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.

5 Mar2015
Inner South London
Concerns raised1
1. Failure to retain recorded observations in the medical records
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
  Require staff to secure all loose clinical documentation in the main clinical notes.
  Stated by Lewisham and Greenwich NHS TrustStated completed
AI-generated summary

Archie Haxell · 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

Archie Haxell was born by forceps delivery on 24 March 2013 and suffered a respiratory arrest about two hours after birth. He was transferred to St Thomas’ Hospital, where he died on 29 March 2013. The principal concerns were breakdowns in communication between healthcare professionals, failure to retain observation records, and failure to inform Archie’s parents about concerns regarding his breathing, contributing to delay in recognising his deteriorating condition.

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 retain recorded observations in the medical records
Wider context from the report
“(1) About 25 minutes after his birth Archie was noted to be grunting and he then developed nasal flaring, both of which are potential signs of respiratory distress. He was ████████ performed a set of observations, including oxygen saturations and she also noticed vomiting, grunting and nasal flaring. The evidence at the inquest was that the observations on a piece of paper because the medical records were not immediately available (her observations were performed shortly after the birth of Archie’s brother who required resuscitation). Midwife ████████ later transcribed these results into the medical records. However, the evidence was that midwife ████████ was not aware of the vomiting, grunting and nasal flaring noticed by midwife ████████ although midwife ████████ believes she did pass this information on verbally. During this period may understandably have been focussed on Archie’s brother. However, I am concerned that the important information about further possible signs of respiratory distress was somehow lost in the communication between the two midwives. Also, the piece of paper on which the observations were recorded was not retained. I am concerned that this should have been retained in the medical records. ”
Source location
Archie Haxell · 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
Require staff to secure all loose clinical documentation in the main clinical notes.

Verbatim wording from the response
“1 – Documentation This issue was raised by the PFD report in relation to loose paper being used to document observations contemporaneously and later transcribed into the clinical notes. In this case the observations taken from Archie were transcribed into the clinical notes by a different person to the member of staff who had performed the observations. All members of staff have been reminded that any loose documentation must be secured into the main clinical notes even if written on a small piece of paper.”

Source location
2015-0081-Response-by-Lewisham-Greenwich-NHS-Trust
Page 2 · response
Published 5 March 2015
Open published response
3 Mar2015
Sunderland
Concerns raised1
1. Insufficient space for commentary in observation records
This report raised 7 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.
Respondent positions 3
1. Position
  Existing national guidance and statutory frameworks provide guidance on patient observation, with local policies expected to align with them.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
1. Position
  Individual NHS Trusts are responsible for developing and implementing patient observation policies appropriate to their patients.
  Stated by Department of Health and Social CareRedirects responsibility
2. Position
  The observation record’s front sheet need not include the RiO number because the patient’s name and hospital number enable electronic record retrieval.
  Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Paige Louise Bell · 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

Paige Louise Bell, aged 20, died at Sunderland Royal Hospital on 14 August 2014 after applying a ligature to her neck following an episode of self-harm. The inquest identified contradictions in the observation policy as a contributing factor. Concerns included case notes not being held together or fully transferred with the patient, and the need for consistent observation policies and updated guidance on managing patients with Borderline Personality Disorder.

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 space for commentary in observation records
Wider context from the report
“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”
Source location
Paige Louise Bell · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing national guidance and statutory frameworks provide guidance on patient observation, with local policies expected to align with them.

Verbatim wording from the response
“You ask if there is a national policy on patient engagement and observation. NHS England is planning to update its Suicide Prevention Audit Tool for Emergency Care, in light of learning from suicides in acute care settings. This stresses the importance of engagement with the patient, the recording of observations and timeliness of mental health assessment.”

Source location
2015-0075-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2015
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
Individual NHS Trusts are responsible for developing and implementing patient observation policies appropriate to their patients.

Verbatim wording from the response
“The Code of Practice provides a legal framework for the NHS. Individual NHS Trusts are expected to develop and implement their own patient observation policies that are appropriate to the needs of their patients and in line with this statutory guidance.”

Source location
2015-0075-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2015
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 observation record’s front sheet need not include the RiO number because the patient’s name and hospital number enable electronic record retrieval.

Verbatim wording from the response
“In relation to the concerns about space on the new observation record, staff are aware that they can write in the box below if necessary. The RiO number (on our electronic patient record system) is not required on the front sheet, as unlike the continuation sheets, the front sheet has the patient's name and hospital number written on it which will enable the patient to be found on RiO.”

Source location
2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015
Open published response
2 Mar2015
Staffordshire South
Concerns raised1
1. Failure to record all necessary patient 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.

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

Peter Jonathan Wright · Prevention of Future Deaths report

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

Report summary

Peter Jonathan Wright, a voluntary patient at St George’s Hospital, died after deliberately cutting an artery in his neck with a broken metal fork. The concerns included understaffing, failure to record necessary observations, a nurse undertaking a drugs round alone contrary to policy, and the lack of an on-site doctor and out-of-hours medical cover.

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 all necessary patient observations
Wider context from the report
“(1) At the time of the death the ward was understaffed. Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just returned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients. She did not record all necessary observations and was doing a drugs round by herself (contrary to policy). This was recognised in the SIR carried out by ████████ but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression I received from the nurse was that there is now some extra support at times but it is still not satisfactory. ”
Source location
Peter Jonathan Wright · Prevention of Future Deaths report
Page 1 · concerns
Open source report
2 Feb2015
Manchester City
Concerns raised1
1. Failure to assign clear responsibility for recording increased 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
  Develop a joint observation procedure and recording charts defining observation requirements, recording arrangements, and staff responsibility.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progress
2. Action
  Provide UHSM with advice on developing its self-harm policy and guidance and protocols for observing patients at risk.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
AI-generated summary

Kimberley Lauren Lindfield · 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

Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.

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 assign clear responsibility for recording increased observations
Wider context from the report
“2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist. ”
Source location
Kimberley Lauren Lindfield · Prevention of Future Deaths report
Page 7 · 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 joint observation procedure and recording charts defining observation requirements, recording arrangements, and staff responsibility.

Verbatim wording from the response
“2. Whenever an increased level of observation is initiated, pending a mental health assessment, because of the concern about patients’ mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations involve and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done.”

Source location
2015-0036-Greater-Manchester-West-NHS-Trust
Page 2 · response
Published 2 February 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
Provide UHSM with advice on developing its self-harm policy and guidance and protocols for observing patients at risk.

Verbatim wording from the response
“In respect of the other concerns raised in your report, MMHSCT has agreed to provide UHSM with advice in respect of their development of a self-harm policy and also with their development of guidance and protocols on observation of patients at risk. MMHSCT has suggested that they may wish to build on our existing observation policy.”

Source location
2015-0036-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 2 February 2015
Open published response
21 Jan2015
Exeter and Greater Devon
Concerns raised1
1. Failure to record neurological observations correctly and at the minimum recommended frequency
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 3
1. Action
  Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.
  Stated by Royal Devon University Healthcare NHS Foundation TrustStated completed
2. Action
  Deliver neurological-observation training to registered nurses and reduced-consciousness assessment training to non-registered support staff.
  Stated by Royal Devon University Healthcare NHS Foundation TrustStated completed
3. Action
  Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.
  Stated by Royal Devon University Healthcare NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  The recommended safety actions are primarily the responsibility of the hospital trust.
  Stated by DRS GIBB MURCH GILLARD BOWYER & GEARYRedirects responsibility
1. Position
  The hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.
  Stated by DRS GIBB MURCH GILLARD BOWYER & GEARYExisting arrangements considered sufficient
AI-generated summary

Robert Alan JONES · 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

Robert Alan JONES suffered multiple falls following a stroke and later deteriorated, dying at South Molton Community Hospital on 1 April 2014. The inquest recorded accidental death, with acute on chronic subdural haematoma and multiple falls due to cerebrovascular accidents. Concerns included inadequate communication about the total number of falls, use of an out-of-date post-falls checklist, and incomplete or incorrectly recorded neurological observations.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record neurological observations correctly and at the minimum recommended frequency
Wider context from the report
“(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”
Source location
Robert Alan JONES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.

Verbatim wording from the response
“(1) Revise the Trust’s falls policy to include the recommended frequency and duration of neurological observations based on NICE guidance for patients where head injury has occurred or cannot be ruled out, and inclusion of relevant history of falls in handovers of care.”

Source location
2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 1 · response
Published 21 January 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
Deliver neurological-observation training to registered nurses and reduced-consciousness assessment training to non-registered support staff.

Verbatim wording from the response
“(3) Ensure delivery of targeted training on performing neurological observations for nursing staff at South Molton Community Hospital and as a general communication across the trust.”

Source location
2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 2 · response
Published 21 January 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
Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.

Verbatim wording from the response
“To support the actions detailed above, the Trust will issue a Patient Safety Alert, which will communicate the need for neurological observations when a head injury has occurred or cannot be ruled out, completion of the post falls checklist, to include the frequency and duration of observations, to ensure the post falls checklist is filed with the patient’s observation chart for ease of access for all Multi-Disciplinary Team members, and to ensure that information relating to falls risk or actual falls is included in safety briefings and bedside handover. Patient Safety Alerts are disseminated across the whole Trust to clinical and managerial leads.”

Source location
2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 2 · response
Published 21 January 2015
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 recommended safety actions are primarily the responsibility of the hospital trust.

Verbatim wording from the response
“The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

Source location
2015-0068-Response-by-The-Health-Centre
Page 1 · response
Published 21 January 2015
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 hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.

Verbatim wording from the response
“The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

Source location
2015-0068-Response-by-The-Health-Centre
Page 1 · response
Published 21 January 2015
Open published response
27 Oct2014
Manchester South
Concerns raised1
1. Failure to carry out or record required nursing observations
This report raised 12 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
  Replace the PARS observation system with NEWS, train staff, and provide a NEWS escalation and response guide.
  Stated by Tameside General HospitalStated completed
AI-generated summary

Agnes Mary Hannan · 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

Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

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 carry out or record required nursing observations
Wider context from the report
“6. This patient needed very careful monitoring at all times and yet there was a period of 24 hours when no nursing observations were carried out or recorded. ”
Source location
Agnes Mary Hannan · 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
Replace the PARS observation system with NEWS, train staff, and provide a NEWS escalation and response guide.

Verbatim wording from the response
“Response At the time of Mrs Hannan’s treatment the Trust used a PARS scoring system for recording nursing observations. That system is designed to track observations, determine the regularity of them and trigger escalation of care whenever required. Instructions for use of the PARS score system was provided to nurses through training and also by clear explanatory notes within each individual nursing observation chart. The insufficient observations in this case arise from failure to adhere to the Trust’s PARS system.”

Source location
2014-0573-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 27 October 2014
Open published response
29 Aug2014
Inner North London
Concerns raised1
1. Failure to record post-fall neurological 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 5
1. Action
  Include documentation and falls management in induction for new medical trainees.
  Stated by Barts Health NHS TrustStated completed
2. Action
  Hold twice-daily safety briefings highlighting the Trust falls protocol.
  Stated by Barts Health NHS TrustStated planned
3. Action
  Remind nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.
  Stated by Barts Health NHS TrustStated completed
1. Action
  Provide nurses with neurological-observation training through the Critical Care Outreach Team.
  Stated by Barts Health NHS TrustStated in progress
2. Action
  Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.
  Stated by Barts Health NHS TrustStated planned
Respondent positions 1
1. Position
  Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.
  Stated by Barts Health NHS TrustDisputes the concern
AI-generated summary

Irshad ALI · Prevention of Future Deaths report

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

Report summary

Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his 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
Failure to record post-fall neurological observations
Wider context from the report
“2. Though the senior sister looking after Mr Ali on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this. Again, the chart appears to have gone missing. ”
Source location
Irshad ALI · 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
Include documentation and falls management in induction for new medical trainees.

Verbatim wording from the response
“Senior medical staff have confirmed that the induction for new medical trainees now includes a section on documentation and management of falls, emphasising the requirement to document actions in the medical records.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 29 August 2014
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
Hold twice-daily safety briefings highlighting the Trust falls protocol.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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 nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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 nurses with neurological-observation training through the Critical Care Outreach Team.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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 nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.

Verbatim wording from the response
“To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 29 August 2014
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
Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.

Verbatim wording from the response
“The missing neurological observation chart has been located and it confirms that appropriate neurological observations were carried out after Mr Ali’s fall. This chart had been inadvertently misfiled.”

Source location
2014-0387-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 29 August 2014
Open published response
30 Jul2014
Leicester City and South Leicestershire
Concerns raised1
1. Failure to provide a designated and accountable system for carrying out and recording observations
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 4
1. Action
  Review the observation policy against the concerns identified.
  Stated by Barons Park Nursing Home LtdStated completed
2. Action
  Issue the revised observation policy to nursing staff.
  Stated by Barons Park Nursing Home LtdStated completed
3. Action
  Implement observation and allocation record sheets defining responsibilities and review requirements.
  Stated by Barons Park Nursing Home LtdStated completed
1. Action
  Monitor observation and allocation sheets through General Manager audits.
  Stated by Barons Park Nursing Home LtdStated in progress
AI-generated summary

Christopher John Royal · 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 John Royal suffered a cardiac event on 25 January 2013 and was found collapsed in the en-suite bathroom of Baron’s Park Nursing Home; CPR was unsuccessful. Concerns included unreliable 15-minute observation records, inadequate emergency response and first-aid training, and the potential impact of lengthy staff shifts on care.

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 provide a designated and accountable system for carrying out and recording observations
Wider context from the report
“1) Mr. Royal was on 15 minute observations. The observations were not carried out by a designated member of staff; there was no system in place; the recorded observations were unreliable and inaccurate; recordings were not made by the staff who had actually observed Mr. Royal. Consideration should be given to a more robust, safe and accountable observation system, and proper training and auditing to ensure this is in place and operating effectively. ”
Source location
Christopher John Royal · 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
Review the observation policy against the concerns identified.

Verbatim wording from the response
“In response to this we have;”

Source location
Royal-2014-0354-Response
Page 2 · response
Published 30 July 2014
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
Issue the revised observation policy to nursing staff.

Verbatim wording from the response
“In response to this we have;”

Source location
Royal-2014-0354-Response
Page 2 · response
Published 30 July 2014
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 observation and allocation record sheets defining responsibilities and review requirements.

Verbatim wording from the response
“c) Created a new record sheet for nursing staff to complete at the commencement and conclusion of shift. The sheet clearly identifies who is responsible for carrying out certain requirements and it places an onus on the nursing staff to review the sheet and the observation requirements (paperwork) at timely intervals (see appendix B, implemented 1st August 2014).”

Source location
Royal-2014-0354-Response
Page 2 · response
Published 30 July 2014
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
Monitor observation and allocation sheets through General Manager audits.

Verbatim wording from the response
“d) Completion of observation sheets and allocation sheets are being monitored by our General Manager for audit purposes and to ensure that the new regime is being implemented in an accurate and effective manner. This is an ongoing process.”

Source location
Royal-2014-0354-Response
Page 2 · response
Published 30 July 2014
Open published response
9 May2014
Inner South London
Concerns raised1
1. Failure to record respiratory and pulse rates
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

Lisa Webb · Prevention of Future Deaths report

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

Report summary

Lisa Webb died suddenly and unexpectedly at home on 10 March 2012, aged 44. The inquest recorded natural causes, including adult respiratory distress syndrome and lower respiratory tract infection, with sleep apnoea and chronic asthma noted. Expert evidence raised concerns about the general practitioner's assessment and management of her asthma and respiratory symptoms, including the prescription of Diazepam.

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 respiratory and pulse rates
Wider context from the report
“Expert evidence was heard that: (1) The management of asthma by the general practitioner on 9th March 2012, when she presented post-operatively with fast breathing and anxiety, was sub-optimal and creates potential risks for other patients. a) Enquiries about her asthma and use of inhalers were not made, before a diagnosis was made of anxiety related hyperventilation (which was not in previous medical history) b) Fast breathing was observed and recorded (sic hyperventilating and mild wheeze, but the respiratory rate not recorded, nor was her pulse rate. c) Her peak flow rate was not recorded. There was only one record of its being measured in the years of general practice care and that was in 2008, when she was given a steroid inhaler. d) Pulse oximetry was not used (2) The prescription of Diazepam, although it did no harm in this instance, was poor treatment for anxiety, it should not be prescribed in sleep apnoea; and ideally should be avoided in respiratory distress. The GP said that he would not have given it in an asthmatic unless she had it before (of which there was no record) and that he was unaware of the diagnosis of sleep apnoea (of which diagnosis there was also no medical record). ”
Source location
Lisa Webb · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Jan2014
Inner North London
Concerns raised1
1. Failure to record required patient observations
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 1
1. Action
  Complete the transition to electronic patient records and register and mitigate risks from the interim hybrid system.
  Stated by Barts Health NHS TrustStated planned
AI-generated summary

Gregg O’REILLY · 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

Gregg O’Reilly was admitted as an emergency with dehydration, poor nutritional state, high stoma output, acute kidney injury and a high white cell count. He later developed multi-organ failure and repeated bleeding from his abdominal wound, but did not recover after surgery and critical care admission. The report raised concerns that he was not referred to critical care by 17.01.14 and that no observation records could be found between midnight and 3am before his second bleed and cardiac arrest call.

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 required patient observations
Wider context from the report
“Further, although he was on two hourly observations, no record of any observation could be found between midnight on 17.01.14 and 3am on 18.01.14, when Mr O’Reilly was found to have suffered a second bleed with very low blood pressure, and a cardiac arrest call was made. ”
Source location
Gregg O’REILLY · 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
Complete the transition to electronic patient records and register and mitigate risks from the interim hybrid system.

Verbatim wording from the response
“3. Ensure the transition period from a paper based system to the full electronic patient record is as short as possible and ensure the risks of the hybrid system are on the Risk Register and appropriate mitigation is in place.”

Source location
2014-0221-Response-by-Barts-Health-NHS-Trust
Page 1 · response
Published 19 May 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to retain recorded observations in the medical records

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

Insufficient space for commentary in observation records

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to record all necessary patient observations

Concerns raised1

Failure to assign clear responsibility for recording increased 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 neurological observations correctly and at the minimum recommended frequency

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to carry out or record required nursing 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

Failure to record post-fall neurological 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.5

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

Actions described in response 1

Respondent positions 3

Actions described in response 2

Actions described in response 3

Respondent positions 2

Actions described in response 1

Actions described in response 5

Respondent positions 1