Concerns raised 1
Failure to update nursing care plan risk assessments in response to changes in clinical presentation and falls View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Anthony David Blower · 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
Anthony David Blower died at home on 25 October 2020 after sustaining multiple falls, bilateral subdural haematoma and further bleeding following hospital admission and surgery. The concerns identified included nursing care-plan risk assessments not being updated, poor documentation, and inadequate oversight of hydration, with Mr Blower becoming seriously dehydrated during his admission.
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× 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 update nursing care plan risk assessments in response to changes in clinical presentation and falls
Wider context from the report “1) Evidence at inquest revealed that none of the nursing care plan risk assessments, which had been completed on Mr Blower’s arrival on the ward, had been updated during his stay . I heard evidence that there are changes to his clinical presentation that were recorded in the nursing notes and that these should have been reflected in updated risk assessments . The multi factorial falls risk assessment had not been fully updated after an in-patient fall by Mr Blower .
The evidence I heard from the nursing staff was that they are potentially missing opportunities for nursing interventions when risk assessments are not updated and that they do not always have the time to review the nursing notes.
I note that the hospital is carrying out audits of documentation completion and updating some systems. However, some 2 years after the death of Mr Blower, the ward manager stated in evidence that her reviews of care plans showed a huge variety in the level of completion and that records with documentation remained poor. The hospital witnesses noted that staff were under significant time pressure and completing documentation is not seen as a priority.
” Source location Anthony David Blower · Prevention of Future Deaths report
Open source 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 Continue ward accreditation assessments, including care-plan and patient-record reviews, feedback, action planning and governance reporting.
Verbatim wording from the response “The trust is in a transitional period with many of our systems moving over to digital formats. This hybrid system makes auditing more challenging in the short term, but I would like to provide you with assurance that auditing does continue, in a variety of ways.” Source location Response from Portsmouth Hospitals University
Open published response
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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 Existing ward accreditation and clinical audit processes are considered sufficient to address nursing documentation and care-plan completion concerns.
Verbatim wording from the response “The trust is in a transitional period with many of our systems moving over to digital formats. This hybrid system makes auditing more challenging in the short term, but I would like to provide you with assurance that auditing does continue, in a variety of ways.” Source location Response from Portsmouth Hospitals University
Open published response
22 Apr 2022 Matthew Alexander CASEBY · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to complete and update risk assessments in a timely manner by suitably experienced staff View source
This report raised 6 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. 8
Priory Group
Remind staff to complete contemporaneous risk assessments through communications, supervision and appraisals.
View source
Priory Group
Triangulate incidents with patient risk assessments and care plans through ward checks and daily flash-meeting confirmation.
View source
Priory Group
Update and reissue Policy H35 to require prompt post-incident risk review and handover communication of resulting care-plan changes.
View source
Priory Group
Add a Datix prompt requiring confirmation that incident-related risk assessments and care plans have been reviewed.
View source
Priory Group
Audit incident reports against risk assessments and care plans weekly and review results at hospital governance meetings.
View source
Priory Group
Continue compliance inspections comparing patient risk assessments with incident reports.
View source
Priory Group
Update Quality Walk Round checks to compare CareNotes risk assessments with patients’ incident profiles.
View source
Priory Group
Review, update and roll out risk-assessment and risk-management training covering contemporaneous documentation and real-time risk sharing.
View source See 5 more actions
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AI-generated summary
Matthew Alexander CASEBY · 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
Matthew Caseby was detained under the Mental Health Act after being found on railway lines and in a school playground, and was transferred to the Priory Hospital in Birmingham. He absconded from the hospital courtyard on 7 September 2020 after being left unattended, and was fatally injured after stepping in front of a train on 8 September 2020. The principal concerns included inadequate recording and communication of absconding risks, failure to update risk assessments, lack of a courtyard observation policy and risk assessment, and inadequate courtyard safety.
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× 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 complete and update risk assessments in a timely manner by suitably experienced staff
Wider context from the report “3. Risk Assessments: The inquest heard how all members of staff can update a Risk Assesment at any time. Despite this, and with clear evidence that Matthew was at risk of absconsion, his risk assessment was not updated over the weekend when the risk materialised . I have serious concerns about how risk assessments are completed, when they are completed, who completes them and whether they are updated in a timely and necessary manner by suitably experienced staff .
” Source location Matthew Alexander CASEBY · Prevention of Future Deaths report
Open source 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 Remind staff to complete contemporaneous risk assessments through communications, supervision and appraisals.
Verbatim wording from the response “Communications to staff: All colleagues at Woodbourne have been reminded about the requirement to complete contemporaneous risk assessments. This has also been raised with colleagues as part of supervision and where necessary, appraisals.” Source location Response from Priory Group
Open published response
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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 Triangulate incidents with patient risk assessments and care plans through ward checks and daily flash-meeting confirmation.
Verbatim wording from the response “Checks by Ward Staff: At Woodbourne, the nurse in charge of the ward (or the on-site manager during weekends and “out-of-hours”) checks reported incidents and triangulates these with the patient risk assessments and risk management plans. Similarly, all incidents that have occurred in the previous 24 hours are highlighted during the morning ‘flash’ meeting (these meetings take place Monday to Friday and are attended by the SMT together with representatives from each ward). The meetings act as a prompt to ward managers to check that such incidents have been reported on Datix and CareNotes and considered within the patient’s risk assessment and care plan. This is then confirmed the following day at the next flash meeting.” Source location Response from Priory Group
Open published response
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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 Update and reissue Policy H35 to require prompt post-incident risk review and handover communication of resulting care-plan changes.
Verbatim wording from the response “Changes to Policy: During May 2022, we incorporated the issues learned from the inquest into Policy H35 Clinical Risk Assessment which has been updated and re-issued. For example, there is now a reference to the risk assessment and risk management plan being reviewed by the senior member of the team as soon as practicable after an incident and this review must be completed before the end of the current shift. The outcome of the risk assessment and any subsequent changes to the care plan (which may include an increase in observation levels) must be communicated to the next shift at handover.” Source location Response from Priory Group
Open published response
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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 Add a Datix prompt requiring confirmation that incident-related risk assessments and care plans have been reviewed.
Verbatim wording from the response “Changes to Datix: The Datix incident reporting system now has a prompt in place asking the staff member reporting the incident to confirm whether the patient’s risk assessment and associated care plans have been reviewed in response to the incident.” Source location Response from Priory Group
Open published response
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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 Audit incident reports against risk assessments and care plans weekly and review results at hospital governance meetings.
Verbatim wording from the response “• Woodbourne is undertaking a weekly audit of a sample of incident reports which are checked against risk assessments and care plans. Results are reviewed at the weekly hospital governance meetings.” Source location Response from Priory Group
Open published response
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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 Continue compliance inspections comparing patient risk assessments with incident reports.
Verbatim wording from the response “• The internal compliance team will continue to review patient risk assessments (which form part of the CareNotes records) against incident reports during their inspections.” Source location Response from Priory Group
Open published response
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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 Update Quality Walk Round checks to compare CareNotes risk assessments with patients’ incident profiles.
Verbatim wording from the response “• The monthly Quality Walk Round template has been updated and includes reference to checks being made on CareNotes that the risk assessment accords with the patient’s incident profile.” Source location Response from Priory Group
Open published response
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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, update and roll out risk-assessment and risk-management training covering contemporaneous documentation and real-time risk sharing.
Verbatim wording from the response “Training: We have initiated a review of our risk assessment and risk management training e-learning module and this will be updated and rolled out during H2 of 2022. The module will include a requirement to ensure that risk assessments and risk management plans are contemporaneous and accurate and that patient risk is shared in “real-time” with all colleagues.” Source location Response from Priory Group
Open published response
11 Jul 2021 ELEANOR ROSE MURPHY-RICHARDS · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 1
Failure to update risk assessments after deviation from an agreed Safety Plan View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North East London NHS Foundation Trust
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AI-generated summary
ELEANOR ROSE MURPHY-RICHARDS · 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
Ellis died on 30 September 2020 after jumping from a footbridge onto a railway track in front of an oncoming train, intending to end his life. Concerns included gaps in the safety plan, a deviation from it without an updated risk assessment, incomplete sharing of information about a recent failed hanging attempt, and advice that did not account for the risk of Ellis leaving the centre.
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 update risk assessments after deviation from an agreed Safety Plan
Wider context from the report “(2) On 30ᵗʰ September 2020 there was a deviation from the agreed Safety Plan without an updated risk assessment .
” Source location ELEANOR ROSE MURPHY-RICHARDS · Prevention of Future Deaths report
Open source report
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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 There was no deviation from the safety plan; a dynamic, though informal, risk assessment was undertaken.
Verbatim wording from the response “If you are referring to the risk assessment and safety plan effective on 30th September 2020 and the alleged deviation from the agreed Safety Plan by the psychiatrist. I note that there was no deviation from Ellis’ safety plan and the risk assessment was carried out by the psychiatrist.” Source location 2021-0237-Response-from-Trust-Head-Office_Published
Open published response
19 May 2021 Liam Kenyon · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1
Failure to update risk assessments after a suspected overdose View source
This report raised 7 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
Liam Kenyon · 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
Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.
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× 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 update risk assessments after a suspected overdose
Wider context from the report “4. In addition following him being found unconscious due to a suspected overdose the Court heard his risk assessment should have been updated and this was not done .
” Source location Liam Kenyon · Prevention of Future Deaths report
Open source report
29 Mar 2021 Raymond Alfred POWELL · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to update residents' falls risk assessments 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. 1
Cole Valley Nursing Home
Display a named nurse list and have the manager and deputy manager monitor and plan evaluations and risk assessments when nurses are unavailable.
View source
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AI-generated summary
Raymond Alfred POWELL · 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
Raymond Alfred POWELL became increasingly frail, moved into Cole Valley Nursing Home, and suffered falls on 3 November 2020 that caused an acute subdural haematoma. He later developed an infection and seizure and died on 5 December 2020. Concerns included failures to record a preceding fall, update his falls risk assessment, accurately document observations, formally review the circumstances, and comply with court orders for evidence, creating an ongoing risk to other residents.
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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 update residents' falls risk assessments
Wider context from the report “(2) The nursing home manager in her written report to the Coroner stated that Raymond's falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon Raymond's arrival, and had never been updated . Raymond's named nurse should have reviewed and updated it at the end of October with the preceding fall on 15 October being a key factor in the updated assessment. The nursing home manager was unable to explain why the named nurse did not update the falls risk assessment as expected.
” Source location Raymond Alfred POWELL · Prevention of Future Deaths report
Open source 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 Display a named nurse list and have the manager and deputy manager monitor and plan evaluations and risk assessments when nurses are unavailable.
Verbatim wording from the response “The manager has now completed a new named nurse list and now is displayed in the nurse’s office. The deputy manager and manager to effectively monitor and plan evaluations and risk assessment when nurses are unable to due to unforeseen circumstances such as sickness.
Upon reflection, new strategies and monitoring systems have been implanted. Resident of the day has been implemented with feedback from all departments to ensure accurate reflection of person-centred care and avoidance of missed evaluations in the future.
Supervisions have now been allocated to head of departments and a matrix is now available for view in nurses offices.
A new daily task folder has also been implemented for the nurses to complete. This contains allocated audits (i.e care plan audits and resident of the day).” Source location 2021-0089-Response-from-Cole-Valley-Nursing-Home-Redacted
Open published response
25 Mar 2021 Azra Parveen HUSSAIN · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Failure to update risk screens after significant changes in presentation View source
This report raised 6 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. 1
Care Quality Commission
Monitor the trust’s ligature-risk and care-planning improvements through monthly leadership meetings and weekly progress reports.
View source
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AI-generated summary
Azra Parveen HUSSAIN · 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
Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.
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× 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 update risk screens after significant changes in presentation
Wider context from the report “1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated , an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs.
” Source location Azra Parveen HUSSAIN · Prevention of Future Deaths report
Open source 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 Monitor the trust’s ligature-risk and care-planning improvements through monthly leadership meetings and weekly progress reports.
Verbatim wording from the response “Conditions were placed on the trust’s registration certificate by CQC following the inspection on 23 November 2020 which identified concerns in relation to ligature risks, risk assessment and care planning. The Trust has complied with our conditions and have been submitting monthly updates on their progress to replace doors and improve care planning. Inspectors have been meeting monthly with the trust leadership team to discuss the progress and improvements made to date. As a result of the meetings CQC has asked for weekly reports on the ward improvements programmes to understand ongoing mitigation whilst the replacement of en-suite doors is incomplete.” Source location 2021-0082-Response-from-CQC-Redacted
Open published response
10 Feb 2021 Eric Harold Bird · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2
Failure to update falls risk assessments and care plans after every fall View source Failure to update falls risk assessments and care plans after every fall View source
This report raised 8 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. 1
Care Quality Commission
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
View source
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AI-generated summary
Eric Harold Bird · 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
Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.
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× 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 update falls risk assessments and care plans after every fall
Wider context from the report “7. There was no evidence of any changes being made to Mr Birds falls care plan after the fall on 14/11/20 and no rationale recorded for not doing so ;
” Source location Eric Harold Bird · 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 Failure to update falls risk assessments and care plans after every fall
Wider context from the report “6. There was no evidence that Mr Bird’s falls risk assessment and falls care plan had been updated after every fall ;
” Source location Eric Harold Bird · Prevention of Future Deaths report
Open source 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 Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Verbatim wording from the response “The matters of concern which arose from the preventing future deaths report have prompted the CQC to take action. In direct response, we held a management review meeting on 17 February 2021. Following the management review meeting, we reviewed the evidence we held about Castlehill Specialist Care Centre, the information held following the specific incident review related to Mr Bird’s death and information following the inspection completed in January 2021.” Source location 2021-0122-Response-from-Care-Quality-Commission-Redacted
Open published response
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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 CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Verbatim wording from the response “• As a result of these findings, CQC held a management review meeting on 18 March 2021 to discuss the findings under our specific incident guidance. In order to open a formal criminal investigation, we have to be able to evidence a Registered Person (either a Registered Provider or Registered Manager) failed to provide safe care and treatment to Mr Bird in relation to this incident and can prove beyond reasonable doubt this incident was avoidable. We did not feel that this threshold was met and therefore will not progress the case.” Source location 2021-0122-Response-from-Care-Quality-Commission-Redacted
Open published response
10 Feb 2021 LISA MARIE THOMPSON · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1
Failure to update care plans and risk assessments with material overdose information and information from clinical reviews and contacts View source
This report raised 2 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. 5
OHFT
Maintain current risk assessments and care plans for Care Programme Approach patients and share them with patients and families as appropriate.
View source
OHFT
Review electronic care-record processes for recording and reviewing risk formulations and assessments, including family views and best-practice family involvement.
View source
OHFT
Embed multidisciplinary team care-plan reviews for patients at risk of suicide.
View source
OHFT
Have the Quality Improvement team consider family involvement, enhanced risk formulation and suicide-risk assessment within thematic improvement work.
View source
OHFT
Include risk-assessment and care-plan quality in Trust audits during the coming year.
View source See 2 more actions
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AI-generated summary
LISA MARIE THOMPSON · 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
Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.
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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 update care plans and risk assessments with material overdose information and information from clinical reviews and contacts
Wider context from the report “Evidence was heard that:
(1) There was no clear care plan in place following an emergency review of Mrs Thompson on 13th March 2020
(2) The care plans and risk assessments at the mental health Trust were not updated :
(a) with material information on the facts and circumstances of Mrs Thompson’s overdoses of her medication.
(b) the two most recent overdoses were not recorded
(c) with further information disclosed by the doctor who treated her most recent overdose that Mrs Thompson had lied about the severity of her overdose that it was probably double that which she initially disclosed also that this was her 4th overdose and another could not be ruled out.
(d) on 13th March 2020 following a review with the Trust Consultant Psychiatrist
(e) on 13th March 2020 when there was a telephone conversation between Mrs Thompson and her care co-ordinator
” Source location LISA MARIE THOMPSON · Prevention of Future Deaths report
Open source 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 Maintain current risk assessments and care plans for Care Programme Approach patients and share them with patients and families as appropriate.
Verbatim wording from the response “The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:” Source location 2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
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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 electronic care-record processes for recording and reviewing risk formulations and assessments, including family views and best-practice family involvement.
Verbatim wording from the response “The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:” Source location 2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
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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 Embed multidisciplinary team care-plan reviews for patients at risk of suicide.
Verbatim wording from the response “The Trust’s complaint investigation has been completed and the Trust wrote to Mr Thompson on 12th March 2021 to report on the findings of the investigation. I can report to you that the Complaint Investigation Officer identified the following issues to be addressed by the Trust:” Source location 2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
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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 Have the Quality Improvement team consider family involvement, enhanced risk formulation and suicide-risk assessment within thematic improvement work.
Verbatim wording from the response “To that end, the Trust has a Quality Improvement team² who are dedicated to working with our local teams to continually improve the quality of our services. Our Chief Nurse has asked the Quality Improvement team to ensure areas of improvement relating to this tragic serious incident are considered alongside other themes identified from the thematic review, in particular:” Source location 2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
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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 Include risk-assessment and care-plan quality in Trust audits during the coming year.
Verbatim wording from the response “Please be assured that this work is a high priority for the Trust. Trust audits in the coming year will include looking at the quality of risk assessments and care plans. We have also included safety planning questions into our CPA and Essential Standards audits. I also hope it will help to inform you about work being carried out if I attach the Trust’s Action Plan record (“C”).” Source location 2021-0171-Response-from-Littlemore-Mental-Health-Centre-Redacted
Open published response
19 Nov 2020 PAUL HILLS · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 1
Failure to update risk assessments when risk scores or behaviour change View source
This report raised 8 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
Ministry of Defence
Improve clinical record keeping to ensure care plans, risk assessments and clinical reasoning are documented clearly and electronically.
View source
Ministry of Defence
Strengthen senior-clinician oversight of record-keeping quality and regularly review clinicians whose performance falls below the required standard.
View source
Ministry of Defence
Introduce enhanced risk-management training for all Department of Community Mental Health clinical staff, including tools for recognising, assessing and managing mental-health risks.
View source
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AI-generated summary
PAUL HILLS · 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
Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.
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 update risk assessments when risk scores or behaviour change
Wider context from the report “2. Care plan had not been updated since October 2019 and his risk assessment remained the same even when the scores changed and there was evidence of escalating risk behaviour .
” Source location PAUL HILLS · Prevention of Future Deaths report
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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 Improve clinical record keeping to ensure care plans, risk assessments and clinical reasoning are documented clearly and electronically.
Verbatim wording from the response “Sgt Hills’ risk was assessed by treating clinicians in Department of Community Mental Health, London, and as a result he was offered a face-to-face appointment. Following discussion with Sgt Hills, who was concerned about attendance in person, a telephone appointment was agreed as an alternative. We agree that the factors his clinicians considered in proceeding with telephone consultations should have been documented more clearly. Steps have now been taken to ensure better record keeping. This is covered in more detail below, in the response to your matters of concern 2 and 4.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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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 Strengthen senior-clinician oversight of record-keeping quality and regularly review clinicians whose performance falls below the required standard.
Verbatim wording from the response “More broadly, steps have been taken to ensure that Senior clinicians focus on the quality of record keeping and, should the performance of any treating clinician fall below the expected standard, that person’s performance will be reviewed regularly until the required quality is achieved. To support this, Defence Primary Healthcare is currently updating its guidance on the delivery of mental healthcare to ensure clinicians, Departments of Community Mental Health and Regions have the support they require and can be held to account for their adherence to clinical policy.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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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 Introduce enhanced risk-management training for all Department of Community Mental Health clinical staff, including tools for recognising, assessing and managing mental-health risks.
Verbatim wording from the response “On the issue of risk management, Defence Primary Healthcare is introducing enhanced risk management training for all Department of Community Mental Health clinical staff. This will be delivered by a recognised national provider and will be completed for all mental health clinicians by the end of March 2021. The training will provide best-practice tools to recognise, assess and manage risks for mental health and related matters.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The care plan was updated and risk levels were reviewed, contrary to the concern that neither had been updated as risk escalated.
Verbatim wording from the response “Sgt Hills’ care plan was updated on a number of occasions and his risk levels were being reviewed. However, the records of this case were not to the standard expected. Sgt Hills’ initial care plan, dated October 2019, formed the basis for treatment. Within a Department of Community Mental Health, subsequent updating of the care plan is part of the overall treatment record, which clinicians document on a review/assessment template. On this template, there is a section for recording any updates to the care plan, or to confirm the extant care plan, as well as assessment of risks, clinical reasonings and any prescribed medication.” Source location 2020-0247-Response-from-MP-MOD-Redacted.pdf
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3 Apr 2020 Edna May Davenport · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to undertake violence risk assessments after admission or incidents View source
This report raised 12 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
Edna May Davenport · 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
Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.
Read the report on judiciary.uk
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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 undertake violence risk assessments after admission or incidents
Wider context from the report “(4) I heard evidence during the inquest that the other resident suspected to have been the assailant was a new referral to the home and that there was a lack of information on her admission. The evidence at inquest was that staff were unaware that she was aggressive as a result of her vascular dementia. There was some evidence identified during the police investigation that this resident had attacked a member of staff shortly after her admission and that she had been inappropriately placed at Oak Court house. There was no evidence that any risk assessment had been undertaken after that resident’s admission or after the first alleged attack to address the risk of violence that the resident posed to others by virtue of the extent of her dementia;
” Source location Edna May Davenport · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.