maintain privacy in these types of situation and what more can be done to keep patients safe whilst maintaining their privacy. This audit will then inform any wider actions needed. The audit is due to be completed by the end of January 2016.”

Source location
Diane-Knight-Response
Page 2 · response
Published 22 October 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Unsafe clinical observations through cell door hatches

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 position dialysis patients within a clear line of sight from the nurses station

Concerns raised1

Failure to maintain best possible visibility from Nurses’ Stations

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

Concerns raised1

Failure of radiography-room layout and communication arrangements to enable recognition of breathing difficulties

Concerns raised1

Failure to reliably assess patients' breathing through the door window

Concerns raised2

Failure of door privacy arrangements to prevent concealment of patient self-harm attempts

Failure of door privacy arrangements to maintain staff visibility of patients

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.4

Actions described in response 1

Actions described in response 2

Actions described in response 4