1 May 2025 Peter Michael ANZANI · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to properly complete patient records View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Place visual notices reminding staff to record patient observations promptly and accurately.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Make additional observation machines available in relevant clinical areas.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Communicate observation-recording requirements through verbal briefings and written emails.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Complete a re-audit of outpatient observation recording.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Review systems and processes supporting accurate and timely clinical documentation.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Implement the Apollo electronic patient record system Trust-wide to support consistent, legible and auditable clinical documentation.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Develop and implement Vitals recording for outpatient observations.
View source
the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Implement a standard operating procedure requiring baseline and higher-risk pre- and post-procedure observations in outpatient clinics.
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AI-generated summary
Peter Michael ANZANI · 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
Peter Michael Anzani died in Birmingham Heartlands Hospital on 23 November 2024 from a pulmonary embolism after being admitted with community-acquired pneumonia. He had a spinal cord injury resulting in tetraplegia and had experienced falls and chest infections. Concerns included inadequate recording of clinical observations, possible staff training issues, and prolonged patient waiting lists linked to staffing and funding difficulties.
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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 properly complete patient records
Wider context from the report “1. I considered evidence from a ████████ who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by the Trust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms ...”.
2. It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff.
3. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed .
” Source location Peter Michael ANZANI · 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 Place visual notices reminding staff to record patient observations promptly and accurately.
Verbatim wording from the response “Following receipt of the PFD report, the Trust took immediate action to address the issues identified, specifically relating to timely and accurate recording of patient observations.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 Make additional observation machines available in relevant clinical areas.
Verbatim wording from the response “Clear and visual notices have been placed in relevant clinical areas to remind staff of the importance of recording patient observations promptly and accurately. Also, additional observation machines have been made available to ensure staff have immediate access to appropriate tools for carrying out vital sign monitoring. In addition, the importance of accurate observation recording has been communicated directly to staff both via verbal briefings and written email communication.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 Communicate observation-recording requirements through verbal briefings and written emails.
Verbatim wording from the response “Clear and visual notices have been placed in relevant clinical areas to remind staff of the importance of recording patient observations promptly and accurately. Also, additional observation machines have been made available to ensure staff have immediate access to appropriate tools for carrying out vital sign monitoring. In addition, the importance of accurate observation recording has been communicated directly to staff both via verbal briefings and written email communication.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 Complete a re-audit of outpatient observation recording.
Verbatim wording from the response “Also, a re-audit was completed on 21 June 2025 in relation to 20 patient who attended the clinic between 16 – 19 June 2025. The results show that a full set of clinical observations was recorded for 100% of patients, including those undergoing procedures. A copy of the audit has been provided in the Trust’s PFD response bundle.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 systems and processes supporting accurate and timely clinical documentation.
Verbatim wording from the response “Digital record keeping system” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 Implement the Apollo electronic patient record system Trust-wide to support consistent, legible and auditable clinical documentation.
Verbatim wording from the response “One of the key tools supporting this work is implementation of our new electronic patient record system called Apollo, which is used Trust wide to facilitate consistent, legible and auditable documentation of patients’ clinical notes. The Outpatient Observation Form now includes all baseline observations, and this essentially follows the process used in the Trust’s Main Outpatient Department. A paper format will be utilised during any period of digital downtime, when access to the digital system is limited, or not available.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 Develop and implement Vitals recording for outpatient observations.
Verbatim wording from the response “In addition to the above, the Trust recognises that it needs to be able to record patient observations taken in the outpatient setting on Vitals (this is a digital platform for recording clinical observations). This is currently in development with the digital team and implementation date is anticipated to be March 2026, although the timeframe is restricted by the external digital company called System C. In the meantime, the Outpatient Observation Form will be the primary source for recording clinical observations for patients attending outpatient appointments.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 Implement a standard operating procedure requiring baseline and higher-risk pre- and post-procedure observations in outpatient clinics.
Verbatim wording from the response “A new Standard Operating Procedure (SOP) has been developed and is in the process of being implemented to provide a clear, visual guide for clinical staff working in outpatient settings. The SOP includes a flowchart to ensure ease of understanding and practical application across all relevant clinics. It outlines mandatory baseline observations for all outpatient appointments. The SOP is scheduled to be approved at the next Patient Safety Meeting on 08 July 2025.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
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 Implementation of outpatient observation recording on Vitals is restricted by the external digital company's development timeframe.
Verbatim wording from the response “In addition to the above, the Trust recognises that it needs to be able to record patient observations taken in the outpatient setting on Vitals (this is a digital platform for recording clinical observations). This is currently in development with the digital team and implementation date is anticipated to be March 2026, although the timeframe is restricted by the external digital company called System C. In the meantime, the Outpatient Observation Form will be the primary source for recording clinical observations for patients attending outpatient appointments.” Source location Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
Open published response
18 Jul 2024 Anna Vivien Elliott · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Failure to complete safe and supportive observation charts to the required standard View source Falsification of safe and supportive observation records View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
East London NHS Foundation Trust
Adjust observation spot-check data to focus specifically on observation quality and begin collecting it.
View source
East London NHS Foundation Trust
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
View source
East London NHS Foundation Trust
Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
View source
East London NHS Foundation Trust
Pilot the Microsoft PowerApps observation-documentation application on four wards and plan wider inpatient rollout.
View source
East London NHS Foundation Trust
Deliver face-to-face Honesty in Documentation training across inpatient services.
View source
East London NHS Foundation Trust
Continue work promoting honesty in documentation.
View source
East London NHS Foundation Trust
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
View source
East London NHS Foundation Trust
Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
View source
East London NHS Foundation Trust
Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
View source See 6 more actions
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AI-generated summary
Anna Vivien Elliott · 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
Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety plans.
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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 safe and supportive observation charts to the required standard
Wider context from the report “Concern 2
The Trust’s policy is very clear on what should be recorded on the safe and supportive observation charts. In addition, all of the witnesses could explain in evidence, the expectation and what good practice looks like. However, only one staff member’s entries met this expectation . All of the other entries that I was taken to simply recorded Anna’s location at the time of the observation . I heard evidence that observation records are audited for quality and entries raised with staff if they do not meet expectations. However, this process of auditing was in place at the time of Anna’s death and the observation entries of the senior nurses responsible for that auditing were of the same poor quality.
” Source location Anna Vivien Elliott · 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 Falsification of safe and supportive observation records
Wider context from the report “Concern 4
In Anna’s case, observation records were backfilled despite the observations not having been conducted . All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done ”. As the spot checks described to me only look at the quality and timings of the written observations, I am not reassured that records are not still being falsified or about how this is being identified and addressed.
” Source location Anna Vivien Elliott · 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 Adjust observation spot-check data to focus specifically on observation quality and begin collecting it.
Verbatim wording from the response “17. The Directorate has now adjusted spot check data to be specific around quality of observations. It will begin collecting data from September 2024.” Source location Response from ELFT
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 Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Verbatim wording from the response “19. The Trust is currently developing a new E-observations (e-obs) platform which has in-built prompts to ensure staff capture the location of a patient, what they observe and their interactions with a patient. Daily spot checks will be undertaken by the clinical nurse manager or the most senior nurse on shift out of hours. It is hoped that this will be in place in the coming six months.” Source location Response from ELFT
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 Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
Verbatim wording from the response “The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.” Source location Response from ELFT
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 Pilot the Microsoft PowerApps observation-documentation application on four wards and plan wider inpatient rollout.
Verbatim wording from the response “A digital application to document observations (using Microsoft PowerApps) has been developed and is in the testing phase. It is planned that this will be piloted from October 2024 on four wards and then scaled across all inpatient units.” Source location Response from ELFT
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 Deliver face-to-face Honesty in Documentation training across inpatient services.
Verbatim wording from the response “Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.” Source location Response from ELFT
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 work promoting honesty in documentation.
Verbatim wording from the response “Continued work on honesty in documentation.” Source location Response from ELFT
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 Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Verbatim wording from the response “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.” Source location Response from ELFT
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 communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
Verbatim wording from the response “Communication
To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.” Source location Response from ELFT
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 Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
Verbatim wording from the response “Standardised processes
To develop a consistent approach to supporting staff to learn from their observations practice through reflection, personal accountability and if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.” Source location Response from ELFT
Open published response
10 Jul 2024 Mahamoud Hussain Ali · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to accurately record required observations View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 14
East London NHS Foundation Trust
Implement the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
View source
East London NHS Foundation Trust
Develop and deliver Honesty in Documentation training face to face across all inpatient services.
View source
East London NHS Foundation Trust
Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
View source
East London NHS Foundation Trust
Implement observation board relay to reduce missed observations and improve handover between staff.
View source
East London NHS Foundation Trust
Test and pilot a Microsoft PowerApps application for documenting observations before planned inpatient-wide scaling.
View source
East London NHS Foundation Trust
Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
View source
East London NHS Foundation Trust
Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
View source
East London NHS Foundation Trust
Conduct senior-staff night visits with spot-check audits and observation of practice.
View source
East London NHS Foundation Trust
Continue work on honesty in documentation.
View source
East London NHS Foundation Trust
Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
View source
East London NHS Foundation Trust
Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
View source
East London NHS Foundation Trust
Continue Trust-wide communications discouraging falsification, encouraging honest reporting and clarifying missed-observation reporting requirements.
View source
East London NHS Foundation Trust
Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
View source
East London NHS Foundation Trust
Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
View source See 11 more actions
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AI-generated summary
Mahamoud Hussain Ali · 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
Mahamoud Hussain Ali fell twice in the street on 19 August 2020 and was later detained under the Mental Health Act and transferred to Lea Ward. On 21 August 2020 he was found unresponsive and died in hospital on 26 August 2020. The principal concern was that required 15-minute observations were not conducted or were falsely recorded, and that subsequent Trust action had not been sufficient to ensure observations were conducted and recorded as required.
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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 accurately record required observations
Wider context from the report “(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep.
East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable .
Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted . One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained.
Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation.
The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022.
I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…”
Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done. ”
Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur.
” Source location Mahamoud Hussain Ali · 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 Implement the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
Verbatim wording from the response “Staff competency | The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.” Source location Response from ELFT
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 Develop and deliver Honesty in Documentation training face to face across all inpatient services.
Verbatim wording from the response “Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.” Source location Response from ELFT
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 Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
Verbatim wording from the response “Safety discussion sessions are facilitated weekly in directorates for all inpatient staff to review observation data, reflect on gaps in practice and disseminate learning.” Source location Response from ELFT
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 Implement observation board relay to reduce missed observations and improve handover between staff.
Verbatim wording from the response “Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:” Source location Response from ELFT
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 Test and pilot a Microsoft PowerApps application for documenting observations before planned inpatient-wide scaling.
Verbatim wording from the response “A digital application to document observations (using Microsoft PowerApps) has been developed and is in the testing phase. It is planned that this will be piloted from October 2024 on four wards and then scaled across all inpatient units.” Source location Response from ELFT
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 Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
Verbatim wording from the response “Standards of professional practice | Expected standards of practice have been communicated to staff, with frequent updates on improvement work since 2021 to date. In 2023, this specifically addressed accountability and responsibility for accurately documenting observations. It included the importance of honesty in documentation and gave guidelines for staff to follow for occasions when observations were missed. The Trust-wide Quality Improvement programme described above has introduced the observation relay board to reduce incidents of observations being left or not handed over.” Source location Response from ELFT
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 Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
Verbatim wording from the response “Audit and monitoring
The Standard Observation Measurement (SOM) Tool was developed for oversight of rates of completion of all observations. Individual ward teams and directorates can access and use their data to drive continued improvement.” Source location Response from ELFT
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 Conduct senior-staff night visits with spot-check audits and observation of practice.
Verbatim wording from the response “Night visits are undertaken by senior staff in directorates to monitor practice through spot check audits and observing work as it happens.” Source location Response from ELFT
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 work on honesty in documentation.
Verbatim wording from the response “Continued work on honesty in documentation.” Source location Response from ELFT
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 Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
Verbatim wording from the response “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.” Source location Response from ELFT
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 Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
Verbatim wording from the response “Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,” Source location Response from ELFT
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 Trust-wide communications discouraging falsification, encouraging honest reporting and clarifying missed-observation reporting requirements.
Verbatim wording from the response “Communication
To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.” Source location Response from ELFT
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 Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
Verbatim wording from the response “To design an internal governance process for the review of reported cases of missed observations and learning that arises from this, that will report into the Patient Safety and Quality Assurance committees.” Source location Response from ELFT
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 a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
Verbatim wording from the response “Standardised processes
To develop a consistent approach to supporting staff to learn from incidents involving poor observations practice through reflection, personal accountability and, if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.” Source location Response from ELFT
Open published response
14 May 2024 James Patrick PEARSON · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1
Lack of documentation of patient observations 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
James Patrick PEARSON · 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 Pearson was struck by a vehicle on 14 June 2023 and later died at a hospice on 22 October 2023 after sustaining traumatic and hypoxic brain injuries, developing pneumonia, and experiencing a prolonged hospital admission. The concerns included undocumented observations, insufficient doctor coverage during his deterioration, and the time needed to obtain blood products; the report also states that an opportunity to provide fluids was missed and that this would probably have prevented his cardiac arrest and subsequent hypoxic brain injury.
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 Lack of documentation of patient observations
Wider context from the report “3. During the inquest, I heard that James was attached to a monitor, which was taking his observations every 15 minutes. None of these observations, however, were documented. This is of concern, as it is not possible to know at what point James began to decline. I am concerned that lack of proper documented observations could lead to future deaths, as staff will not be able to follow the observation pattern and notice a decline in presentation.
” Source location James Patrick PEARSON · 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 Reiterate observation-recording standards at Emergency Department huddles.
Verbatim wording from the response “The standards set out above and expected documentation has been reiterated at Emergency Department huddles to ensure that recording within noting is robust and will be audited as part of the action plan following this Serious Incident Investigation to provide assurance that these standards are being adhered to.” Source location Response from University Hospitals Birmingham
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 compliance with observation-recording standards as part of the Serious Incident Investigation action plan.
Verbatim wording from the response “The standards set out above and expected documentation has been reiterated at Emergency Department huddles to ensure that recording within noting is robust and will be audited as part of the action plan following this Serious Incident Investigation to provide assurance that these standards are being adhered to.” Source location Response from University Hospitals Birmingham
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 monitoring and NEWS2 procedures are considered sufficient despite observations not being documented every 15 minutes.
Verbatim wording from the response “Whilst observations are not documented every 15 minutes, they are monitored and any trigger actioned according to the Trust Acutely Ill Adult NEWS2 Procedure AcutelyIllAdultsNewscoreprocedure.pdf. (NEWS2 is a standardised National Early Warning Score devised to standardise the assessment and response to acute illness or deterioration.)” Source location Response from University Hospitals Birmingham
Open published response
Concerns raised 1
Lack of audit trail for signed constant observation forms and sergeant briefings 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. 2
South Yorkshire Police
Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
View source
South Yorkshire Police
Consult the Performance and Governance team about activating body-worn video during constant observations.
View source
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AI-generated summary
Matthew Terrill · 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 Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.
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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 audit trail for signed constant observation forms and sergeant briefings
Wider context from the report “6. Lack of safety net for custody suit documentation, specifically the constant supervision forms.
I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant. I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given . I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers.
” Source location Matthew Terrill · 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 compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
Verbatim wording from the response “Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.” Source location Response from South Yorkshire Police and Humberside Police
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 Consult the Performance and Governance team about activating body-worn video during constant observations.
Verbatim wording from the response “The Custody lead for South Yorkshire Police is to have further consultation with the Performance and Governance team to look at whether BWV should be activated when observing a prisoner, this could then capture the briefing, roles and responsibilities, action of the officers and any behaviour of the detainee.” Source location Response from South Yorkshire Police and Humberside Police
Open published response
12 Mar 2024 Giuseppe TABONE and Andrew EVANS · Prevention of Future Deaths report East Sussex
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Concerns raised 1
Inaccurate recording of prisoner roll checks View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Giuseppe TABONE and Andrew EVANS · 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
Giuseppe Tabone and Andrew Evans died at HMP Lewes after intentionally inhaling isotonitazene, a synthetic opioid. Prison staff failed to carry out required roll checks at 7.30pm and 8.45pm on 27 June 2022, and the report raises concerns about staff compliance with, understanding of, and monitoring of required prisoner checks.
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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 Inaccurate recording of prisoner roll checks
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” Source location Giuseppe TABONE and Andrew EVANS · 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 Review and clarify the roll-check local operating procedure, including required times and recording arrangements.
Verbatim wording from the response “The Governor of HMP Lewes has informed me that the prison’s LOP on roll checks was reviewed in August 2023 and clearly sets out the times that roll checks are required to be carried out and where staff must sign to confirm that the checks have been completed. The LOP provides guidance on checks during the week, on weekends and during the night state so that staff understand what their duties are at all times.” Source location Response from HM Prison and Probation Service
Open published response
Concerns raised 1
Failure to maintain accurate and complete ACCT observation records View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
HM Prison and Probation Service
Present an operational briefing to all staff on assigned ACCT-check responsibilities.
View source
HM Prison and Probation Service
Require Case Co-Ordinators to verify document completion and specify clear, precise observation intervals before reviews.
View source
HM Prison and Probation Service
Require Supervising Officers to check the preceding 24 hours of ACCT records daily and challenge discrepancies.
View source
HM Prison and Probation Service
Share quality-assurance findings with relevant managers and retain confirmation that identified errors were rectified.
View source See 1 more action
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AI-generated summary
Martin Samuel WILLIS · 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
Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.
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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 maintain accurate and complete ACCT observation records
Wider context from the report “1. The ACCT procedure was not properly implemented, complied with or supervised . A scheduled observation at 8 am did not take place and a false entry was entered at 7:30 am and later deleted . The last correct entry was at 7 am with earlier omissions .
” Source location Martin Samuel WILLIS · 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 Present an operational briefing to all staff on assigned ACCT-check responsibilities.
Verbatim wording from the response “ACTION TO BE TAKEN:
I will be presenting an Operational Briefing on 21st December to all staff, taking into consideration the Governors Order GO 01/2023 which reads as follows:” Source location 2024-0171 - Response from HMPPS
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 Require Case Co-Ordinators to verify document completion and specify clear, precise observation intervals before reviews.
Verbatim wording from the response “• Prior to all reviews the Case Co-Ordinator will ensure that all relevant documents have been completed and that all observations are clear and precise for example 5x observations per day every 2 hours or 3 x observations during the day every 3 hours.” Source location 2024-0171 - Response from HMPPS
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 Require Supervising Officers to check the preceding 24 hours of ACCT records daily and challenge discrepancies.
Verbatim wording from the response “• The Supervising Officer will check daily to ensure that the previous 24 hours have been recorded accurately and any discrepancies challenged accordingly.” Source location 2024-0171 - Response from HMPPS
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 Share quality-assurance findings with relevant managers and retain confirmation that identified errors were rectified.
Verbatim wording from the response “• Safer Custody and Senior Leadership Team (SLT) will ensure all QA is shared with relevant managers, and a confirmation email that the errors have been rectified will be saved as evidence.” Source location 2024-0171 - Response from HMPPS
Open published response
19 Dec 2023 MORGAN-ROSE HART · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure to ensure complete therapeutic engagement records in patient observation sheets View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
MORGAN-ROSE HART · 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
Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.
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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 ensure complete therapeutic engagement records in patient observation sheets
Wider context from the report “(5) Trust oversight of care – the quality of record keeping was acknowledged not to be appropriate by nurses and senior staff during evidence, yet had been signed off:
a. Observations sheets for vulnerable detained mental patients were signed off by nurses in charge as being appropriate despite an absence of any recorded therapeutic engagement
b. Omissions in the recording of food and fluid charts required by the Responsible Clinician for a patient who was losing weight with a diagnosis of Body Dysmorphic Disorder.
c. The Responsible Clinician’s evidence was that the absence of appropriate food and fluid charts for other patients was an ongoing issue on Chelmer Ward that had been raised with nursing staff
” Source location MORGAN-ROSE HART · 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 Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
Verbatim wording from the response “All clinical staff are being retrained or trained in the use of Oxevission and observations. In line with the Oxevission SOP and the Therapeutic engagement and supportive observation policy.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Roll out electronic observations across all wards with daily audit functionality and project-board oversight.
Verbatim wording from the response “We have rolled out ‘e-observations’, across all wards, which is a mobile tablet (IPAD) electronic observation recording system; which records the patient observation with detail of patient presentation and engagement in the moment. There is an audit function within the system to enable ward managers to audit the quality of recording and engagement on a daily basis. There is an Oxehealth E-observations Project Board that has oversight of implementation, delivery and outcomes.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Circulate and reinforce the Therapeutic Engagement and Supportive Observation policy across all wards.
Verbatim wording from the response “The review of the Therapeutic Engagement and Supportive Observation policy has been completed and circulated to all staff.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
Concerns raised 1
Failure to complete observation charts adequately View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Paul Perrott · 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 Perrott, an inpatient detained under the Mental Health Act, died on 31 July 2020 after attempting to hang himself on Ashcombe Ward. Concerns included inadequate recording of his 15-minute observations, unclear responsibility for checking observation charts, insufficient staff awareness of his recent and historical suicide risk, and a focus on immediate rather than historical and contextual risks.
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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 complete observation charts adequately
Wider context from the report “(1) Paul Perrott’s observations charts were not filled out adequately or at all on the date of his death
” Source location Paul Perrott · 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 Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.
Verbatim wording from the response “An amendment to the Trust therapeutic engagement and observation policy has been requested to state that the nurse in charge of each shift is responsible for ensuring completion of observations on a shift by shift basis and taking immediate action where these are not completed. This will go through ratification in January 2024 and has been discussed with the Director and Deputy Director of Nursing.” Source location Response from Devon Partnership NHS Trust
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 Conduct monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.
Verbatim wording from the response “Policy states that observation audits to check completion of observations are completed monthly by senior nurse managers. This process is in place through the quality review of clinical records and the results of those audits are submitted to the governance manager, feedback to staff and ward governance meetings. The audit performance is then reviewed monthly with ward managers at inpatient governance meetings. Engagement and observation competency checklists are completed for all new staff and these are reviewed and stored by ward managers with the senior nurse manager’s administrator monitoring compliance for wards.” Source location Response from Devon Partnership NHS Trust
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 inpatient wards' shift-by-shift observation-record initials to check that nurses in charge evidence completion.
Verbatim wording from the response “In addition, the patient observation record has a tick box on each observation sheet where the nurse in charge adds their initials to evidences completion on a shift by shift basis. This has been reviewed on each inpatient ward by the senior nurse manager to check it is being completed by the nurse in charge.” Source location Response from Devon Partnership NHS Trust
Open published response
27 Oct 2023 Geoffrey Alan WHATLING · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to record observations in Care Records 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
Geoffrey Alan WHATLING · 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
Geoffrey Alan Whatling entered Amberley Hall Care Home for rehabilitation and later became unwell, with deteriorating NEWS2 scores leading to hospital admission on 10 April 2023. He died on 26 April 2023, with the medical cause of death recorded as infective exacerbation of chronic obstructive pulmonary disease, with frailty and old age. Concerns included incomplete food and fluid records, failures to call emergency services when required, inadequate observation frequency, and gaps in care-record documentation and follow-up.
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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 record observations in Care Records
Wider context from the report “5. Some of Mr Whatling’s observations were recorded on a piece of paper and were not logged in his Care Records
” Source location Geoffrey Alan WHATLING · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.