Recurring concern

Unreliable recording of required observations in care and custody

First to latest report 23 Oct 2013 — 19 May 2026

Reports that mention this concern
83
Times this concern has been raised
90
Stated actions linked to this concern
181

What this concern includes

Includes failures in recording required patient or prisoner observations, including inaccurate, delayed, anticipatory, incomplete or falsified entries, where records do not reliably reflect the observations performed. Includes paper, electronic and ACCT-related observation records across care and custody settings.

What is not included
  • Excludes failures to perform or maintain the required observation itself where the recording process is not deficient.
  • Excludes unclear observation requirements, observation-level decisions and generic observation assurance or auditing where inaccurate or delayed recording is not the shared unsafe condition.
  • Excludes general clinical, care or custody record-keeping deficiencies unrelated to required observations.
  • Excludes recording of non-observation activities, such as searches, movements, inspections or clinical decisions, unless the assertion specifically concerns a required observation record.

Reports and published responses 83 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Valerie Ann Simmons · 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

    Valerie Ann Simmons developed a large left-thigh haematoma after receiving Fragmin while receiving anticoagulation therapy, was later admitted to hospital, deteriorated and died on 11 January 2023. Concerns included the absence of recorded observations after a change in her presentation and the need for further training on the risks of hypovolaemia in an anticoagulated patient.

    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 record observations following changes in patient presentation

    Wider context from the report

    “Where there was a change in a patient’s presentation, it would be expected that a set of observations would be undertaken and recorded in a patient’s notes; ”

    Source location

    Valerie Ann Simmons · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and share a learning-from-experience poster with community nursing teams on observations, deterioration recognition and documentation.

    Verbatim wording from the response

    “We recognise that policy updates and training changes can take time. To reassure the family, as part of our meetings, we have undertaken learning from experience to develop a poster which will be shared across all community nursing teams demonstrating the importance of recognising the signs of a deteriorating patient and highlighting the importance of taking and recording basic observations when there is change in clinical presentation.”

    Source location

    Response from Cornwall Partnership NHS Foundation Trust
    Page 4 · response
    Published 31 October 2023

    Open published response

  2. Exeter and Greater Devon

    AI-generated summary

    Stewart Stanley · 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

    Stewart Stanley was remanded in custody at HMP Exeter and was found hanging in his cell on 12 July 2020 after the level of his observation had been reduced. He was taken to hospital and died on 14 July 2020. The concerns included inconsistent approaches to conducting and recording ACCT observations, differing interpretations of observation requirements, inaccurate recording of observation times, and evidence of excessive staff working hours. The inquest jury concluded that his death was probably caused or contributed to by failures to follow processes, including excluding the staff best qualified to assess his risk from the decision to remove him from constant watch.

    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 accurately record ACCT observation times

    Wider context from the report

    “(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording observations on prisoners subject to the Prison Service suicide and self-harm prevention procedures (known as ACCT). (2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations. (3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately. (4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.” ”

    Source location

    Stewart Stanley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement an ACCT assurance procedure with supervising-officer allocation, daily observation checks and escalation of discrepancies.

    Verbatim wording from the response

    “HMP Exeter have reviewed the management of the ACCT process and have introduced an assurance procedure to ensure there is consistency and effective completion of all ACCT documents including observations. All ACCT are now allocated to a supervising officer who is responsible for conducting daily checks to ensure all set observations for the previous 24 hours have been completed. Any discrepancies are highlighted with the safety team for prompt action.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

    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

    Provide two ACCT safety Floorwalkers to deliver regular staff upskilling on accurate observation completion.

    Verbatim wording from the response

    “Since February 2023, the Prison Performance Support Programme (PPSP) have provided funding for 12 months for two Band 4 ACCT safety ‘Floorwalkers’ who are responsible for conducting regular upskilling sessions which include the need for accurate completion of observations. Further to this, ACCT V6 observation posters have been displayed in all wing offices and guides have been produced for staff.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

    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

    Display ACCT V6 observation posters in wing offices and produce staff guides.

    Verbatim wording from the response

    “Since February 2023, the Prison Performance Support Programme (PPSP) have provided funding for 12 months for two Band 4 ACCT safety ‘Floorwalkers’ who are responsible for conducting regular upskilling sessions which include the need for accurate completion of observations. Further to this, ACCT V6 observation posters have been displayed in all wing offices and guides have been produced for staff.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

    Open published response

  3. East London

    AI-generated summary

    Winbourne Gregory Charles · 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

    Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to maintain accurate and reliable observation records

    Wider context from the report

    “5. The credibility of evidence provided by Trust staff. a. Two Trust witnesses declined to answer questions put to them regarding whether their observation records were truthful. b. Observation records appeared to have been created utilising a “cut and paste” function. c. Records often inaccurately recorded the prescribed frequency of observation. d. Factually inaccurate entries were made in the record following Mr Charles’ death. On 11ᵗʰ April 2021 an entry stated that Mr Charles was, “awake in his bedroom sitting on his bed (sic)” at 07.21. On 12ᵗʰ April two entries made at 9.48 and 11.40 recorded that Mr Charles’ was alive and well. Senior Trust witnesses characterised these entries as dishonest. ”

    Source location

    Winbourne Gregory Charles · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce observation-record training, audit records and address compliance in supervision.

    Verbatim wording from the response

    “15. Record keeping training is available and audits take place”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 7 · response
    Published 5 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review electronic-observation functionality.

    Verbatim wording from the response

    “3. Review of Electronic Observation functionality”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 7 · response
    Published 5 May 2023

    Open published response

    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

    Concerns about care provision and coordination are mainly for the NHS Trust to address.

    Verbatim wording from the response

    “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 5 May 2023

    Open published response

  4. Manchester North

    AI-generated summary

    Ania Sohail · 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

    Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of 1:5 observation records to evidence five-minute checks

    Wider context from the report

    “(6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes. Instead the current documentation, simply requires one signature per hour. There is therefore no mechanism by which observations can be effectively audited. ”

    Source location

    Ania Sohail · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Adopt five-minute observation recording sheets and audit completion at least weekly.

    Verbatim wording from the response

    “The current Trust observation policy does have a 1:5 minute recording sheet that requires a signature every 5 minutes. This has now been adopted by the service and its completion is audited by the ward manager as a minimum weekly.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review observation policy and practices against best-practice standards, guidance and potential digital innovations.

    Verbatim wording from the response

    “The Trust is currently undertaking a review of our Observation policy and practices through a task and finish working group which to date has reviewed best practice standards and guidance on the management and practice of therapeutic observations & engagement including the review of any digital innovations to support practice.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 2023

    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 staff training package and competency assessment framework for therapeutic observations and engagement.

    Verbatim wording from the response

    “Senior members of this group have attended workshops facilitated by the CQC who acknowledge that carrying out and recording observations is a National issue. A training needs analysis of the requirements for staff training and education is being undertaken and a training package and competency assessment framework is being developed.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The current observation policy already requires signatures every five minutes, with completion audited weekly by the ward manager.

    Verbatim wording from the response

    “(6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes. Instead, the current documentation, simply requires one signature per hour. There is therefore no mechanism by which observations can be effectively audited.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 22 February 2023

    Open published response

  5. Leicester City and South Leicestershire

    AI-generated summary

    Samantha Jane BOAZMAN · 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

    Samantha Jane Boazman, who was detained under section 3 of the Mental Health Act and living in a locked rehabilitation ward, was found unresponsive in her bathroom on 22 October 2021 and was pronounced dead later that evening. The report identified concerns about delayed access to emergency equipment and CPR, and about predictable and inadequate recording of patient observations. The inquest jury found gross neglect involving shortcomings including inadequate training, failure to remove ligature risks from bedrooms, and inadequate induction and training of temporary staff.

    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

    Disconnect between observation policy, staff instructions and pre-printed recording forms

    Wider context from the report

    “2. Observation Policy At the time of Samantha’s death observations were conducted and recorded in a predictable and prescriptive way by healthcare staff. The quality of the observations recorded at the time of Samantha’s death were such that they did not accord with the expectation of the policy and merely recorded where the patient was and what they were doing. Effective observations were acknowledged as being a vital tool to assess and manage the risk of a patient. Inmind Healthcare Group’s new observation Policy states: ‘Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery. The use of enhanced observation levels should never be regarded as routine practice…… Observation practice must focus on engaging the person therapeutically and enabling them to address their difficulties constructively. Our interactions must seek to create rapport which allows those in our care to feel valued and safe to share their experiences with us’. Since Samantha’s death changes have been made by Inmind Healthcare Group to their policy and practice, in that observations are now recorded at the precise time they are conducted and are infrequent in their predictability (eg: hourly observation should be conducted once hourly rather than on the hour every hour). Evidence of recent observation records demonstrated that this was now practice. However, there was a disconnect between the new policy and the pre-printed forms being used to record observations; what staff were being instructed to do and what they were recording. This was confusing and the evidence produced did not support the expectations of the new policy or demonstrate it had become embedded practice. The evidence produced did not support a change in staff recording quality observations, so that whilst precise and intermittent timings were evidenced, beyond the location of the patient or what they were doing, the actual presentation of the patient was not being recorded. ”

    Source location

    Samantha Jane BOAZMAN · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record the patient’s actual presentation during observations

    Wider context from the report

    “2. Observation Policy At the time of Samantha’s death observations were conducted and recorded in a predictable and prescriptive way by healthcare staff. The quality of the observations recorded at the time of Samantha’s death were such that they did not accord with the expectation of the policy and merely recorded where the patient was and what they were doing. Effective observations were acknowledged as being a vital tool to assess and manage the risk of a patient. Inmind Healthcare Group’s new observation Policy states: ‘Observations are a therapeutic intervention aimed at reducing factors which contribute to increased risk and promoting recovery. The use of enhanced observation levels should never be regarded as routine practice…… Observation practice must focus on engaging the person therapeutically and enabling them to address their difficulties constructively. Our interactions must seek to create rapport which allows those in our care to feel valued and safe to share their experiences with us’. Since Samantha’s death changes have been made by Inmind Healthcare Group to their policy and practice, in that observations are now recorded at the precise time they are conducted and are infrequent in their predictability (eg: hourly observation should be conducted once hourly rather than on the hour every hour). Evidence of recent observation records demonstrated that this was now practice. However, there was a disconnect between the new policy and the pre-printed forms being used to record observations; what staff were being instructed to do and what they were recording. This was confusing and the evidence produced did not support the expectations of the new policy or demonstrate it had become embedded practice. The evidence produced did not support a change in staff recording quality observations, so that whilst precise and intermittent timings were evidenced, beyond the location of the patient or what they were doing, the actual presentation of the patient was not being recorded. ”

    Source location

    Samantha Jane BOAZMAN · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Replace hospital observation forms with two centralised forms used across all Inmind hospitals.

    Verbatim wording from the response

    “13. Inmind immediately reviewed the forms used at Sturdee Community Hospital and in the other hospitals run by Inmind and found staff had been using a variety of forms rather than one centralised document. All pre-existing forms have been systematically deleted from computers in the hospitals and replaced with two forms which are now available on the shared drive and used by all Inmind Hospitals. Copies of these two forms are appended: Intermittent observations (MV5) and Continuous Observations (MV6).”

    Source location

    Response from Inmind Healthcare Group
    Page 6 · response
    Published 31 January 2023

    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

    Update the Inmind Observations Policy to require centralised forms and compliance with national NHS standards.

    Verbatim wording from the response

    “14. The Inmind Observations Policy has been updated to ensure these centralised forms are used and ensure that observations are made in line with national NHS standards.”

    Source location

    Response from Inmind Healthcare Group
    Page 7 · response
    Published 31 January 2023

    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

    Train HCAs and other staff to complete meaningful observation records, followed by competency assessment.

    Verbatim wording from the response

    “15. Further training has been provided to HCAs and other staff to ensure the completion of these observation forms is optimised so that the entries are meaningful and assist others in gathering information about the patient and any potentially escalating scenarios. After training, staff undergo a competency assessment.”

    Source location

    Response from Inmind Healthcare Group
    Page 7 · response
    Published 31 January 2023

    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

    Carry out regular audits of observation-record quality across all Inmind hospitals, overseen by the Group Medical Director.

    Verbatim wording from the response

    “16. In addition to the further training provided to staff, I confirm that regular audits of the quality of the entries in observation records will be carried out by the Hospital Directors (or Deputy Hospital Directors) across all the Inmind hospitals. These audits will be overseen by the Medical Director of the Inmind Healthcare Group. Any HCA who fails to make appropriate observation entries will be spoken to and further training provided, if necessary.”

    Source location

    Response from Inmind Healthcare Group
    Page 7 · response
    Published 31 January 2023

    Open published response

  6. Norfolk

    AI-generated summary

    Eliot HARRIS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record observations in accordance with policy

    Wider context from the report

    “1) Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of observations or have undergone and assessment of their competency to carry out observations ”

    Source location

    Eliot HARRIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver ward-specific Safety Day training on clinical risk, care planning, incident learning and therapeutic observations.

    Verbatim wording from the response

    “Locally, within Great Yarmouth Acute Service the team have implemented a Safety Day, which is training specifically developed for the ward and includes sessions on clinical risk assessment, care planning, learning from incidents with a detailed focus on therapeutic observations policy. To date, 19 of the 27 staff have attended the day with two further days planned. In addition, the Matron is leading on refreshing staffs understanding of the therapeutic observation policy by re-completion of the competency assessment.”

    Source location

    Response form Norfolk and Suffolk Foundation Trust
    Page 1 · response
    Published 3 October 2022

    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

    Refresh staff understanding of the therapeutic observations policy through competency reassessment.

    Verbatim wording from the response

    “Locally, within Great Yarmouth Acute Service the team have implemented a Safety Day, which is training specifically developed for the ward and includes sessions on clinical risk assessment, care planning, learning from incidents with a detailed focus on therapeutic observations policy. To date, 19 of the 27 staff have attended the day with two further days planned. In addition, the Matron is leading on refreshing staffs understanding of the therapeutic observation policy by re-completion of the competency assessment.”

    Source location

    Response form Norfolk and Suffolk Foundation Trust
    Page 1 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Therapeutic Observations Policy to consider strengthened training, documentation, ward controls, staff guidance and assurance processes.

    Verbatim wording from the response

    “The goal of improving the application of therapeutic observations is important with a continuing improvement and monitoring focus. Training and audits form parts of the system to manage the safety and quality. The Trust is commencing a planned review of the Therapeutic Observations Policy, examining options to strengthen all areas including training, documentation, ward controls, guidance for staff and assurance processes. In addition, the ward has reviewed and significantly enhanced their local induction process which is overseen by the Clinical Team Leader.”

    Source location

    Response form Norfolk and Suffolk Foundation Trust
    Page 2 · response
    Published 3 October 2022

    Open published response

  7. Manchester City

    AI-generated summary

    Shona Christine Michaela Campbell · 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

    Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

    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 keep accurate records of patient observations

    Wider context from the report

    “3. Patient observations were not being completed as directed and accurate records were not being kept. ”

    Source location

    Shona Christine Michaela Campbell · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    Lilian Bernadette BEHRENDT · 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

    Lilian Bernadette Behrendt, aged 91, deteriorated at her care home on 28 November 2021 and died later that evening after being taken to hospital, where she was diagnosed with chest sepsis. The report raised concerns about an incorrectly graded ambulance call, records describing her as “content” despite deterioration, missing observation results, uncertainty about DNACPR and ReSPECT documentation, and unclear responsibility and accountability within the care home.

    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 accurately record residents’ deteriorating condition and observation results

    Wider context from the report

    “1) The records relating to Mrs Behrendt referred to her as being “content” throughout the 28 November 2021 and did not refer to her deteriorating condition. There was no record of the result of the observations taken throughout the day or why these were taken, i.e. Mrs Behrendt’s condition was deteriorating and at the request of her family due to their concerns with regard to Mrs Behrendt’s poor presentation. ”

    Source location

    Lilian Bernadette BEHRENDT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Revise PCS software to remove emotionally charged dropdown terms, require manual presentation descriptions, and reduce reliance on visual icons.

    Verbatim wording from the response

    “As a result of this concern the Company engaged with its external software engineers and requested that all pre-loaded emotionally-charged words within the PCS, including references to ‘content,’ be removed entirely from the drop-down lists within the programming. The word has not been replaced and instead staff are now required to manually enter into care records a description of each individual service user’s presentation and assessment of their happiness rating. This change has been applied across all of the homes operated by the Company and the revised software has now gone live.”

    Source location

    Response from Kingsley Healthcare
    Page 1 · response
    Published 16 September 2022

    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

    Provide standardised PCS training through required staff training and centrally accessible induction videos covering recording, assessment, care planning, and changing needs.

    Verbatim wording from the response

    “All staff who are required to create entries within the PCS as part of their role have received training in respect of the above revisions, as well being reminded of the need to fully record comprehensive and contemporaneous records. To ensure consistency of training across all sites, the Company has produced two training videos, which are delivered by the Director of Compliance and reflect real-life examples from within the Company as a whole. Each video is approximately two hours long and are shown to new starters as part of their induction. In addition, the videos are electronically stored in a central location and are accessible to staff whenever required to be viewed.”

    Source location

    Response from Kingsley Healthcare
    Page 1 · response
    Published 16 September 2022

    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

    Audit care records routinely at home and head-office levels, including monthly Downham Grange sampling, and feed findings back to relevant staff.

    Verbatim wording from the response

    “In order to prevent a recurrence, and ensure that staff are compliant with the training which has been provided to them, the Company regularly audits care plans – at both local level by the home management, as well as the Company’s Head Office. Both audits involve a thorough and wholesale review of records, to include reference to the inclusion of routine observations. Downham Grange’s senior management dip sample audit the PCS records of three service users every month. Feedback from the audits is provided to staff, either individually or, where more general issues of practice are identified, to all relevant staff.”

    Source location

    Response from Kingsley Healthcare
    Page 3 · response
    Published 16 September 2022

    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

    Provide rolling refresher training reinforcing the requirement to record all care and observations in individual service-user records.

    Verbatim wording from the response

    “The Company disputes the suggestion that the NIC – or any member of staff – was unaware of the requirement to record every action. Not only is this an explicit requirement within the NMC’s Code of Conduct (and in respect of which, the Company submits, the NIC would have been intimately familiar as a result of her professional training and qualifications), but was also included within the Company’s training, as detailed above. Following Mrs Behrendt’s death the Company has reinforced its expectation, by way of rolling refresher training, that all care provided and observations taken must be recorded within each individual service user’s care records.”

    Source location

    Response from Kingsley Healthcare
    Page 4 · response
    Published 16 September 2022

    Open published response

  9. Surrey

    AI-generated summary

    Richard Scott-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

    Richard Scott-Powell, aged 61, suffered a spinal cord injury after a fall at home in March 2020 and later died from COVID-19 pneumonia at Holy Cross Hospital on 18 January 2021. The principal concerns were the lack of recorded escalation of high NEWS2 scores and abnormal vital signs, incomplete recording of observations, and uncertainty about whether appropriate policies and training were in place for taking, recording and escalating vital observations.

    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

    Incomplete recording of vital signs

    Wider context from the report

    “The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”

    Source location

    Richard Scott-Powell · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.

    Verbatim wording from the response

    “• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

    Source location

    Response from Holy Cross Hospital
    Page 2 · response
    Published 27 April 2022

    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

    Train staff on the Managing a Deteriorating Patient policy after implementation.

    Verbatim wording from the response

    “• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

    Source location

    Response from Holy Cross Hospital
    Page 2 · response
    Published 27 April 2022

    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

    Implement an electronic patient record system requiring measured values instead of narrative descriptions.

    Verbatim wording from the response

    “We are also implementing an Electronic Patient Record System in the second half of 2022/23. This will provide better standardisation over paper records, and will require measured values to be entered (rather than a narrative ‘okay’).”

    Source location

    Response from Holy Cross Hospital
    Page 2 · response
    Published 27 April 2022

    Open published response

  10. Liverpool and the Wirral

    AI-generated summary

    Sarah-Louise Jennifer Doyle · 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

    Sarah-Louise Jennifer Doyle, aged 19, was found hanging in her room while detained under the Mental Health Act and subject to five-minute observations. She was taken to hospital but died at 01:40 on 27 February 2022; concerns were raised that observations were recorded at predictable times and may not have been precise.

    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

    Inadequate recording of individual five-minute observations

    Wider context from the report

    “On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations. The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations. ”

    Source location

    Sarah-Louise Jennifer Doyle · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue urgent instructions on using and recording intermittent supportive observations.

    Verbatim wording from the response

    “I can confirm that in relation to supportive observations the following actions are already either complete or well underway:”

    Source location

    2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
    Page 1 · response
    Published 8 March 2022

    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

    Standardize language and roll out recording observations at unpredictable times within five-, ten- or fifteen-minute windows.

    Verbatim wording from the response

    “2. On March the 8th 2022 the Regulation 28 was discussed at the local division safety huddle with all inpatient Matrons present. An immediate action was for them to discuss with their”

    Source location

    2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
    Page 1 · response
    Published 8 March 2022

    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

    Conduct local audits, spot checks and additional dip audits to verify accurate, random-time recording of supportive observations.

    Verbatim wording from the response

    “4. A local audit has been developed with Inpatient Matrons to check and provide assurance that recording the actual time service users were checked is taking place, as opposed to rounding to the nearest 5-minute time window. As additional assurance, spot checks are being undertaken by the Senior Leadership Team and Inpatient Matron/Ward Manager group.”

    Source location

    2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
    Page 2 · response
    Published 8 March 2022

    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

    Revise the Ward Assurance Audit, operate interim recording changes and conduct weekly audits with findings shared through safety and clinical meetings.

    Verbatim wording from the response

    “9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.”

    Source location

    2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 8 March 2022

    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

    Introduce an electronic system supporting unpredictable-interval supportive observations.

    Verbatim wording from the response

    “9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.”

    Source location

    2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 8 March 2022

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026