Recurring concern

Unreliable recording of required observations in care and custody

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First reported 23 Oct 2013•Latest report 19 May 2026

Definition

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.

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
83

Distinct published reports

Individual concerns
90

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
181

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8
HM Prison and Probation Service8
Care Quality Commission7
NHS England6
East London NHS Foundation Trust4
Greater Manchester Mental Health NHS Foundation Trust4
Ministry of Justice4
NHS Greater Manchester Integrated Care Board4
University Hospitals Sussex NHS Foundation Trust4
Barts Health NHS Trust3
Essex Partnership University NHS Foundation Trust3
North London NHS Foundation Trust3
Central and North West London NHS Foundation Trust2
Coventry and Warwickshire Partnership NHS Trust2
General Medical Council2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · 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

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

    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 routine observations, fluid balance and gastrointestinal losses

    Wider context from the report

    “4. Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus. There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding. ”

    Source location

    Rhi anne Anoushka Florence BARTON · 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

    Run an awareness campaign emphasising accurate fluid-balance documentation on Joan Booker Ward.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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 training and competency assessments for staff completing fluid-balance charts.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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 redesigned fluid-balance chart to support complete recording of patient input and output.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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 a repeat in-depth audit of fluid-balance documentation after the new chart is introduced and embedded.

    Verbatim wording from the response

    “In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated. As a result, a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and competency assessments were introduced for staff who complete fluid balance charts. A redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. A repeat, in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    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 the Vitalpac electronic system for capturing patient observations across most inpatient areas.

    Verbatim wording from the response

    “An electronic system (Vitalpac) for capture of patient observations has been introduced into the Trust in the majority of inpatient areas. The Division have approached the developer of this system to see if modifications can be made to make it suitable for use in a maternity setting. This system can automatically calculate 'early warning scores' and issue alerts based on predetermined criteria.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 2 · response
    Published 1 June 2016

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Charlie Mark Jermyn · 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

    Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

    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 undertake and record routine physiological observations of mothers and babies

    Wider context from the report

    “2. Routine physiological observations of mother and baby were not undertaken and recorded by the Community Midwives. This practice is not in line with national practice. The accurate temperature, heart rate and other appropriate observations/ recording should be routine and formally recorded with stethoscope and thermometer etc (not just visual and touch). NEWS should be completed on all babies. ”

    Source location

    Charlie Mark Jermyn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Mr Critall · 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

    Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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 before and after chest drain procedures

    Wider context from the report

    “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

    Source location

    Mr Critall · 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

    Develop a patient pathway linking ward and radiology teams, requiring pre- and post-procedure observations and clear handover communication.

    Verbatim wording from the response

    “2. A patient pathway has been developed for patients undertaking this type of procedure to ensure improved communication between staff on the ward and in radiology. The pathway ensures base line observations are recorded prior to and following the procedure and requires clear communication on handover.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 6 · response
    Published 16 May 2016

    Open published response

  4. Brighton and Hove

    AI-generated summary

    Christine Valerie STREET · Prevention of Future Deaths report

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

    Report summary

    Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.

    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 document specialling and observations

    Wider context from the report

    “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed. The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA. The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all. This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy. There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust. The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately. ”

    Source location

    Christine Valerie STREET · Prevention of Future Deaths report
    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

    Correct staff understanding that the specialist care record applies to patients requiring constant observation, including neurological patients.

    Verbatim wording from the response

    “I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.

    Verbatim wording from the response

    “It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Inform bank staff about observation policy and documentation requirements for one-to-one care.

    Verbatim wording from the response

    “Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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

    Run refresher teaching for healthcare assistants on one-to-one care requirements.

    Verbatim wording from the response

    “Since Mrs Street’s fall, more work has been done to ensure the bank staff are well-informed about the policy for the observation of adult patients with mental health problems, and the associated documentation to be used if they are asked to provide one to one care for a patient. Teaching sessions have also been run for the Trust’s health care assistants, to refresh their knowledge about what is required when they are asked to provide one to one care to any patient.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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 every patient requiring constant observation and collate the findings for subsequent learning and action.

    Verbatim wording from the response

    “Furthermore an audit has been carried out very recently of every patient being specialised. The findings are now being collated and action will be taken, including if necessary revision of the current policy, in the light of any learning points that emerge from this audit.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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

    Organise a monthly neurosurgical records audit to improve documentation quality.

    Verbatim wording from the response

    “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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 senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.

    Verbatim wording from the response

    “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    Open published response

  5. Manchester West

    AI-generated summary

    Mary Walker · 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

    Mary Walker, who had dementia and had been admitted to hospital after a stroke before being discharged to a care setting, was found dead on 10 October after overnight checks. She had died of bronchopneumonia. Concerns were raised about the lack of detail recorded during night-time checks and unclear procedures for Care Assistants escalating health concerns.

    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 patients’ condition during night-time checks

    Wider context from the report

    “(1) At the inquest there was no specific evidence about what was revealed in the night time checks that had been carried out upon the deceased. There was a global summary stating the times at which checks had been carried out but there was no information as to what the patient’s condition was at the checks. This procedure requires review. ”

    Source location

    Mary Walker · 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

    Undertake a comprehensive ratings inspection of Belong Wigan Care Village, including review of the provider’s response to the report findings.

    Verbatim wording from the response

    “Following receipt of this Report we held a management review meeting to look at the information we held in relation to this case. At this meeting we took the decision to:”

    Source location

    2016-0150-Response-by-Care-Quality-Commission
    Page 1 · response
    Published 21 April 2016

    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 refresher training to Belong Wigan staff on safe records management and accurate date-and-time recording.

    Verbatim wording from the response

    “• Refresher training has been provided by the management team to all staff in Belong Wigan, on the ‘Safe management of records’ policy and procedures with an emphasis on the importance of accurate recording of progress against dates and times.”

    Source location

    2016-0150-Response-by-Belong
    Page 1 · response
    Published 21 April 2016

    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 provider’s response and inspection consideration were sufficient, so no written confirmation or further action evidence was requested.

    Verbatim wording from the response

    “We noted the response provided to you by the registered provider, CLS Care Services Limited known as Belong on 27 April 2016. In light of this response it was not felt necessary for CQC to contact the registered provider to request written confirmation and”

    Source location

    2016-0150-Response-by-Care-Quality-Commission
    Page 1 · response
    Published 21 April 2016

    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

    Following inspection and document review, no further investigation into the death or regulated activities was considered necessary.

    Verbatim wording from the response

    “Thank you for providing us with disclosure during the Coronial investigation. We can confirm that following our inspection and a review of these documents we do not intend to undertake further investigations in relation to the death of Mary Walker or the provision of regulated activities by CLS Care Services Limited.”

    Source location

    2016-0150-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 21 April 2016

    Open published response

  6. Surrey

    AI-generated summary

    Adam James Withers · 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

    Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.

    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

    Insufficient recording of psychiatric patient observations and interactions

    Wider context from the report

    “It was apparent from the evidence that periodic observations of psychiatric patients are conducted not only to check that each is present, but also in order to observe and assess their current state of mind and presentation, by means of a meaningful interaction, if possible. The importance of nursing staff (Registered Nurses and Health Care Assistants) making a sufficient written record of these observations was acknowledged. Regular notes of a patient’s condition are important for the purposes of diagnosis and they provide the information which is needed for a reliable assessment of the patient’s progress and current level of risk of harm or death. It was accepted in evidence that this is especially so in relation to any patient whose condition fluctuates. It was clear from the evidence that the nursing staff involved in Adam Withers’ care failed to record sufficiently his presentation and their interactions with him. For example, on the day of his death Adam Withers was subject to four observations per hour but no entries were made on his RIO notes or elsewhere about his state of mind or presentation at these observation points and no record was made about the conversation a nurse conducted with him that afternoon. Some of the nursing staff who gave evidence appeared to have little understanding of the need to make such written records and/or their importance. If permitted to continue, the insufficient recording of observations and events could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives. ”

    Source location

    Adam James Withers · 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

    Implement purposeful engagement in adult inpatient services and require timely recording of staff interactions in clinical records.

    Verbatim wording from the response

    “We acknowledge that our record keeping practice did not meet our desired and expected quality levels in this instance and we have learnt from these identified deficiencies. We have already instigated work to further improve the quality of our engagement with people using our adult inpatient services, by ensuring that all interactions are meaningful, using a process of purposeful engagement (a modified form of intentional rounding). The purposeful engagement process assists our staff in ensuring continuous assessment of individuals so timely interventions can be undertaken when necessary. As part of this process we expect all staff in these services to record interactions in the person’s clinical records in a timely way.”

    Source location

    Adam-WITHERS-Response
    Page 1 · response
    Published 15 February 2016

    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 Observation Policy to require comprehensive risk assessments and documented observation decisions, risks and triggers.

    Verbatim wording from the response

    “We have also revised our Observation Policy to include much clearer guidance on how, when and where people should record all clinical interventions. This includes a review of the assessment section of this policy, which clearly states that all people that use our inpatient services will have a comprehensive Risk Assessment. This will include”

    Source location

    Adam-WITHERS-Response
    Page 1 · response
    Published 15 February 2016

    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 Records Management Policy and establish standards for factual, accurate, evidence-based and timely record keeping.

    Verbatim wording from the response

    “We have since reviewed our Records Management Policy which has a section outlining the ‘Standards for Record Keeping’. Under these standards there is clear expectation that:”

    Source location

    Adam-WITHERS-Response
    Page 2 · response
    Published 15 February 2016

    Open published response

  7. Portsmouth and South East Hampshire

    AI-generated summary

    James Robertson · 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 Robertson died on 22 July 2015 while resident at Cams Ridge Care Home, after he was last checked at around 13.00 hours and found apparently deceased at around 15.30 hours. Concerns included inaccurate recording of care-check times, delayed recognition of his DNACPR status, and inadequate equipment in the emergency resuscitation pack, particularly the lack of a suction unit.

    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 the timing of resident checks

    Wider context from the report

    “1) At Mr Robertson's Inquest, his care notes were referred to and I was told that carers were not required to accurately report the time of carrying out checks on him. This meant the Inquest could not accurately ascertain when he had been checked by care staff on the day of his death. ”

    Source location

    James Robertson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report

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

    Report summary

    Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

    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 information gained from patient observations correctly

    Wider context from the report

    “(1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a "two members of staff to one patient" basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm's length or within eyesight and how to record the information gained from the Observation. ”

    Source location

    CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Birmingham and Solihull

    AI-generated summary

    Allan Richard Beasley · 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

    Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and review.

    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

    Inaccurate completion of 15 minute observation forms

    Wider context from the report

    “(3) 15 minute observation forms were found to be inaccurate as staff in the office were completing the form when not seeing the patient. In addition the observation forms were felt to be inaccurate as a member of staff signed for observations when it was found they were undertaking another task. ”

    Source location

    Allan Richard Beasley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Brighton and Hove

    AI-generated summary

    MR. ANTHONY GEERTS · 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

    Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.

    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 nursing observations and NEWS

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce integrated documentation for all clinical staff treating patients on Twineham ward.

    Verbatim wording from the response

    “b) introduction of integrated documentation for use by all the clinical staff treating each patient on the ward”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.

    Verbatim wording from the response

    “c) joint development of a training package for all the staff based on Twineham ward, by the senior physiotherapy and nursing staff, to assist with accurate and detailed documentation. This includes a specific focus on the potential consequences of poor documentation”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    Open published response
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Data last updated 7 September 2026