11 Jul 2019 Robert Charles Rostron · Prevention of Future Deaths report Manchester West
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Concerns raised 4
Medication administration by agency nurses unfamiliar with the unit View source Reliance on nursing qualifications and agencies to establish agency nurses' ability, suitability and training View source Use of agency nurses as senior staff in charge of shifts View source
Lack of formal induction and orientation for agency nurses View source See 1 more concern
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Hc-One Limited
Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
View source
Hc-One Limited
Complete and distribute a strengthened agency-staff orientation booklet across the company.
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Hc-One Limited
Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.
View source
Hc-One Limited
Require agency nurses to submit insulin-training records, audit qualifications annually, and suspend non-compliant agencies.
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Hc-One Limited
Revise the implemented agency procedure to strengthen checks on agency suppliers.
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Hc-One Limited
Store agency profiles with completed orientation booklets in Cornerstone and allow agency workers to retain booklet copies.
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AI-generated summary
Robert Charles Rostron · 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
Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Medication administration by agency nurses unfamiliar with the unit
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” Source location Robert Charles Rostron · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Reliance on nursing qualifications and agencies to establish agency nurses' ability, suitability and training
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse . I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” Source location Robert Charles Rostron · Prevention of Future Deaths report
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 Use of agency nurses as senior staff in charge of shifts
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift . I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” Source location Robert Charles Rostron · Prevention of Future Deaths report
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 Lack of formal induction and orientation for agency nurses
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” Source location Robert Charles Rostron · Prevention of Future Deaths report
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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 Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
Verbatim wording from the response “There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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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 Complete and distribute a strengthened agency-staff orientation booklet across the company.
Verbatim wording from the response “There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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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 Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.
Verbatim wording from the response “As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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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 agency nurses to submit insulin-training records, audit qualifications annually, and suspend non-compliant agencies.
Verbatim wording from the response “The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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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 Revise the implemented agency procedure to strengthen checks on agency suppliers.
Verbatim wording from the response “Since 2016, we have developed and implemented an agency procedure and although this was not due for a review until next year, a revision is in train to revise and this has already resulted in improvements in ensuring robust checks to agencies. I have attached (Appendix 4) the current version, not in place at the time of the incident, and will be happy to supply the updated version when finalised.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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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 Store agency profiles with completed orientation booklets in Cornerstone and allow agency workers to retain booklet copies.
Verbatim wording from the response “The agency profiles already in operation and expected standard practice in all our homes, will be required to be held alongside the completed orientation booklet and held within the quality assurance system, Cornerstone. We have developed the system to allow the agency worker to also retain a copy of their booklet.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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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 HC-One does not rely solely on nursing qualifications; it verifies agency nurses’ training, skills and qualifications for safe insulin administration.
Verbatim wording from the response “The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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13 Mar 2017 James O’Brien · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to ensure agency nurses are familiar with the ward before starting duties View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
James O’Brien · 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
James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.
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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 agency nurses are familiar with the ward before starting duties
Wider context from the report “(9) The agency nurse in charge of the ward was called shortly before the shift started , was not familiar with the ward , and did not have time to read the care plans of the patients before starting his duties.
” Source location James O’Brien · Prevention of Future Deaths report
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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 induction processes to cover record keeping, observation and emergency response, including orientation tours for unfamiliar staff.
Verbatim wording from the response “5. Induction – the hospital had already reviewed its induction processes. This specifically includes the topics of record keeping, observation and responding to emergencies. Staff that are not familiar with the hospital are provided with a “tour” by more experienced staff when they first start work at the hospital. The hospital is committed to using its own staff and their pool of bank staff wherever possible rather than agency staff. To ensure appropriate staffing levels on any particular shift, managers are required to plan bank staff cover in advance to address planned staff absences. Since August 2016, no agency staff have been used at the hospital.” Source location 2017-0082-Response-by-Cambian-Group-PLC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an agency-nurse induction protocol requiring short-notice staff to attend early and receive policy and environmental orientation.
Verbatim wording from the response “However, notwithstanding the commitment to no longer employing agency staff on an ad hoc basis, it is impossible to say that this could “never” occur because of the obvious need to ensure appropriate staffing levels and the fact that emergencies might arise where additional staff cover is required. Accordingly, our client has developed and implemented an “agency nurse induction protocol” aimed specifically at any staff who may be booked at short notice to cover a shift. They are required to attend work one hour before the shift commences to go through an induction, and receive orientation to key policies and the environment.” Source location 2017-0082-Response-by-Cambian-Group-PLC
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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 The former operator no longer controls future hospital safety steps, which fall to the successor operator.
Verbatim wording from the response “The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.” Source location 2017-0082-Response-by-Cambian-Group-PLC
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21 Nov 2016 Dennis Plater · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Insufficient testing and monitoring of agency staff training, knowledge and understanding View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Dennis Plater · 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
Dennis Plater died of natural causes at Medway Maritime Hospital on 3 February 2016, following deterioration associated with acute kidney injury, sepsis and metastatic lung adenocarcinoma. The report identified incomplete fluid-balance records, failures in NEWS scoring and escalation by an agency nurse, and concerns about the Trust’s monitoring of agency staff training and compliance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient testing and monitoring of agency staff training, knowledge and understanding
Wider context from the report “3)That the Trust did not have in place a sufficiently rigorous or effective system for testing and monitoring the training, knowledge, understanding and compliance of agency staff .
” Source location Dennis Plater · Prevention of Future Deaths report
Open source report
10 May 2016 Christine Valerie STREET · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Lack of assurance that bank staff are trained to Trust standards View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of assurance that bank staff are trained to Trust standards
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
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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
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6 Mar 2015 Emmeline Hampson · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Lack of Agency staff training in documentation, record keeping and risk assessment procedures View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Emmeline Hampson · 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
Emmeline Hampson died in hospital on 6 November 2014 after a fall at her nursing home caused a subdural haematoma and intracerebral bleeding. The concerns included repeated falls without review of her falls risk assessment or referral back to the Falls Service, inadequate procedures and record keeping, shortcomings in alarm audibility and differentiation, and insufficient training of agency staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of Agency staff training in documentation, record keeping and risk assessment procedures
Wider context from the report “vi. The evidence at the Inquest in relation to the fall on the 29th October 2014 was given by a trained nurse employed by an Agency who did not appear to be familiar with the documentation and record keeping particularly relating to risk assessments and there did not appear to be any training of Agency Staff in relation to those procedures .
” Source location Emmeline Hampson · Prevention of Future Deaths report
Open source report
17 Feb 2015 George Marks · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2
Failure of agency staff to understand the Drug Prescription Chart View source Failure of agency staff to understand medication administration and medication refusal policies and procedures View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Mayday Healthcare plc
Send monthly SMS reminders to all staff about documentation, escalation, medication administration and compassion.
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Mayday Healthcare plc
Send quarterly formal letters to staff reinforcing documentation, escalation, medication administration and compassion.
View source
Mayday Healthcare plc
Update the yearly training programme on documentation, escalation, medication administration and compassion beyond mandatory training requirements.
View source
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AI-generated summary
George Marks · 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
George Marks was admitted with confusion, immobility and a chest infection, and was later diagnosed with a deep vein thrombosis and a thrombus in the pulmonary artery. After his anticoagulant medication was changed to Rivaroxaban, he was not given it from the evening of 28 February until 4 March, and he died on 6 March 2014. The principal concerns were agency staff’s failures in medication administration, record-keeping and handover procedures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of agency staff to understand the Drug Prescription Chart
Wider context from the report “2) Agency Staff failed to have an understanding of the Drug Prescription Chart and / or failed to make any record, or any adequate record in the said chart
” Source location George Marks · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of agency staff to understand medication administration and medication refusal policies and procedures
Wider context from the report “1) Agency staff failed to have an understanding of the basic policies and procedures in place when administering medication and / or where a patient refused to take such medication .
” Source location George Marks · Prevention of Future Deaths report
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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 Send monthly SMS reminders to all staff about documentation, escalation, medication administration and compassion.
Verbatim wording from the response “• A generic SMS has been sent to all staff detailing the importance of documentation, escalation, administration of medication and compassion. This is done once a month to remind all staff of their basic duties.” Source location 2015-0057-Response-by-Mayday-Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Send quarterly formal letters to staff reinforcing documentation, escalation, medication administration and compassion.
Verbatim wording from the response “• Formal letters sent to all staff, detailing the importance of documentation, escalation, administration of medication and compassion. This is currently being done every quarter.” Source location 2015-0057-Response-by-Mayday-Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the yearly training programme on documentation, escalation, medication administration and compassion beyond mandatory training requirements.
Verbatim wording from the response “• Updated our yearly training program in regards to documentation, escalation, administration of medication and compassion, which is outside of the framework requirements for the Mandatory Training subjects” Source location 2015-0057-Response-by-Mayday-Healthcare
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8 Jan 2015 George Hulme · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to adequately induct and familiarise agency staff with residents and identification methods View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
George Hulme · 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
On 25 June 2014, George Hulme was assaulted by another resident at Bamford Grange Nursing Home, collapsed and required CPR. The wrong resident file, which recorded a DNR, was retrieved after he was incorrectly identified, and CPR ceased; concerns included inadequate resident identification systems, induction and room labelling for agency staff and emergency responders.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adequately induct and familiarise agency staff with residents and identification methods
Wider context from the report “2) Agency members of staff are supposed to have an induction and tour of the home upon their first visit. This did not take place adequately to sufficiently familiarise the staff with the residents or any method of correctly identifying residents .
” Source location George Hulme · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.