Recurring concern

Unreliable observation of patients in specialist mental health units

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First reported 6 Mar 2014•Latest report 1 Apr 2026

Definition

What this concern includes

Includes failures in observation policies, guidance, training, risk-based observation levels, timing or execution within specialist mental health units, including age-inappropriate adult-derived guidance, predictable observations and unclear requirements for physical room entry or environmental checks.

Not included

  • Excludes general patient observation failures outside specialist mental health units unless the assertion explicitly concerns the same specialist mental-health observation process.
  • Excludes failures of continuous or one-to-one observation where no specialist mental-health-unit observation context is identified.
  • Excludes generic staffing, training or documentation deficiencies unless they directly impair observation in a specialist mental health unit.
  • Excludes unrelated ligature, accommodation, treatment or risk-assessment failures where observation is not the deficient control.
Reports
18

Distinct published reports

Individual concerns
21

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
63

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care5
East London NHS Foundation Trust3
NHS England3
Greater Manchester Mental Health NHS Foundation Trust2
Manchester University NHS Foundation Trust2
North London NHS Foundation Trust2
Affinity Healthcare Limited1
Coventry and Warwickshire Partnership NHS Trust1
Devon Partnership NHS Trust1
Essex Partnership University NHS Foundation Trust1
Lancashire & South Cumbria NHS Foundation Trust1
Ludlow Street Healthcare Group Limited1
Metropolitan Police Service1
Midlands Partnership University NHS Foundation Trust1
NHS Greater Manchester Integrated Care Board1

Concerns and responses across reports

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

  1. Inner North London

    AI-generated summary

    Dominic Michael WHITE · 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

    Dominic White, who had bipolar affective disorder and psychosis, rapidly deteriorated over several days and was assessed as requiring detention under section 2 of the Mental Health Act. Before he could be conveyed to a mental health hospital, he left the emergency unit and was found the following day at an electricity substation with injuries consistent with a fall from height. The concerns included whether mental health observation levels were communicated effectively and the clinical decision-making involved in allowing him to leave after detention had been decided.

    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 ensure that all relevant personnel are aware of the patient’s mental health observation level

    Wider context from the report

    “1. I heard that, following Mr White’s death, the level of (mental health) observations of a patient at the Whittington Hospital Emergency Unit is now clearly documented. However, I am not sure that there is yet a robust protocol in place to ensure that all relevant personnel (Whittington EU doctors, nurses and security officers; also visiting independent s12 doctors, BEH and C&I staff) are aware of the level. My concern arises because sometimes, when anyone can look at a record, that nobody actually does. ”

    Source location

    Dominic Michael WHITE · 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

    Update mental health policies and the joint observation protocol to define roles, responsibilities and decision-making case studies.

    Verbatim wording from the response

    “We set out below our agreed approach for ensuring that all relevant personnel are aware of a mental health patient’s level of observation. In order to address both concerns identified in the PFD, the Whittington and Camden & Islington have reviewed their mental health policies. These are being updated to ensure the roles and responsibilities are explicit and will also include case studies to assist in decision making. This will be included in Camden & Islington NHS Foundation Trust’s Mental Health Liaison Operational Policy and the Whittington Health NHS policy for mental health patients in the Emergency Department which is currently being updated.”

    Source location

    2017-0177-Response-by-Whittington-Hospital-NHS2-Trust
    Page 2 · response
    Published 4 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Display Emergency Department signage showing the observation process and responsible nursing and special-staff assignments.

    Verbatim wording from the response

    “6. As part of improving communication between organisations signage has been introduced in Whittington ED, which is prominently placed around the nurses’ station, to ensure that visiting doctors and AMHPs are aware of this process and that the name of the patient’s allocated nurse and any 1:1 or ‘special’ staff member is visible outside the patient’s cubicle (see images).”

    Source location

    2017-0177-Response-by-Whittington-Hospital-NHS2-Trust
    Page 2 · response
    Published 4 August 2017

    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 five daily senior-staff situation reports and follow-up reviews covering mental health patients’ risks, observation compliance, care quality and confirmed plans.

    Verbatim wording from the response

    “8. To ensure that the level of observations is being complied with and that the clinical decision making regarding Mental Health patients is robust Senior Whittington ED staff members (nurse in charge, site team, ED registrar or consultant) conduct a situation report 5 times per day in which the status of the department including”

    Source location

    2017-0177-Response-by-Whittington-Hospital-NHS2-Trust
    Page 2 · response
    Published 4 August 2017

    Open published response

  2. Liverpool and the Wirral

    AI-generated summary

    Linsay Bushell · 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

    Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.

    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

    Unclear recording and communication of patient observation levels

    Wider context from the report

    “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area. The Jury found: Para 3 1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital. 2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014. 3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation. 4. Linsay put herself in the position in which she was found however her intention was unclear. 5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder. 6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death. 7. The risk was managed adequately and effectively during Linsay's period as an in-patient. 8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made. a. In the Trust Position Statement Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them. 2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015. 3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material. 4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest. 5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity. 6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism. It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment. a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour. b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism. c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism. 7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust. 8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows: a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub. b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour. c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient. d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases. e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package. 9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation. 10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided. 11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels. 12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better. b. In the implementation of Lessons learnt the Trust further accepts 1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay". a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:- b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan. c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay. d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all. e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear. f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan. g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time. h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together. i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs. j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for. k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission. l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation. m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective. 2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation. Discontinuity of Care/Management of Care 3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B. 4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units. 5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach. 6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager. 7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse. 8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway. 9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible. Risk Assessment/Care Planning 10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk. 11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required. ”

    Source location

    Linsay Bushell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Exeter and Greater Devon

    AI-generated summary

    Matthew Llewellyn-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

    Matthew Llewellyn-Jones, who had been detained under section 2 of the Mental Health Act after becoming acutely unwell with psychosis, left a locked hospital ward unaccompanied and was later found hanging by a ligature in the hospital grounds. The concerns included breaches of the ward’s locked door, predictable observations, inadequate collection of information from family and carers, insufficient assessment and observation, inadequate staff induction, and staffing levels that contributed to failings in his care and security.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of ward policy to require unpredictable and irregular observations

    Wider context from the report

    “(2) Observations when carried out in the context of a secure mental health environment should not be predictable or entirely regular. This is not currently part of the ward policy, although it appeared to be accepted by senior staff at inquest. The Trust should consider further measures to ensure that training and instruction given to all staff in relation to observations is clear, constantly reinforced, and in line with best practise. ”

    Source location

    Matthew Llewellyn-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

    Finalize and implement revised Engagement Policy requirements for documenting and varying intermittent engagement and observation intervals.

    Verbatim wording from the response

    “The ‘Engagement Policy’ has been reviewed by the Deputy Director of Nursing and is currently being finalised, it has been changed to include the following -”

    Source location

    2016-0385-Response-by-Devon-Partnership-NHS-Trust
    Page 1 · response
    Published 25 October 2016

    Open published response

  4. Brighton and Hove

    AI-generated summary

    Christine Valerie STREET · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to maintain required arm’s length observation

    Wider context from the report

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

    Source location

    Christine Valerie STREET · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Hold L8AW nursing study days covering deprivation of liberty, falls prevention, one-to-one care, end-of-life care and documentation.

    Verbatim wording from the response

    “A series of study days has been held for the nurses on L8AW, to help them understand fully their responsibilities and obligations. Topics addressed have included Deprivation of Liberty; falls prevention and management; one to one care; end of life care; and documentation. A practice educator took up post on the ward earlier this year, who provides training both on specific neuro-competencies for nurses and also on more general nursing skills.”

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

  5. Blackpool and the Fylde

    AI-generated summary

    Piotr Grzegorz Kucharz · 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

    Piotr Kucharz was admitted to a mental health hospital and later found unresponsive after using a cord as a ligature; he died in hospital on 12 October 2014. Concerns included the absence of an effective translation service and a lack of consistency and clarity among staff about what constituted an effective observation, including whether staff should enter a patient’s room and engage verbally.

    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 clearly require physical entry into patients’ rooms to check the environment during observations

    Wider context from the report

    “1. Piotr Kucharz was a Polish gentleman who commenced living in the United Kingdom in April 2014. At the time he sought to strangle himself with a cord he was an informal patient at the Conway Ward at Parkwood, a mental health facility in Blackpool. At his inquest, evidence was heard from a number of members of staff as regards what constitutes an effective observation. He was the subject of what were described as Safety and Security [SAS] and general observations, the completion of which was the responsibility of a number of members of care staff. The evidence heard from staff raised an area of concern because that evidence indicated quite clearly that there was a lack of consistency and clarity as regards what constitutes an effective observation. An independent expert witness indicated in a report that he completed prior to the inquest that he felt custom and practice was such that some staff were merely checking on the “whereabouts” of the patient. Some staff felt that they were expected to enter the room of the patient and to try to engage with him and to check the room environment for anything that may pose a risk to him. Others felt that whether they were expected to actually enter a patient’s room to conduct the observation could vary depending on the level of risk a particular patient presented, in other words that they felt they had an element of discretion as regards whether they entered the room. This evidence appeared to be in contrast to a Trust policy. In the case of Piotr Kucharz, as can be seen above he had limited understanding of English, and a number of staff gave evidence that he remained in his room throughout his time on the Conway Ward and did not wish to engage with them. Nevertheless, the author of the Trust’s Sudden Untoward Incident Review document agreed that there was no such discretion and that staff ought to enter the room to complete and effective observation. At the conclusion to the inquest I expressed the view that I was concerned that there is a risk of future deaths because staff remain unclear about what amounts to an effective observation, and more specifically whether there are circumstances which may allow them to refrain from verbally engaging with a patient, or from physically entering a patient’s room to check the environment, and that should that lack of consistency and clarity prevail, other patients may be placed at risk as a result of inadequate observations. For the avoidance of doubt, I confirm that I am of the opinion that the above concern remains valid despite the fact that further to Piotr Kucharz’s death the provision of mental health care for patient’s such as Piotr has moved from the Conway Ward at Parkwood to another facility within my jurisdiction at which members of staff who were working at the time of Piotr’s death continue to be employed in a similar capacity. ”

    Source location

    Piotr Grzegorz Kucharz · 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 clearly require verbal engagement during patient observations

    Wider context from the report

    “1. Piotr Kucharz was a Polish gentleman who commenced living in the United Kingdom in April 2014. At the time he sought to strangle himself with a cord he was an informal patient at the Conway Ward at Parkwood, a mental health facility in Blackpool. At his inquest, evidence was heard from a number of members of staff as regards what constitutes an effective observation. He was the subject of what were described as Safety and Security [SAS] and general observations, the completion of which was the responsibility of a number of members of care staff. The evidence heard from staff raised an area of concern because that evidence indicated quite clearly that there was a lack of consistency and clarity as regards what constitutes an effective observation. An independent expert witness indicated in a report that he completed prior to the inquest that he felt custom and practice was such that some staff were merely checking on the “whereabouts” of the patient. Some staff felt that they were expected to enter the room of the patient and to try to engage with him and to check the room environment for anything that may pose a risk to him. Others felt that whether they were expected to actually enter a patient’s room to conduct the observation could vary depending on the level of risk a particular patient presented, in other words that they felt they had an element of discretion as regards whether they entered the room. This evidence appeared to be in contrast to a Trust policy. In the case of Piotr Kucharz, as can be seen above he had limited understanding of English, and a number of staff gave evidence that he remained in his room throughout his time on the Conway Ward and did not wish to engage with them. Nevertheless, the author of the Trust’s Sudden Untoward Incident Review document agreed that there was no such discretion and that staff ought to enter the room to complete and effective observation. At the conclusion to the inquest I expressed the view that I was concerned that there is a risk of future deaths because staff remain unclear about what amounts to an effective observation, and more specifically whether there are circumstances which may allow them to refrain from verbally engaging with a patient, or from physically entering a patient’s room to check the environment, and that should that lack of consistency and clarity prevail, other patients may be placed at risk as a result of inadequate observations. For the avoidance of doubt, I confirm that I am of the opinion that the above concern remains valid despite the fact that further to Piotr Kucharz’s death the provision of mental health care for patient’s such as Piotr has moved from the Conway Ward at Parkwood to another facility within my jurisdiction at which members of staff who were working at the time of Piotr’s death continue to be employed in a similar capacity. ”

    Source location

    Piotr Grzegorz Kucharz · 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 the observation policy and procedure using learning from serious incidents and national best practice.

    Verbatim wording from the response

    “The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice. This review is currently underway and we will be developing and implementing a revised observation policy and procedure. The new observation policy and procedure will be implemented by 31 March 2016.”

    Source location

    2015-0465-Response
    Page 2 · response
    Published 24 November 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and implement a revised observation policy and procedure by 31 March 2016.

    Verbatim wording from the response

    “The Trust is also in the process of reviewing the observation policy and procedure. We are taking into account the learning from previous serious incidents and national best practice. This review is currently underway and we will be developing and implementing a revised observation policy and procedure. The new observation policy and procedure will be implemented by 31 March 2016.”

    Source location

    2015-0465-Response
    Page 2 · response
    Published 24 November 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 an internal patient safety alert reminding inpatient services of the current observation policy and procedure.

    Verbatim wording from the response

    “In the interim, until this new policy and procedure is developed and implemented, an internal patient safety alert has been issued to remind staff of the current policy and procedure. This alert was sent to all inpatient services across the Trust.”

    Source location

    2015-0465-Response
    Page 2 · response
    Published 24 November 2015

    Open published response

  6. Manchester City

    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

    Lack of a written protocol defining increased observations and required recording

    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

    Review and bring into effect the revised Mental Health Act Code of Practice, including guidance on enhanced patient observation.

    Verbatim wording from the response

    “Further guidelines for patient observation are contained in the Mental Health Act 1983 Code of Practice. This has recently been reviewed by the Department of Health and the revised edition came into effect on 1st April 2015. Within this code is a section which advises on enhanced observation for patients in hospital wards and services.”

    Source location

    2015-0036-Response-by-Department-of-Health
    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

    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

  7. Manchester North

    AI-generated summary

    Miss Samiyo Sahra Shih Farah · 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

    Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of age-appropriate observation guidance for children and adolescents in specialist mental health units

    Wider context from the report

    “1) Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units. At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues. The care needs of young people are quite different to those of adults. ”

    Source location

    Miss Samiyo Sahra Shih Farah · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. West Sussex

    AI-generated summary

    Natasha Raghoo · 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

    Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

    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

    Unclear policy on the duration of patient observations

    Wider context from the report

    “9. The policy on length of time staff are expected to conduct observations, and the quality of handover from one member of staff to another. ”

    Source location

    Natasha Raghoo · 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, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.

    Verbatim wording from the response

    “Lessons Learned and changes made”

    Source location

    2014-0100-Response-by-Partnership-in-Care
    Page 6 · response
    Published 6 March 2014

    Open published response
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Data last updated 7 September 2026