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
Individual concerns: 21
Date range: 2014–2026
Stated actions: 63

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 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 Apr2026
West London
Concerns raised1
1. Failure to attempt engagement during 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 9
1. Action
  Implement the revised Observation and Engagement Policy, including clarified expectations for general and intermittent observations and an agreed staff code of conduct.
  Stated by South West London and St George'S Mental Health NHS TrustStated planned
2. Action
  Deliver organisation-wide webinars launching the revised observation policy for substantive, bank and agency staff.
  Stated by South West London and St George'S Mental Health NHS TrustStated planned
3. Action
  Update observation e-learning and require staff to complete it alongside a new competency framework demonstrating understanding and compliance.
  Stated by South West London and St George'S Mental Health NHS TrustStated planned
1. Action
  Pilot digital recording of general and intermittent observations across six inpatient wards, supported by PDSA cycles and evaluation.
  Stated by South West London and St George'S Mental Health NHS TrustStated planned
2. Action
  Provide staff with credit-card-sized observation memory cards distinguishing observation levels and minimum engagement expectations.
  Stated by South West London and St George'S Mental Health NHS TrustStated completed
3. Action
  Implement mandatory competency-based observation assessments and reinforce staff roles, responsibilities and expectations through training and regular supervision.
  Stated by South West London and St George'S Mental Health NHS TrustStated in progress
4. Action
  Increase leadership oversight through regular ward visits to support safe observation practice and policy compliance.
  Stated by South West London and St George'S Mental Health NHS TrustStated planned
5. Action
  Create and deploy a dashboard showing the quality of observations to clinical staff.
  Stated by South West London and St George'S Mental Health NHS TrustStated in progress
6. Action
  Continue monitoring the effectiveness of observation improvements and embedding them into routine practice.
  Stated by South West London and St George'S Mental Health NHS TrustStated in progress
Respondent positions 1
1. Position
  General observations are intended to locate patients and visually check wellbeing, while meaningful engagement applies to intermittent observations.
  Stated by South West London and St George'S Mental Health NHS TrustDisputes the concern
AI-generated summary

Lajos MANDRIK · 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

Lajos MANDRIK died on 13 September 2023 after hanging himself during a period when no staff member was allocated to carry out intermittent observations on Ellis Ward at Tolworth Hospital. The report’s principal concern is that general and intermittent observations appeared not to be carried out in accordance with the Trust’s policy, including the required attempt at engagement.

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 attempt engagement during patient observations
Wider context from the report
“The Trust's policy - in common with that of other Trusts - is that all observations should include an attempt, at least, at engagement. The written logs of observations suggest that, most of the time, no attempt is made at engagement during observations, in September 2023 or now. Intermittent observations may be recorded as, for example, 'Corridor - pacing' because the HCA has seen the patient but not attempted to engage with the patient. General observations, once per hour, appear to be no more than a headcount to make sure all patients are present on the ward (then and now). This impression, gleaned from the documentation, appeared to be confirmed by the oral evidence of HCAs at the inquest. It appears that the general and intermittent observations on Ellis Ward are not being carried out in accordance with the Trust's policy. If this was and remains the culture on Ellis Ward, it may also be the culture on other wards operated by the Trust (since some staff work on more than one Trust ward). ”
Source location
Lajos MANDRIK · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the revised Observation and Engagement Policy, including clarified expectations for general and intermittent observations and an agreed staff code of conduct.

Verbatim wording from the response
“the Nurse in Charge as well as weekly assurance Audits. There was continuous work done on revising the policy and adjustments made in line with the existing training package to include an agreed code of conduct that clearly lays out expectation on roles and responsibility by staff who undertake observation.”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 2 · response
Published 29 April 2026
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 organisation-wide webinars launching the revised observation policy for substantive, bank and agency staff.

Verbatim wording from the response
“The governance process to support implementation of the revised policy will ensure a smooth transition for the implementation and the actions are as follows: - The revised policy was presented in the Quality Governance Group in May 2026, this will be ratified at the June 2026 meeting. - Webinars are scheduled for the launching of the policy from July through to September. This is across all inpatient services and includes both substantive and bank/agency staff. - The e-learning package has been updated to include the changes made in the policy and all staff will be expected to compete this with a new competency framework to demonstrate understanding and compliance with Observation. This will be reviewed by 30 December 2026 to ensure staff are compliant”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update observation e-learning and require staff to complete it alongside a new competency framework demonstrating understanding and compliance.

Verbatim wording from the response
“The governance process to support implementation of the revised policy will ensure a smooth transition for the implementation and the actions are as follows: - The revised policy was presented in the Quality Governance Group in May 2026, this will be ratified at the June 2026 meeting. - Webinars are scheduled for the launching of the policy from July through to September. This is across all inpatient services and includes both substantive and bank/agency staff. - The e-learning package has been updated to include the changes made in the policy and all staff will be expected to compete this with a new competency framework to demonstrate understanding and compliance with Observation. This will be reviewed by 30 December 2026 to ensure staff are compliant”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026
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
Pilot digital recording of general and intermittent observations across six inpatient wards, supported by PDSA cycles and evaluation.

Verbatim wording from the response
“The Trust has an existing digital system that supports recording Constant and Enhanced Observation. To improve consistency, transparency and auditability of observations, the Trust will move general and intermittent observations to the same digital format. To enable this process, there is a plan to pilot the use of digital technology, ‘e-obs’ in 6 inpatient wards across the organisation, to ensure a collaborative approach to change in practice. This digital system will support a more detailed documentation which will include a safety and wellbeing check on patients during both general and intermittent observation. A set of PDSA cycles will be undertaken to ensure the change is supported and understood by staff. With a final evaluation of the pilot completed by 31 July 2026, with a planned phased roll-out across all inpatient wards by 31 October 2026, subject to evaluation findings.”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026
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 staff with credit-card-sized observation memory cards distinguishing observation levels and minimum engagement expectations.

Verbatim wording from the response
“In addition, a new credit card sized memory Card has been created as an aid-memoir that can be kept on staff’s lanyard that will support staff at a glance to”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026
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 mandatory competency-based observation assessments and reinforce staff roles, responsibilities and expectations through training and regular supervision.

Verbatim wording from the response
“We acknowledge that HCAs were specifically referenced in HM Coroner’s concerns and recognising that sustainable improvement requires cultural as well as procedural change, the Trust is implementing a programme of workforce development for all disciplines across all inpatient wards including:”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 4 · response
Published 29 April 2026
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
Increase leadership oversight through regular ward visits to support safe observation practice and policy compliance.

Verbatim wording from the response
“We will also increase visibility of leadership by regular ward visits to support staff in safe management of patients on observation and better oversight on whether the Observation Policy is being followed by staff. This oversight will:”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 4 · response
Published 29 April 2026
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
Create and deploy a dashboard showing the quality of observations to clinical staff.

Verbatim wording from the response
“The Trust also has a Nursing Optimisation & Workforce Programme that is focusing on compliance with observation and the quality of these. Having learned from the death of Mr Mandrik, the programme has reviewed the quality of observations and aims to ensure that all observations are supportive of the patient and are a therapeutic intervention. A dashboard to understand the quality of observation is being created and aim to be in use and visible to clinical staff in June 2026.”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 4 · response
Published 29 April 2026
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
Continue monitoring the effectiveness of observation improvements and embedding them into routine practice.

Verbatim wording from the response
“We will continue to monitor the effectiveness of these actions and ensure that they are embedded into routine practice.”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 5 · response
Published 29 April 2026
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
General observations are intended to locate patients and visually check wellbeing, while meaningful engagement applies to intermittent observations.

Verbatim wording from the response
“1. Trust Policy – Clarification of the observation model The Trust has undertaken a comprehensive review of the Observation and Engagement Policy in line with NICE guidelines with an increased focus on quality observations to improve patient’s experience as well as to provide greater clarity regarding expectations for all levels of observation. Specifically, the revised policy outlines the expectation for staff carrying out General and Intermittent Observation stating: General observations are the baseline observation applied within the trust, these low-level observations are performed hourly with the intention of locating a patient and visually checking their wellbeing.”

Source location
Response from South West London and St George's Mental Health NHS Trust
Page 3 · response
Published 29 April 2026
Open published response
24 Oct2025
Essex
Concerns raised1
1. Failure to undertake Level 2 intermittent observations at the required frequency
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 6
1. Action
  Shift observation practice toward therapeutic engagement through updated guidance and training.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Re-undertake Observation and Engagement competencies for the staff member requiring renewed training.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
3. Action
  Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
1. Action
  Deliver focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Stephen John Neville · 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

Stephen John Neville, aged 68, was an informal inpatient at Beech Ward for planned ECT after a history of severe treatment-resistant depression, anxiety, agitation, and repeated suicide attempts. He died by hanging while in hospital. The report identified concerns including failures in risk communication and assessment, abrupt medication changes, inadequate therapeutic observations and engagement, insufficient auditing and quality assurance, and failure to mitigate risks associated with an unlocked shower room.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake Level 2 intermittent observations at the required frequency
Wider context from the report
“1. There was a failure on the part of EPUT nursing and (particularly) support staff to appropriately undertake and record the required therapeutic engagement and interaction observations. Members of support staff demonstrably misunderstood (and appear to still misunderstand) the nature and purpose of Level 2 ‘intermittent’ (4 to 5 times) hourly observations, apparently routinely conducting such observations every 15 minutes on the hour, the quarter past and so on. Whilst the observations, when made, recorded the location of the patient and (very occasionally) noted what the patient may be doing, nothing was recorded in respect of an interaction or therapeutic engagement, as required by Trust policy. Such a lack of understanding of the basic role of the support worker and/or nursing staff in undertaking such critically important roles disclosed an (on-going) deficit in training. 2. Further, the clear evidence also disclosed an on-going failure in the quality assurance and auditing processes deployed by EPUT. A purported weekly quality assurance check being undertaken by the Ward Manager in December 2021, which claimed “an audit score of 100%”, was entirely at odds with the evidence at inquest which revealed repeated and significant inadequacies in the nature and quality of the observations undertaken and recorded. 3. Of even greater concern is that even after the move from paper to electronic observation records the same Beech Ward Manager (then and now) stated in evidence: “I have no audit tool …. I am not confident that the audits are accurate and complete now … there is no audit process in place to check the quality of observation and engagement documentation.” 4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” 5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”
Source location
Stephen John Neville · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Shift observation practice toward therapeutic engagement through updated guidance and training.

Verbatim wording from the response
“Response: In line with the details set out in the Trust’s learning statement filed with the Court, with respect to the Trust’s approach to Observation and Engagement, the Trust continues to shift focus to Therapeutic engagement rather than observation alone. This aligns with the national working group the Trust participated in across 2024 and led to the development of the Mental Health / Learning Disability Nurse Director guidance document.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 1 · response
Published 5 November 2025
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
Re-undertake Observation and Engagement competencies for the staff member requiring renewed training.

Verbatim wording from the response
“At this Inquest it was evident that one Health Care Assistant (HCA) did not understand the requirements of level 2 observation in relation to the random nature of level 2 observations. It is of that that they had been absent from work for a period of 9 months before the inquest. The Ward Manager is working with this staff member to re-undertake Observation and Engagement Competencies.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.

Verbatim wording from the response
“The Ward Manager has also undertaken a check of all staff Observation and Engagement competencies to ensure confidence in current staff practice. As part of this process the Ward Manager checked that all staff have completed Oxevision E-Observation training, which includes training on documenting o-benservations to ensure therapeutic engagement is captured. This ensures a focus on the quality of the therapeutic engagement and observation.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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 focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.

Verbatim wording from the response
“To further enhance Trust routine online training, the Ward Manager is providing a number of focused face to face training sessions with ward staff to further gain assurance around interpretation and understanding. This will include highlighting the importance of recording therapeutic engagement and space for reflection on learning. This is due to be completed by the end of December 2025.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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
Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.

Verbatim wording from the response
“As part of the Trustwide learning response, the learning from this inquest has been shared through the care unit quality and safety meeting to ensure shared learning across the wider care unit. This has also been shared with the Training team with a specific focus on Oxevision e-observation training to ensure this training robustly guides staff on engagement techniques and importance of the quality of recording of the engagement. This training was reviewed in February 2025 following the Trust’s recent review of the Oxevision SOP.”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 2 · response
Published 5 November 2025
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 three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.

Verbatim wording from the response
“Building on this review, further enhancements were introduced following inquest-related reflections. In November 2025, three new Oxevision audits were implemented to strengthen oversight of observation and therapeutic engagement, incorporating both staff and patient feedback:”

Source location
Response from Essex Partnership NHS Foundation Trust
Page 3 · response
Published 5 November 2025
Open published response
1 Sep2025
Inner North London
Concerns raised2
1. Failure to maintain effective 1:1 or within-eyesight observations
2. Failure to conduct and record patient observations accurately, sufficiently and therapeutically
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Update mobile-phone policy requirements for staff working in clinical areas.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Deliver shared learning to unit staff on mobile-phone use while on duty.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Introduce CCTV auditing of recorded observations after completing staff training on footage access.
  Stated by East London NHS Foundation TrustStated planned
1. Action
  Use board relays to improve observation practices and therapeutic engagement.
  Stated by East London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  No further action is considered necessary because considerable work has addressed the identified concerns.
  Stated by East London NHS Foundation TrustNo action considered necessary
AI-generated summary

Name not published · 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

████████ was detained under the Mental Health Act and admitted to psychiatric wards at the Tower Hamlets Centre for Mental Health before being found unresponsive in a patient room on 7 June 2022; her death was verified later that day. The jury identified several contributing factors, including a non-functioning door-locking system and shortcomings in patient observations. Further concerns included risk assessment, staff understanding and attitudes towards risk, auditing, and clinical oversight.

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 effective 1:1 or within-eyesight observations
Wider context from the report
“2) 1:1 or ‘within eyesight’ Observations The CCTV footage played at inquest showed a member of staff who was allocated to ‘within eyesight’ observations of another patient sat on the back of a chair (with their back facing the patient’s bedroom door) and engaged on their mobile telephone. That member of staff initially told the court that they were conducting the ‘within eyesight’ observations correctly and could see the patient in question. This raises significant concern, not only about the quality of 1:1 observation but also about staff attitudes and approach to observations that are integral to keeping patients safe (see below at para 7)). ”
Source location
Name not published · Prevention of Future Deaths report
Page 3 · 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 conduct and record patient observations accurately, sufficiently and therapeutically
Wider context from the report
“1) Patient Observations (generally) I am aware that, prior to ████████ final admission under the care of the Trust in 2022, other concerns had been raised by a coroner regarding patient observations within the Trust. Those concerns were first raised in 2021 (following a patient death in 2018). Concerns included the quality of observations and the falsification of observations. Despite assurances from the Trust in numerous action plans since, the evidence in this inquest revealed widespread concerns across two wards at THCMH (Brick Lane Ward and Rosebank Ward) about observations that were carried out. Such concerns included: the level of detail in observation records not meeting the expectations of the Trust’s own policy; the accuracy of timing’s in some observations was questionable; observations were often not used as a tool to aid therapeutic engagement with patients; and some observations were inaccurate or possibly falsified. The evidence received and heard during the inquest did not reassure me that this matter has been adequately addressed. Given the importance of observations in keeping patients safe, I remain concerned that significant risks remain. ”
Source location
Name not published · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update mobile-phone policy requirements for staff working in clinical areas.

Verbatim wording from the response
“The member of staff in question has had their knowledge refreshed about the expectations of the Trust’s observations policy and the Trust’s mobile phone policy. The latter was updated in 2024 to include material on staff use of mobile phones, making it clear that they are not allowed in clinical areas unless there is an exceptional reason agreed with a local manager. There has been shared learning with all staff across the unit on the use of mobile phones whilst on duty, in 2024.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 2 December 2025
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 shared learning to unit staff on mobile-phone use while on duty.

Verbatim wording from the response
“The member of staff in question has had their knowledge refreshed about the expectations of the Trust’s observations policy and the Trust’s mobile phone policy. The latter was updated in 2024 to include material on staff use of mobile phones, making it clear that they are not allowed in clinical areas unless there is an exceptional reason agreed with a local manager. There has been shared learning with all staff across the unit on the use of mobile phones whilst on duty, in 2024.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 2 December 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce CCTV auditing of recorded observations after completing staff training on footage access.

Verbatim wording from the response
“The Trust is moving towards using CCTV to objectively audit whether observations have been made as recorded. This is anticipated to commence in January 2026 to allow for staff training to download and access CCTV footage.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 2 December 2025
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
Use board relays to improve observation practices and therapeutic engagement.

Verbatim wording from the response
“I would like to draw your attention to an article published in the International Journal for Quality in Healthcare shortly after ████████ inquest took place, where the results of some of the Trust’s interventions to improve observation practices have been quantified. Observation completion and therapeutic engagement were shown to have improved following the introduction of zonal observations, a board relay, and life skills activities led by recovery workers. Sustained improvements were seen in all 10 measures used in this work, as evidenced by shifts in statistical process control charts. General observation completion increased by 1.2% (to 99.57%), and intermittent observation completion rose by 1.9% (to 98.25%). Incidents of physical violence were reduced by 23%, verbal aggression by 38% and racial aggression by 60%.”

Source location
Response from East London NHS Foundation Trust
Page 2 · response
Published 2 December 2025
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
No further action is considered necessary because considerable work has addressed the identified concerns.

Verbatim wording from the response
“I have addressed these in turn below. Please note that in respect of Concerns 2, 4, 5, 6, 7 and 8 the Trust entirely acknowledges the reasons for your concerns and has considered them extremely”

Source location
Response from East London NHS Foundation Trust
Page 1 · response
Published 2 December 2025
Open published response
10 Jul2024
Inner North London
Concerns raised1
1. Failure to conduct required 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 18
1. Action
  Increase each ward shift by one unregistered Band 3 staff member and add a weekday Band 4 Life Skills Recovery Worker.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Review and update ward rotas for safer staffing, with advance senior approval and quarterly monitoring.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Implement the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
  Stated by East London NHS Foundation TrustStated completed
1. Action
  Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Implement observation board relay to reduce missed observations and improve handover between staff.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Implement twilight shifts that add staffing during reduced activity periods and provide therapeutic activities.
  Stated by East London NHS Foundation TrustStated completed
4. Action
  Implement zonal observations to support continuous patient engagement and monitoring across wards.
  Stated by East London NHS Foundation TrustStated completed
5. Action
  Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
  Stated by East London NHS Foundation TrustStated completed
6. Action
  Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
  Stated by East London NHS Foundation TrustStated completed
7. Action
  Conduct senior-staff night visits with spot-check audits and observation of practice.
  Stated by East London NHS Foundation TrustStated completed
8. Action
  Continue reviewing escalation protocols for acuity, demand and staffing shortages, including task allocation, rapid resource deployment and reporting compromised care.
  Stated by East London NHS Foundation TrustStated planned
9. Action
  Review and relaunch use of the Standard Observation Measurement tool and its outputs to influence practice.
  Stated by East London NHS Foundation TrustStated planned
10. Action
  Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
  Stated by East London NHS Foundation TrustStated planned
11. Action
  Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
  Stated by East London NHS Foundation TrustStated in progress
12. Action
  Review the Human Factors Analysis findings and suggested improvements through senior leadership.
  Stated by East London NHS Foundation TrustStated planned
13. Action
  Develop a learning system linking internal incident and improvement learning with national observation-practice work.
  Stated by East London NHS Foundation TrustStated planned
14. Action
  Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
  Stated by East London NHS Foundation TrustStated planned
15. Action
  Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Mahamoud Hussain 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

Mahamoud Hussain Ali fell twice in the street on 19 August 2020 and was later detained under the Mental Health Act and transferred to Lea Ward. On 21 August 2020 he was found unresponsive and died in hospital on 26 August 2020. The principal concern was that required 15-minute observations were not conducted or were falsely recorded, and that subsequent Trust action had not been sufficient to ensure observations were conducted and recorded as required.

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 conduct required observations
Wider context from the report
“(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep. East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable. Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted. One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained. Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation. The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022. I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…” Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done.” Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur. ”
Source location
Mahamoud Hussain 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
Increase each ward shift by one unregistered Band 3 staff member and add a weekday Band 4 Life Skills Recovery Worker.

Verbatim wording from the response
“Overarching theme | Therapeutic engagement and observation improvement work undertaken Staffing/resource availability | Staff establishment reviews were undertaken in 22/23 and 23/24. Correct and agreed investments have gone into teams, increasing staff on each shift by one unregistered Band 3. Additional investment has been made for a Band 4 Life Skills Recovery Worker on Mondays to Fridays 9am to 5pm to increase the delivery of activities and opportunities for meaningful engagement.”

Source location
Response from ELFT
Page 2 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and update ward rotas for safer staffing, with advance senior approval and quarterly monitoring.

Verbatim wording from the response
“Staffing rotas for the wards have been reviewed and updated to reflect safer staffing requirements; senior approval of rotas is required six weeks in advance of the current period and quarterly rota monitoring meetings are in place.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
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 the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.

Verbatim wording from the response
“Staff competency | The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
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
Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.

Verbatim wording from the response
“Safety discussion sessions are facilitated weekly in directorates for all inpatient staff to review observation data, reflect on gaps in practice and disseminate learning.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
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 board relay to reduce missed observations and improve handover between staff.

Verbatim wording from the response
“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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 twilight shifts that add staffing during reduced activity periods and provide therapeutic activities.

Verbatim wording from the response
“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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 zonal observations to support continuous patient engagement and monitoring across wards.

Verbatim wording from the response
“Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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
Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.

Verbatim wording from the response
“Standards of professional practice | Expected standards of practice have been communicated to staff, with frequent updates on improvement work since 2021 to date. In 2023, this specifically addressed accountability and responsibility for accurately documenting observations. It included the importance of honesty in documentation and gave guidelines for staff to follow for occasions when observations were missed. The Trust-wide Quality Improvement programme described above has introduced the observation relay board to reduce incidents of observations being left or not handed over.”

Source location
Response from ELFT
Page 4 · response
Published 31 July 2024
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
Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.

Verbatim wording from the response
“Audit and monitoring The Standard Observation Measurement (SOM) Tool was developed for oversight of rates of completion of all observations. Individual ward teams and directorates can access and use their data to drive continued improvement.”

Source location
Response from ELFT
Page 5 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct senior-staff night visits with spot-check audits and observation of practice.

Verbatim wording from the response
“Night visits are undertaken by senior staff in directorates to monitor practice through spot check audits and observing work as it happens.”

Source location
Response from ELFT
Page 5 · response
Published 31 July 2024
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
Continue reviewing escalation protocols for acuity, demand and staffing shortages, including task allocation, rapid resource deployment and reporting compromised care.

Verbatim wording from the response
“Staffing/resource availability Continue to review escalation protocols to senior staff on site in response to changes in acuity or demand or if there are staff shortages on a shift. This is to include:”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and relaunch use of the Standard Observation Measurement tool and its outputs to influence practice.

Verbatim wording from the response
“Professional practice Review and relaunch use of SOM tool and outputs to impact on practice.”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.

Verbatim wording from the response
“Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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
Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.

Verbatim wording from the response
“Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the Human Factors Analysis findings and suggested improvements through senior leadership.

Verbatim wording from the response
“Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,”

Source location
Response from ELFT
Page 6 · response
Published 31 July 2024
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 learning system linking internal incident and improvement learning with national observation-practice work.

Verbatim wording from the response
“Learning system To develop a learning system that includes learning from incidents and improvement work internally, but that also links in with national work in relation to observations practice.”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
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
Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.

Verbatim wording from the response
“To design an internal governance process for the review of reported cases of missed observations and learning that arises from this, that will report into the Patient Safety and Quality Assurance committees.”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
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 consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.

Verbatim wording from the response
“Standardised processes To develop a consistent approach to supporting staff to learn from incidents involving poor observations practice through reflection, personal accountability and, if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
Open published response
26 Sep2022
Surrey
Concerns raised1
1. Limited risk reduction from observation frequency for high-risk patients
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
  Review national risk-assessment guidance and assess moving to an evidence-based, personalised safety-planning approach.
  Stated by NHS EnglandStated in progress
AI-generated summary

Sandra Kirk · 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

Sandra Kirk was found unresponsive in the ensuite bathroom of her bedroom at Cygnet Hospital on 2 August 2021 and was declared deceased after resuscitation attempts were unsuccessful. The inquest found that she died from asphyxia due to a ligature around her neck. Concerns included inadequate guidance on identifying and removing potential ligatures, including items of clothing, and the limited risk reduction provided by observation intervals.

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
Limited risk reduction from observation frequency for high-risk patients
Wider context from the report
“- The evidence in this inquest was that Cygnet’s Ligature Risk Reduction Policy and the Ligature Audit Tool/Ligature Risk Assessment are standard documents used by Mental Health inpatient providers, including NHS Psychiatric Trusts. - The Ligature Risk Reduction Policy quotes the CQC guidance of 2015, that “Three-quarters of people who kill themselves whilst on a psychiatric ward do so by hanging or strangulation”. - Whilst these documents provide detailed guidance in respect of minimising ligature anchor points, they do not give guidance as to minimising potential ligatures themselves, which are defined as “Any item which can be used to make a loop or noose with the intention of limiting the supply of oxygen to an individual by hanging or asphyxiation”. - Rather than emphasising the very real risk that specific items of clothing, ████████, can pose to vulnerable patients, the document places emphasis on avoiding ‘blanket restrictions’ which does not assist in identifying where the real risks lie. - Death by the use of a ligature is likely to occur within a few minutes, whereas observations for a high-risk patient not assessed as being in immediate crisis, will generally be carried out four times in every hour, which therefore provides only a limited degree of risk reduction. Consideration should be given as to efficacy of such a policy and whether this can be improved by recognising that some items of clothing will be more obvious ligature risks and may need to be removed in all cases. ”
Source location
Sandra Kirk · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review national risk-assessment guidance and assess moving to an evidence-based, personalised safety-planning approach.

Verbatim wording from the response
“Regarding the national guidance around risk assessments (relevant to your comments around observations and risk reduction), I would like to provide my assurance that this is currently being reviewed and work is underway to assess a move to a more personalised safety planning approach, in line with an evidence base. The concerns raised in PFD reports, including your Report dated 26 September 2022, are communicated to the national policy and programme teams to help inform their work around this.”

Source location
Response from NHS England (2)
Page 2 · response
Published 7 October 2022
Open published response
25 Nov2021
Manchester South
Concerns raised1
1. Lack of standardised observation charts and completion rules on mental health wards
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.

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

Dr Malcolm Dixon · 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

Dr Malcolm Dixon became unwell in autumn 2019 with what was later diagnosed as a severe depressive illness and was admitted as an informal, voluntary patient to Priory Hospital, Altrincham. He died there on 29 December 2019 following an impulsive act undertaken in the context of severe mental illness. Concerns included inaccurate observation records, electronic care-record timestamps being overwritten, and the absence of professional documentation requirements for some unregistered staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of standardised observation charts and completion rules on mental health wards
Wider context from the report
“1. Given the particular importance of documented observations being taken at specific intervals on mental health wards, it is a matter of concern that standardised observation charts (together with accompanying standard rules as to how they should be completed) are not in use across these settings both in the NHS and private sectors; ”
Source location
Dr Malcolm Dixon · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Apr2021
East London
Concerns raised1
1. Failure to undertake required intermittent 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 4
1. Action
  Require all inpatient nursing staff to complete and annually renew the observations competency checklist, with completion recorded and reported for oversight.
  Stated by East London NHS Foundation TrustStated planned
2. Action
  Review observation practice daily and through weekly night ward visits, discuss findings with Ward Matrons, and escalate compliance information through nursing leadership.
  Stated by East London NHS Foundation TrustStated in progress
3. Action
  Implement daily observation audits and a directorate data-reporting structure for reliable monitoring, governance review and local remedial action.
  Stated by East London NHS Foundation TrustStated in progress
1. Action
  Create an observations training module and ESR compliance record, deliver training annually, and report completion data for management and Board review.
  Stated by East London NHS Foundation TrustStated in progress
AI-generated summary

Rohan Dayal Singh · 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

Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to undertake required intermittent observations
Wider context from the report
“2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable, staff accepted that they had failed to undertake observations and made false records, further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated. ”
Source location
Rohan Dayal Singh · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Require all inpatient nursing staff to complete and annually renew the observations competency checklist, with completion recorded and reported for oversight.

Verbatim wording from the response
“One of the first steps being taken to address this problem is that all nursing staff (including new staff members and bank staff) working in Trust in-patient services must complete the observations competency checklist that forms part of the Trust’s Observation Policy by 30 June 2021. This is irrespective of whether they have completed the checklist in the past. Local Ward Matrons managing this process have been identified. They will send the staff records showing completed competency training to the Trust’s Learning and Development Team, who will upload the information on each Nurse’s ESR. The Matrons will then feed the information about compliance back to the Director of Nursing for senior oversight.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 3 · response
Published 5 May 2021
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review observation practice daily and through weekly night ward visits, discuss findings with Ward Matrons, and escalate compliance information through nursing leadership.

Verbatim wording from the response
“Clinical Nurse Managers have already started reviewing nurses’ observation practice daily. They are also undertaking weekly night visits on the wards to observe compliance with the observation policy at night - as this has traditionally been overlooked.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 3 · response
Published 5 May 2021
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 daily observation audits and a directorate data-reporting structure for reliable monitoring, governance review and local remedial action.

Verbatim wording from the response
“A new system for auditing observations is being implemented. Templates for monitoring auditing observation practice were sent to the Borough Lead Nurses as of 30 May 2021 to be cascaded down to their respective teams. Ward Managers will complete the audits daily and report to Ward Matrons on the numbers of observations being undertaken properly and any patterns of failures or concerns.”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 4 · response
Published 5 May 2021
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
Create an observations training module and ESR compliance record, deliver training annually, and report completion data for management and Board review.

Verbatim wording from the response
“Nurse Observation Training Modules”

Source location
2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Page 4 · response
Published 5 May 2021
Open published response
10 Sep2020
Shropshire, Telford and Wrekin
Concerns raised1
1. Failure to observe patients in the garden unless eyesight observations are required
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Remove the lower portion of the day-room window film to improve visibility into the garden while retaining upper-level privacy screening.
  Stated by Midlands Partnership University NHS Foundation TrustStated planned
AI-generated summary

Lee William Davies · 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

Lee William Davies, a detained patient, absconded from a mental health ward on 17 June 2019 and was found unconscious the following day after an out-of-hospital cardiac arrest. He died in hospital on 18 June 2019 after treatment was withdrawn; the inquest recorded a brain injury caused by illicit drug use. Concerns included the reduction of his observation levels despite his risk of absconding to obtain drugs, and ward-garden planting and monitoring arrangements that could allow drugs or other items to be concealed.

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 observe patients in the garden unless eyesight observations are required
Wider context from the report
“(1) During the course of the inquest I heard evidence that it was likely that Mr Davies had absconded on 17/6/19 by scaling a perimeter fence in the garden of Laurel Ward. The Jury was told that patients had unrestricted access to the garden except when the doors were locked overnight between 10.30 pm – 7.30 am; (2) The inquest heard that on 5/6/19 Mr Davies attempted to climb over the fence with a chair; (3) Mr Davies had absconded from Laurel Ward on 2 occasions since he was detained under s3 MHA on 24/5/19 and on 15/6/19 and used drugs. On the latter occasion he was reported by a peer to have climbed over the fence. (4) On 16/6/19 Mr Davies attempted to abscond again by trying to climb over the fence and was stopped by staff. He was observed to be arranging items to help him climb over the fence namely a bin and a chair. (5) The deceased was admitted to the Centre with a known substance abuse problem; (6) The jury was told by the Responsible Clinician that the deceased was also at risk of obtaining drugs from within the ward itself as the ward was not secure; (7) I also received evidence during the investigation that when Mr Davies’s personal belongings were collected following his death, these included a crushed metal can likely to have been used for narcotic use; (8) The inquest heard evidence that the fence of Laurel Ward garden was approximately 3100 mm in height having been increased in 2015. (9) The inquest was provided with two photographs of the fence taken on the morning of the third day of inquest being 8/10/20 that showed a wooden panelled fence with a metal mesh/wire upper level behind a paved pathway with a shrubbery filled with green foliage and plants; (10) The photographs showed that some of the shrubbery plants were almost as high as the wooden part of the fence and very dense to the extent the fence could not be seen behind them and nor could the ground beneath due to ground level foliage; (11) I heard evidence at the conclusion of the inquest in the absence of the Jury that the shrubbery was not considered to be dense enough by the head of security to conceal any items and that after an incidents of absconding a anti climb review was undertaken; (12) My concern is that it is not sufficient to carry out a search of the area after a patient has absconded. The current planting arrangements based on the most recent photographs, do appear to provide ample ground coverage for ANY item to be concealed including drugs, drug paraphernalia, weapons, items that could be used as weapons and items in connection with absconding. (13) There was no evidence that the garden was searched on a regular basis, patients were not observed in the garden unless their level of observation included eyesight observations, and there was no CCTV covering the garden area. (14) My view is that circumstances of the current planting arrangements in the shrubbery present a risk of deaths which will continue to exist. This also extends to a risk of injury to staff on Laurel Ward and other patients. ”
Source location
Lee William Davies · 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
Remove the lower portion of the day-room window film to improve visibility into the garden while retaining upper-level privacy screening.

Verbatim wording from the response
“2. The second point relates to a ‘film’ which is covering the windows in the day room which looks out onto the garden. This film has been installed for privacy against overlooking houses close to the ward perimeter and to reduce glare into the day room. However, it was highlighted that this can impact on observations into the garden from the day room and therefore, the film will be removed at a lower level (to allow for unhindered vision into the garden) and kept at a higher level (to enable privacy to be maintained and continue to limit glare).”

Source location
2020-0261-Response-from-Midlands-Partnership-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 31 December 2020
Open published response
5 Dec2017
South Wales Central
Concerns raised1
1. Inconsistent conduct of enhanced observations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review, update, ratify, circulate and implement the Levels of Observation Policy.
  Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated planned
2. Action
  Trial amended enhanced-observation documentation with guidance, actual observation times, staff coaching, monitoring and evaluation.
  Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated planned
3. Action
  Update the training package with instructional video and completed-documentation exemplars.
  Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated planned
AI-generated summary

Stephanie Cave · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inconsistent conduct of enhanced observations
Wider context from the report
“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep. ”
Source location
Stephanie Cave · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review, update, ratify, circulate and implement the Levels of Observation Policy.

Verbatim wording from the response
“Action: Review and update Levels of Observation Policy for ratification by the Policy Committee”

Source location
2017-0361-Response
Page 1 · response
Published 11 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Trial amended enhanced-observation documentation with guidance, actual observation times, staff coaching, monitoring and evaluation.

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

Source location
2017-0361-Response
Page 1 · response
Published 11 February 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Update the training package with instructional video and completed-documentation exemplars.

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

Source location
2017-0361-Response
Page 2 · response
Published 11 February 2018
Open published response
13 Nov2017
Coventry
Concerns raised2
1. Failure to provide adequate and reliable intermittent observations
2. Lack of staff knowledge of intermittent observation requirements and observation sheets
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.

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

John James Leo Scallan · Prevention of Future Deaths report

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

Report summary

John James Leo Scallan was admitted to hospital after sustaining injuries in an alleged assault and was subsequently transferred to a mental health ward as an informal patient. He was found unresponsive following a cardiac arrest, and the levels of sedative drugs in his blood after death exceeded those prescribed. Concerns were raised about the adequacy and reliability of intermittent observations, including staff understanding of the observation policy and reluctance to enter a patient's room to conduct checks.

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 adequate and reliable intermittent observations
Wider context from the report
“1. 1. The adequacy and reliability of the intermittent observations. 2. 2. The Observation and Engagement Policy indicates checks should be seen in terms of positive engagement with the patient and involve, whenever possible, interaction and positive contact with the patient and sighting the patient from a distance and recording whereabouts is not acceptable intermittent observation. The evidence from the front-line health care assistants showed little insight into the requirements of intermittent observations as well as awareness of the new observation sheets and how these should be completed in line with the policy. There was a clear reluctance by members of staff to enter a patient’s room to conduct observations in particular, when the patient was sleeping in the middle of the day. ”
Source location
John James Leo Scallan · Prevention of Future Deaths report
Page 3 · 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
Lack of staff knowledge of intermittent observation requirements and observation sheets
Wider context from the report
“1. 1. The adequacy and reliability of the intermittent observations. 2. 2. The Observation and Engagement Policy indicates checks should be seen in terms of positive engagement with the patient and involve, whenever possible, interaction and positive contact with the patient and sighting the patient from a distance and recording whereabouts is not acceptable intermittent observation. The evidence from the front-line health care assistants showed little insight into the requirements of intermittent observations as well as awareness of the new observation sheets and how these should be completed in line with the policy. There was a clear reluctance by members of staff to enter a patient’s room to conduct observations in particular, when the patient was sleeping in the middle of the day. ”
Source location
John James Leo Scallan · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to attempt engagement during patient observations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

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

Concerns raised1

Failure to undertake Level 2 intermittent observations at the required 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.6

Concerns raised2

Failure to maintain effective 1:1 or within-eyesight observations

Failure to conduct and record patient observations accurately, sufficiently and therapeutically

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.4

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

Concerns raised1

Failure to conduct required 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.18

Actions described in response 9

Respondent positions 1

Actions described in response 6

Actions described in response 4

Respondent positions 1

Actions described in response 18