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
Individual concerns: 90
Date range: 2013–2026
Stated actions: 181

Reports over time

Reports about this concern issued each year.

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

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.

24 Sep2019
South Wales Central
Concerns raised2
1. Inadequate recording of patient condition in 15-minute observation charts
2. Failure to complete NEWS chart fields correctly
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Annette Susan HEWINS · 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

Annette Susan Hewins was detained under the Mental Health Act on 7 February 2017 for assessment and treatment of psychotic symptoms and opiate withdrawal. She was found unconscious in hospital on 8 February 2017 and died despite resuscitation; the post-mortem identified extensive coronary artery atherosclerosis as the likely cause of death. Concerns included inconsistent clinical record-keeping, incorrectly completed NEWS charts, missed observations, inadequate documentation and requesting of an ECG, insufficient detail in observation records, and the absence of a Trust policy for managing opiate-dependent patients in acute admissions.

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 patient condition in 15-minute observation charts
Wider context from the report
“(5) It was considered that some of the detail provided by Nurses/HCA’s when completing the 15 minute observations chart was inadequate. In particular entries such as “bed”. It was accepted that such information was inadequate & a brief addendum adding the condition of the patient was desirable – i.e. recording not simply where a patient was located at the time, but also their state – calm, agitated, sleeping, etc. It was felt that guidance/training on the appropriate completion of these observation charts was indicated, so that patterns of physical & mental health symptoms could be assessed. ”
Source location
Annette Susan HEWINS · Prevention of Future Deaths report
Page 2 · 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 complete NEWS chart fields correctly
Wider context from the report
“(2) Erroneously completed NEWS charts – it transpired that Nursing Staff/HCA’s were using the frequency of observation box, to record the time observations were carried out. This may require guidance/training to remind staff completing the NEWS charts of the importance of ensuring the appropriate boxes are completed. ”
Source location
Annette Susan HEWINS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Jul2019
Inner South London
Concerns raised1
1. Failure to maintain accurate and truthful patient observation records and reports
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Conduct ongoing investigations into concerns arising from the case.
  Stated by NHS Professionals LimitedStated in progress
Respondent positions 1
1. Position
  Client Trusts complete performance assessments and directly manage staff compliance with Trust policies, guidelines and record-keeping requirements.
  Stated by NHS Professionals LimitedRedirects responsibility
AI-generated summary

Mr Alex Blake · 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 Alex Blake died from a self-administered heroin overdose while a sectioned in-patient at Lambeth Hospital, sometime before 04.13 on 24 June 2018. The jury found that inadequate observations, unsuitable record sheets, ineffective observations and poor communication meant his death went unnoticed for several hours. Concerns were also raised about unreliable or potentially false accounts and records by staff regarding observations of him before he was found dead.

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 truthful patient observation records and reports
Wider context from the report
“The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless. The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59. The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible. The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court. ”
Source location
Mr Alex Blake · 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
Conduct ongoing investigations into concerns arising from the case.

Verbatim wording from the response
“I can confirm that the concerns raised were acted upon immediately and are currently the subject of ongoing investigations. I would therefore wish to assure all concerned that action will be taken to remedy any identified organisational or individual deficits arising from this process in the interests of patient safety.”

Source location
2019-0259-Response-from-NHS-Professionals-Redacted-1
Page 3 · response
Published 6 September 2019
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
Client Trusts complete performance assessments and directly manage staff compliance with Trust policies, guidelines and record-keeping requirements.

Verbatim wording from the response
“NHS Professionals uses an online performance review and monitoring system that helps to resolve concerns informally at an early stage. It identifies Bank Members who are performing well and also highlights any lack of skills or knowledge development. Performance assessment is completed by the client Trust. NHS Professionals will put in place improvement measures for Bank Members where poor performance or skill deficit has been identified by a Trust.”

Source location
2019-0259-Response-from-NHS-Professionals-Redacted-1
Page 3 · response
Published 6 September 2019
Open published response
24 Apr2019
Brighton and Hove
Concerns raised1
1. Failure to accurately and contemporaneously record NEWS observations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Roll out an electronic system for recording NEWS observations and nursing assessments.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
AI-generated summary

Ioannis AVGOUSTI · 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

Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

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 and contemporaneously record NEWS observations
Wider context from the report
“(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him. I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours. The observations were added up to 9. In fact the total was 13. NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care. This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty) If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative. Whilst I cannot say categorically that this would have been the case I believe it is highly likely. NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018. ”
Source location
Ioannis AVGOUSTI · 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
Roll out an electronic system for recording NEWS observations and nursing assessments.

Verbatim wording from the response
“I agree with you that NEWS is a very important tool and should be used and followed correctly. I regret the NEWS documentation was not to the standard we expect. The ward team have reflected at length and the case was discussed by the wider team at the Medicine Division’s Clinical Governance meeting on 17 May 2019. I am pleased to say, after a successful trial, the Trust has purchased an electronic system for recording NEWS and nursing assessments. This system is currently rolling out electronic recording of observations, and NEWS scores of all patients will therefore be available to view by the”

Source location
2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Page 2 · response
Published 14 June 2019
Open published response
12 Apr2019
Buckinghamshire
Concerns raised1
1. Variation in recording of hourly patient observations
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review and revise the Safe and Supportive Observations policy to improve the safety and effectiveness of observation practices.
  Stated by Oxford Health NHS Foundation TrustStated in progress
2. Action
  Implement and evaluate new approaches to enhanced observations through a quality improvement project.
  Stated by Oxford Health NHS Foundation TrustStated completed
AI-generated summary

Emma Felicity BUTLER · 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

Emma Butler was an inpatient at Ruby Ward who died at Stoke Mandeville Hospital from blood loss after incised wounds inflicted outside the Whiteleaf Centre while she was on unescorted leave. The report raised concerns about access to means of self-harm on and outside the ward, hourly observations, urgent access to ward support, and planning for discharge.

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
Variation in recording of hourly patient observations
Wider context from the report
“(3) General observations. The process for conducting and recording hourly observations left scope for significant variation on the actual time between and the manner in which such observations of a particular patient were undertaken and recorded. There was an indication that this would be reviewed but the risk remains of an incident of planned or spontaneous self-harm occurring between observations for a patient not on a higher level of observations. ”
Source location
Emma Felicity BUTLER · 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
Review and revise the Safe and Supportive Observations policy to improve the safety and effectiveness of observation practices.

Verbatim wording from the response
“The policy is currently undergoing a review. It was last discussed at the Clinical Effectiveness Sub-Committee in April 2019. Your concerns are being considered as part of that review. The revised policy will be presented to the Sub-committee on 18th July 2019 by the Trust’s Deputy Director of Nursing for Mental Health.”

Source location
2019-0133-Response-by-Oxford-Health-NHS-Trust
Page 3 · response
Published 14 June 2019
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 and evaluate new approaches to enhanced observations through a quality improvement project.

Verbatim wording from the response
“I can also add that the issue of enhanced observations was the subject of a 2018/19 quality improvement project completed by Oxford Healthcare Improvement (OHI) in partnership with one of our wards, the results of which were reported to our Quality Committee in May 2019. OHI trains and develops staff at the Trust in order to deliver better and safer care through a programme of quality improvement projects, training and research. OHI works with national and international organisations, universities, health and social care providers, commissioners, the academic health science network, patient safety collaborative and industrial partners. The outcome of the project was extremely encouraging and patients and staff have reported very positive outcomes from new approaches to enhanced observations.”

Source location
2019-0133-Response-by-Oxford-Health-NHS-Trust
Page 3 · response
Published 14 June 2019
Open published response
18 Dec2018
South Yorkshire (Western)
Concerns raised1
1. Failure to record patient observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.
  Stated by Brancaster Care Homes LimitedStated completed
2. Action
  Train all registered nurses to complete contemporaneous records in accordance with NMC guidelines.
  Stated by Brancaster Care Homes LimitedStated completed
3. Action
  Conduct scheduled monthly internal and external audits of care records.
  Stated by Brancaster Care Homes LimitedStated completed
AI-generated summary

John Duckenfield · 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

John Duckenfield was receiving intermediate care following a fall and was later admitted to Northern General Hospital, where he died on 21 January 2018. The inquest identified concerns about falsely asserted and unrecorded observations, failure to call a GP when requested, and inaccurate or misleading care-home 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 to record patient observations
Wider context from the report
“During the inquest, evidence showed:- 1. ████████ falsely asserted he had taken observations of Mr Duckenfield in the presence of the family. Not only I, but safeguarding also, felt this assertion was dishonest. 2. He failed to record observations he said he carried out despite accepting a need to do so. 3. Falsely asserted he was never asked to call a GP 4. The care home manager, ████████ said observations should have been taken daily and recorded but were not. Surprisingly therefore, she asserted the care rendered was reasonable. 5. Records kept by the home were inaccurate and misleading. ”
Source location
John Duckenfield · 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
Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.

Verbatim wording from the response
“• I attach a procedure regarding observations (resident observation P52) and the recording of such (specific observations F13u and monthly observations F13l). The objective of this procedure is to: ◦ ensure that the residents are observed relevant to their condition/diagnosis; ◦ ensure that the observations are recorded; ◦ make sure relatives are fully aware of the observations and treatment required as a result of the observations; and ◦ ensure changes in baseline observations are reported to other professionals.”

Source location
2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019
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 all registered nurses to complete contemporaneous records in accordance with NMC guidelines.

Verbatim wording from the response
“• My client organised staff training to ensure that record keeping is undertaken contemporaneously and follows NMC guidelines. All registered nurses attended this training which took place on 3, 8, 9 and 10 January 2019;”

Source location
2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019
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 scheduled monthly internal and external audits of care records.

Verbatim wording from the response
“• Audit checks on care records are undertaken by home managers but also by other home managers external to the home on a scheduled monthly basis. These audits are ongoing;”

Source location
2018-0389-Response-by-Brancaster-Care-Home
Page 2 · response
Published 13 May 2019
Open published response
8 May2018
London Inner (South)
Concerns raised1
1. Failure to make contemporaneous observation-log entries
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Issue an internal Blue Light Bulletin to registered nurses using the case to reinforce observation and recording practice standards.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
2. Action
  Review the Therapeutic Engagement and Observation Policy, focusing on practice-standard clarity and policy implementation.
  Stated by South London and Maudsley NHS Foundation TrustStated in progress
3. Action
  Deliver annual Learning the Lessons presentations on timely observation and recording to newly registered nurses, using the case as teaching material.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
1. Action
  Deliver annual Learning the Lessons presentations on timely observation and recording to nurses in training years one to three, using the case as teaching material.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
2. Action
  Develop a timeline for transforming mental health safety and engagement observations into the e-observation framework, beginning with scoping.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
3. Action
  Conduct six-monthly snap audits of compliance with observation standards, report results through quality governance meetings, and take necessary improvement steps.
  Stated by South London and Maudsley NHS Foundation TrustStated in progress
AI-generated summary

WILLIAM DICKENS · 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

WILLIAM DICKENS, who was assessed as at high risk of repeat self-harm, died on 10 May 2017 after being discovered hanging by a belt from the bed in his room at a mental health unit. The report raises concerns that required intermittent observations were not carried out, that observation-log entries were made after the event, and that defects in the logging process could create a risk of future deaths.

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 make contemporaneous observation-log entries
Wider context from the report
“(1) From 10 am on the morning of 10 May 2017 the observation regime for the ward was not complied with. While there are notes on the observation log suggesting that some patients had been seen in the period between 10 am and 11 am, Mr Dickens was not seen from 9.47 am until he was discovered hanging by a belt from the bed in his room just before 10.40 am. The observation log shows that several other patients were unaccounted for during the same period. (2) During the inquest the nurse in charge of the ward gave evidence that the entries she had made on the observation log for the period between 10 am and 11 am were not made contemporaneously but after Mr Dickens had died. No note had been made on the log to indicate that the entries were being made after the event. (3) While the observation log may have different purposes, it seems to me that two reasonable purposes of it are (i) to act as a prompt to make sure that the necessary checks on the patients were in fact conducted; and (ii) to ensure that there is a record that at a certain time, certain patients had been accounted for and were safe. (4) Those purposes are plainly frustrated if entries are made on the log at times that are different to the actual observations, and after the event. (5) Given that part of the purpose of the log is to ensure the safety of patients, particularly those such as Mr Dickens who are at high risk of self-harm or suicide, defects in the observation log process give rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future. ”
Source location
WILLIAM DICKENS · 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 an internal Blue Light Bulletin to registered nurses using the case to reinforce observation and recording practice standards.

Verbatim wording from the response
“1) The Director of Nursing to use the case as the basis of an internal safety alert ‘Blue Light Bulletin’ to be sent out to all registered nurses to reinforce the practice standards. To be completed by 6/07/18”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 1 · response
Published 1 July 2018
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 Engagement and Observation Policy, focusing on practice-standard clarity and policy implementation.

Verbatim wording from the response
“3) The Therapeutic Engagement and Observation Policy to be reviewed and particular attention to be paid to the clarity of practice standards and the implementation of the policy.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 1 · response
Published 1 July 2018
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
Deliver annual Learning the Lessons presentations on timely observation and recording to newly registered nurses, using the case as teaching material.

Verbatim wording from the response
“4) From September 2018 the cohort of newly registered nurses to receive a “Learning the Lessons” presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
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
Deliver annual Learning the Lessons presentations on timely observation and recording to nurses in training years one to three, using the case as teaching material.

Verbatim wording from the response
“5) From September 2018 the cohorts of nursing in training (year 1-3) to receive a Learning the Lessons presentation, using this case as the basis, of the importance of timely observation and recording in preserving safety and confidence in those we care for. Commencing September 2018 and annual thereafter.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
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 timeline for transforming mental health safety and engagement observations into the e-observation framework, beginning with scoping.

Verbatim wording from the response
“7) The Director of Nursing as Chair of the E-observation Project Group to develop the timeline for transforming mental health safety and engagement observations into the e-observation framework. This is a long term project that is complex to deliver, a time frame is difficult to reliably commit to, the aim will be scoping from January 2019.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
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 six-monthly snap audits of compliance with observation standards, report results through quality governance meetings, and take necessary improvement steps.

Verbatim wording from the response
“8) The Director of Nursing will commission six monthly snap audits to establish compliance with the standard and take necessary steps to improve compliance. Audits commissioned, results to be delivered between August 18 and January 19 and to be considered in the Quality Governance meetings for each Operational Directorate.”

Source location
2018-0137-Response-by-South-London-Maudsley-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response
14 Feb2018
Nottinghamshire
Concerns raised1
1. Failure to record Glasgow Coma Scale observations after deterioration in consciousness
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Commence a serious incident investigation to review the care provided.
  Stated by United Lincolnshire Teaching Hospitals NHS TrustStated planned
AI-generated summary

Elaine Bradbrook · 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

Elaine Bradbrook suffered a severe ischaemic stroke, deteriorated into a deep coma, underwent a craniectomy, and died at Queen’s Medical Centre on 27 April 2017. Concerns included failures to escalate and monitor her deterioration, reassess her condition before transfer, and reduce risks during transfer, including transfer with an unprotected airway and without clinical escort. The report also raised concerns about the trust’s failure to investigate the circumstances, fulfil its duty of candour, and support or properly represent witnesses during the inquest.

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 Glasgow Coma Scale observations after deterioration in consciousness
Wider context from the report
“b. There was a failure to record a single GCS after 14.00, when her level of consciousness dropped. I found no evidence of any clinical or nursing review after this time. ”
Source location
Elaine Bradbrook · 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
Commence a serious incident investigation to review the care provided.

Verbatim wording from the response
“I agree that there are clear learning points from this case and I have asked the Risk Team to commence an SI investigation to review the care and submit an action plan, as necessary. I will of course share this with you and the family once complete.”

Source location
2018-0044-Response-by-United-Lincolnshire-Hospitals-NHS-Trust
Page 1 · response
Published 7 June 2018
Open published response
19 Dec2017
Manchester North
Concerns raised1
1. Failure to record vital signs and observations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Maintain electronic NEWS scoring linked to bedside vital-sign recording and observation-frequency escalation.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
2. Action
  Develop a visual aid supporting timely completion of clinical observations in busy ward environments.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
AI-generated summary

Mrs Lindsey Parker · 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

Mrs Lindsey Parker had metastatic lung cancer and subsequently developed toxic epidermal necrolysis while receiving medical treatment. Her condition deteriorated on 8 July 2017, with concerns about delayed medical review, inadequate recognition and escalation of deterioration, gaps in observations and fluid-balance recording, lack of continuity in medical care, and the qualifications of out-of-hours coordinators. She died at Salford Royal Hospital on 9 July 2017.

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 vital signs and observations
Wider context from the report
“2. Matron's review identified gaps in basic nursing care – vital signs/observations not recorded, potentially affecting the NEWS and inadequate fluid balance chart completion. Both are critical to patient care and safety, particularly given Mrs Parker's serious clinical diagnosis (TEN), against a backdrop of an already life limiting/threatening diagnosis. ”
Source location
Mrs Lindsey Parker · 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
Maintain electronic NEWS scoring linked to bedside vital-sign recording and observation-frequency escalation.

Verbatim wording from the response
“Compliance with adult observation physiological monitoring policy”

Source location
2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
Page 3 · response
Published 12 February 2018
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 visual aid supporting timely completion of clinical observations in busy ward environments.

Verbatim wording from the response
“Further monitoring is in place to ensure that elevated NEWS scores are escalated appropriately and within the timeframe stated in the adult observation policy via a weekly audit of the process. As a result of Mrs Parker’s case the staff have developed a visual aid to support the completion of timely clinical observations in a busy ward environment.”

Source location
2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
Page 4 · response
Published 12 February 2018
Open published response
5 Dec2017
South Wales Central
Concerns raised2
1. Inconsistent recording of enhanced observations
2. Failure to routinely record precise times of enhanced observations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review current enhanced-observation recording documentation.
  Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated planned
2. Action
  Trial amended enhanced-observation documentation with guidance, actual observation times, staff coaching, monitoring and evaluation.
  Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated planned
3. Action
  Introduce the evaluated amended enhanced-observation documentation.
  Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated planned
1. Action
  Update the training package with instructional video and completed-documentation exemplars.
  Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated planned
AI-generated summary

Stephanie Cave · 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

Stephanie Cave had a history of deteriorating mental health, self-harm and attempts to end her life, and died after being found with a ligature around her neck on 17 August 2017 while in hospital care. The concerns identified included inconsistent enhanced observations, lack of training and written guidance for conducting and recording observations, and failure to routinely record precise observation times.

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
Inconsistent recording of enhanced observations
Wider context from the report
“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep. ”
Source location
Stephanie Cave · Prevention of Future Deaths report
Page 2 · 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 routinely record precise times of enhanced observations
Wider context from the report
“(3) The evidence also revealed that precise times of such observations were not routinely being recorded. ”
Source location
Stephanie Cave · 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
Review current enhanced-observation recording documentation.

Verbatim wording from the response
“Review current enhanced observation recording documentation”

Source location
2017-0361-Response
Page 1 · response
Published 11 February 2018
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
Trial amended enhanced-observation documentation with guidance, actual observation times, staff coaching, monitoring and evaluation.

Verbatim wording from the response
“Introduce amended recording documentation for 2 week trial commencing 22 January, 2018 with provision for coaching of staff, monitoring and evaluation”

Source location
2017-0361-Response
Page 1 · response
Published 11 February 2018
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 evaluated amended enhanced-observation documentation.

Verbatim wording from the response
“Introduce evaluated amended documentation”

Source location
2017-0361-Response
Page 1 · response
Published 11 February 2018
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 training package with instructional video and completed-documentation exemplars.

Verbatim wording from the response
“Update current training package to include: video that clearly shows the correct way to complete the documentation; exemplar copies of completed for the finalised documentation record”

Source location
2017-0361-Response
Page 2 · response
Published 11 February 2018
Open published response
22 Nov2017
Manchester West
Concerns raised1
1. Failure to record observations of residents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Use hourly observation charts for residents requiring more frequent checks, including mobile residents.
  Stated by BIOcareMStated completed
AI-generated summary

Kathleen Joan Devine · 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

Kathleen Joan Devine, a 94-year-old resident of a nursing home with advanced dementia and a history of falls, suffered an unwitnessed fall on 8 June 2017 while attempting to mobilise unsupervised. She sustained a right femur fracture, underwent surgery, and died on 10 June 2017 after her condition deteriorated post-operatively. Concerns included gaps in recorded observations, the removal and unplugging of a falls mat and sensor, and inadequate handover information for agency 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
Failure to record observations of residents
Wider context from the report
“1. The failure of staff to record observations between 6.30am and 8.30am; ”
Source location
Kathleen Joan Devine · 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
Use hourly observation charts for residents requiring more frequent checks, including mobile residents.

Verbatim wording from the response
“• There was no documentation from the times between 06.30-08.30, at Arden Court we now have hourly observation charts for residents who require more frequent checks, such as someone mobile like Kathleen Devine and these are now actively used (Appendix 5: Hourly check form).”

Source location
2017-0411-Response-by-Bloom-Care
Page 2 · response
Published 26 February 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Inadequate recording of patient condition in 15-minute observation charts

Failure to complete NEWS chart fields correctly

Concerns raised1

Failure to maintain accurate and truthful patient observation records and reports

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to accurately and contemporaneously record NEWS observations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Variation in recording of hourly patient observations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to record patient observations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to make contemporaneous observation-log entries

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Concerns raised1

Failure to record Glasgow Coma Scale observations after deterioration in consciousness

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to record vital signs and observations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 1

Respondent positions 1

Actions described in response 1

Actions described in response 2

Actions described in response 3

Actions described in response 6

Actions described in response 1

Actions described in response 2