20 Dec 2024 Edith Theresa PYE · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure of handover documents to communicate required personal-care staffing arrangements View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Care UK
Introduce key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
View source
Care UK
Review handover templates so they highlight key aspects of each resident’s care needs.
View source
Care UK
Review handover sheets weekly and update them when residents’ care needs change, under management supervision.
View source
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AI-generated summary
Edith Theresa PYE · 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
Edith Theresa PYE sustained a fracture after rolling from her bed at Chandler Court Care Home on 29 March 2024 while receiving personal care from one carer instead of the required two. She underwent an above-knee amputation, developed a chest infection and pulmonary emboli, and died at the care home on 28 April 2024. Concerns included ambiguous care-plan and handover information, inadequate staff awareness and compliance, lack of auditing, and weaknesses in the internal investigation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of handover documents to communicate required personal-care staffing arrangements
Wider context from the report “3) At the inquest, I was shown a handover document which had been drafted by the home’s Deputy Manager, and was told that a nurse in charge would have gone through this document with all carers at the beginning of the relevant shift. The document was meant to highlight each resident’s care needs, based on their respective care plans. It did not make clear that Mrs. Pye required two carers for the provision of personal care, or that at least one of those carers should be female ;
” Source location Edith Theresa PYE · Prevention of Future Deaths report
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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 key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
Verbatim wording from the response “Additionally, Chandler Court now involves key workers who, along with the shift leads, are responsible for having a sound knowledge of the residents’ care needs and disseminating key information to their teams.” Source location 2024-0706 - Response from Care UK Ltd
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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 handover templates so they highlight key aspects of each resident’s care needs.
Verbatim wording from the response “Care UK has reviewed our handover templates to ensure that they highlight the key aspects of each resident’s care needs.” Source location 2024-0706 - Response from Care UK Ltd
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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 handover sheets weekly and update them when residents’ care needs change, under management supervision.
Verbatim wording from the response “At Chandler Court, handover sheets are now reviewed by the Deputy Manager at the weekly clinical review meetings to ensure accuracy. In addition, any changes to a resident’s care needs are reported during the daily morning meetings and the person in charge of the suite, which would either be the Team Leader and/or Registered Nurse, is directed to complete the relevant update under the supervision of either the Deputy Manager or the Home Manager.” Source location 2024-0706 - Response from Care UK Ltd
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18 Jul 2024 Anna Vivien Elliott · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure of written handover records to capture vital information View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Anna Vivien Elliott · 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
Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety plans.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of written handover records to capture vital information
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in Anna’s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information .
” Source location Anna Vivien Elliott · Prevention of Future Deaths report
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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 roll out a standardised 24-hour handover template with daily and quarterly audits.
Verbatim wording from the response “13. Tower Hamlets is currently working on creating a standardised handover template. This project is being led by the Deputy Borough Lead Nurse. The aim is to have a running document over a 24-hour period. The handover template has been tested on some of the wards and is currently being rolled out to the remaining wards. Roll out should be completed by the end of September 2024. The Matron responsible for ward will be responsible for the initial audit daily, this will be audited by the Lead Nurses quarterly.” Source location Response from ELFT
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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 using Safety Huddles and document discussions on the handover template.
Verbatim wording from the response “14. In addition, the Trust will continue to use Safety Huddles as a way of discussion and decision making during a shift. Safety Huddle discussions will be documented on the handover template. This will ensure vital information during a shift is captured in the handover documentation.” Source location Response from ELFT
Open published response
31 May 2024 Frazer Charlie Williams · Prevention of Future Deaths report Dorset
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Concerns raised 1
Lack of national guidance for healthcare handover to receiving prisons View source
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Frazer Charlie Williams · 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
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of national guidance for healthcare handover to receiving prisons
Wider context from the report “iv. There is a lack of national guidance for healthcare teams working in prisons around the handover of healthcare of a prisoner to the receiving prison when they are transferred to another prison.
” Source location Frazer Charlie Williams · Prevention of Future Deaths report
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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 Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Verbatim wording from the response “With regard to the other concerns you have raised around a lack of national guidance relating to a range of healthcare issues in prison settings; operational issues regarding the ACCT process and engagement with prisoners’ family members, I would expect the other recipients of your report to address these in their responses, as they are responsible for matters relating to day to day operations within prison settings. I look forward to seeing their responses and working with them where appropriate, to avoid a repetition of the horrific events of this case.” Source location Response from DHSC
Open published response
20 May 2024 Miriam STONE · Prevention of Future Deaths report Derby and Derbyshire
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Concerns raised 1
Failure to clearly allocate responsibility for admission tasks during staff handover View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Miriam STONE · 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
Miriam Stone died on 20 February 2022 after being found with a ligature around her neck in a mental health unit on 18 February, following admission after an overdose. The concerns included uncertainty over responsibility for admission tasks during staff handover, a lack of formal policy protecting handover time, inadequate or incomplete risk and safety assessments, and observations that were not individually assessed and were found likely inappropriate.
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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 allocate responsibility for admission tasks during staff handover
Wider context from the report “Miriam was admitted to the mental health unit at approximately 8.30pm. The unit has a staff handover between 9.00pm and 9.30pm. The evidence at inquest was contradictory as to which shift had assumed responsibility for completing admission tasks including risk assessments and care / safety plans. It was recognised that admission shortly before or during shift handover can increase risks relating to the quality of information sharing and the allocation of admission tasks such as assessing the level of observations required .
The court heard evidence that whilst efforts would be made to avoid admission during staff handover time this was a local practice rather than part of any formal policy. The court further heard evidence that senior staff considered that avoidance of admission at handover times would be difficult to achieve because there were too many different organisations who might be requesting admission. This appeared to overlook the fact that it is the bed allocation team based at the trust who are the central point of contact.
The current operational policy covering admission procedures (Acute Inpatient Operational Policy) does not mention a need for handover time to be protected, avoiding admission during this time. Without a formal policy on this topic there is a risk that future deaths could occur.
” Source location Miriam STONE · Prevention of Future Deaths report
Open source report
7 Dec 2023 KATHARINE ANNE FOX · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to provide continuity and handover between hospital and community psychology services View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Essex Partnership University NHS Foundation Trust
Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
View source
Essex Partnership University NHS Foundation Trust
Regularly audit handovers to verify safe transfer of psychological care to community teams.
View source
Essex Partnership University NHS Foundation Trust
Review the operational model for transitions and handovers between inpatient and community psychological services.
View source
Essex Partnership University NHS Foundation Trust
Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
View source
Essex Partnership University NHS Foundation Trust
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
View source See 2 more actions
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AI-generated summary
KATHARINE ANNE FOX · 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
Katharine Fox died by hanging in October 2022 after being discharged from hospital, having been unable to access community psychology services during the following months. Concerns related to the lack of handover and continuity between hospital and community psychology services, substantial waiting times, and possible inability of clinicians to access notes held on different computer systems.
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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 continuity and handover between hospital and community psychology services
Wider context from the report “(1) I am concerned that the disconnection between the provision of psychology services to patients in hospital and the provision of similar psychology services to patients in the community , including the fact that the community psychology service does not receive any form of handover and that there is a substantial wait for the provision of psychology sessions which may well require continuity to be delivered effectively.
” Source location KATHARINE ANNE FOX · Prevention of Future Deaths report
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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 formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
Verbatim wording from the response “Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner. The Community Team psychological practitioner will discuss the care and treatment with the community mental health team to ensure the patient receives appropriate care and support in the community. The care in the community can be provided by the psychological practitioner or other appropriate team member under the supervision of a qualified registered psychological practitioner.” Source location Response from Essex Partnership University NHS Foundation Trust
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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 Regularly audit handovers to verify safe transfer of psychological care to community teams.
Verbatim wording from the response “The process of handover will be regularly audited to ensure that the care is safely transferred to the Community Team.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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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 operational model for transitions and handovers between inpatient and community psychological services.
Verbatim wording from the response “Further, the Unit is currently reviewing the operational model to improve the transition and handover of care between inpatient and community psychological services, with the aim of streamlining this provision.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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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 locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
Verbatim wording from the response “The new process will include a joint consultation between the inpatient and community psychological services in order to aid care planning and formal handover of appropriate inpatient cases prior to discharge across each locality in Essex. Handover will be recorded on the patient’s electronic notes.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
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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 Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Verbatim wording from the response “Further, the Court is advised that it is commissioning a unified Electronic Medical Records System, in the interim Psychological Services will now have access to all of the required clinical systems and will also embed a new mechanism to ensure robust clinical information sharing between inpatient and community clinicians. This will be achieved through the aforementioned joint forum which will incorporate a formal handover of all required information. Should access to more detailed clinical information be required, this can be requested.” Source location Response from Essex Partnership University NHS Foundation Trust
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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 Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.
Verbatim wording from the response “Whilst it is noted that patients do not always require immediate on-going psychological therapy upon discharge from hospital, Psychological Services will, going forward, embed a mechanism for clinical prioritisation in order to ensure that the most urgent cases are appropriately identified and prioritised in the community, ensuring continuity of psychological treatment and minimising waiting times as much as is practicably possible. This will be monitored through the waiting time data that is collected by each service team, and which is reported through our Trust Accountability Framework process.” Source location Response from Essex Partnership University NHS Foundation Trust
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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 Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Verbatim wording from the response “The Court is respectfully advised that EPUT (like a number of NHS Trusts) uses multiple Electronic Medical Records Systems, which includes PARIS and MOBIUS. Staff within the Inpatient Psychological Services team have access to both systems, as well as Health Information Exchange (HIE) and can therefore access all records/reports. Our IT department has recently confirmed that all clinical staff in Adult Community Psychological Services can also access both systems.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
18 Sep 2023 Anthony John Friend · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3
Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns View source Failure by incoming care providers to identify previous care providers and seek a handover View source Failure to provide handovers between care agencies about care needs and safety concerns View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Bluebird Care (Bromsgrove & Redditch) Herefordshire and Worcestershire Health and Care NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Bluebird Care (Bromsgrove & Redditch)
Write to Herefordshire and Worcestershire CHC to seek clarification on handover protocols and establish best-practice standards for potential improvements.
View source
Bluebird Care (Bromsgrove & Redditch)
Follow the enhanced handover process for all customers transitioning to or from Bluebird Care, not only CHC-funded customers.
View source
Herefordshire and Worcestershire Health and Care NHS Trust
Introduce a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.
View source
Bluebird Care (Bromsgrove & Redditch)
Proactively seek opportunities to observe care calls when taking over packages, where circumstances require, to support assessment and handover.
View source See 1 more action
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AI-generated summary
Anthony John Friend · 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
Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling . In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies” , but that it “was not something which we had ever done” ;
5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care. In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so.
” Source location Anthony John Friend · Prevention of Future Deaths report
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 by incoming care providers to identify previous care providers and seek a handover
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies”, but that it “was not something which we had ever done”;
5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care . In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so .
” Source location Anthony John Friend · Prevention of Future Deaths report
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 provide handovers between care agencies about care needs and safety concerns
Wider context from the report “In the course of the inquest, I heard evidence that:
1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death );
2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist;
3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.;
4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies” , but that it “was not something which we had ever done” .
” Source location Anthony John Friend · Prevention of Future Deaths report
Open source report
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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 Write to Herefordshire and Worcestershire CHC to seek clarification on handover protocols and establish best-practice standards for potential improvements.
Verbatim wording from the response “Whilst, as above, we do consider that in this case the handover process captured all the relevant information we had to share with the new provider, in an effort to improve this process going forward we have written to Herefordshire and Worcestershire CHC to seek guidance and clarification on the existing handover protocol for care providers when either taking on, or serving notice on, a package of care from CHC, as well as establishing best practice standards to implement any possible improvements. We are dedicated to continuing to be a high-quality care provider, and although the circumstances are unfortunate, we want to take this opportunity to work in partnership with other health care professionals to provide the best care and support to all those that we support.” Source location Response from Bluebird Care
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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 Follow the enhanced handover process for all customers transitioning to or from Bluebird Care, not only CHC-funded customers.
Verbatim wording from the response “From our perspective, this process will not be limited to handovers concerning CHC funded patients and will be followed for all customers that are transitioning to or from our care.” Source location Response from Bluebird Care
Open published response
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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 a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.
Verbatim wording from the response “We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.” Source location Response from Herefordshire and Worcestershire Health and Care
Open published response
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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 Proactively seek opportunities to observe care calls when taking over packages, where circumstances require, to support assessment and handover.
Verbatim wording from the response “5. We would also value the opportunity, should it be required, to observe a care call being carried out by an outgoing provider if we were to take over a package of care. We have proactively sought out these opportunities ourselves and have found them beneficial when circumstances require this, for example visiting a customer in hospital to make observations prior to returning home, and visiting another customer at home who had an existing homecare provider visiting daily.” Source location Response from Bluebird Care
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.
Verbatim wording from the response “As part of this meeting, the management team reviewed the detailed care plan that had been prepared by CHC based on information provided by ourselves and provided to Divine Health Care as part of the process of finding a new care provider. Although the handover was from CHC to Divine Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns regarding the sling were very clearly documented within this detailed 14-page document. Our identity as the outgoing care provider was also included within this document. This document was shared with Divine Health Care in advance of them carrying out their assessment and agreeing to take over Mr Friend's package of care.” Source location Response from Bluebird Care
Open published response
27 Jul 2023 Johanne Blackwood · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Lack of clarity in formal handovers of Care Coordinator responsibility View source Lack of a formal policy or procedure requiring recording of Care Coordinator handovers View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Johanne Blackwood · 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
Johanne Blackwood, known as Jo, died by suicide on 12 June 2021 after placing herself in the path of a train. The report identified concerns about unclear Care Coordinator handovers and responsibility for oversight after discharge, the absence of an allocated Care Coordinator for several weeks, failure to update her risk assessment, care plan and security plan, and inappropriate over-reliance on family members to keep her safe.
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 clarity in formal handovers of Care Coordinator responsibility
Wider context from the report “1. Evidence confirmed a conspicuous lack of clarity as to when, where and by (or between) whom any formal handover of responsibility as Care Coordinator (CC) for Jo took place as between a number of CCs allocated to Jo over a period of many months from the lead up to and following her discharge as an in-patient back to the community team on December 18ᵗʰ 2020 and through to early May 2021.
” Source location Johanne Blackwood · Prevention of Future Deaths report
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 a formal policy or procedure requiring recording of Care Coordinator handovers
Wider context from the report “2. Consequently , the evidence confirmed, despite her clear vulnerabilities, Jo did not have an allocated Care Coordinator for several weeks up to the beginning of May 2021. The evidence also confirmed that the lack of clarity as to the timing and conduct of CC handovers and the absence of an allocated CC to work with Jo (and by extension, her family) was informed by lack of a formal policy or procedure requiring that a full, detailed, formal record of handover between Care Coordinators is to be placed on EPUT electronic records .
” Source location Johanne Blackwood · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and use a Trust-wide electronic Care Coordinator to Care Coordinator Transfer of Care Document for structured handovers and continuity oversight.
Verbatim wording from the response “As part of the Inquest hearing, it was recommended by yourself, as the presiding Coroner, that the operational management at Essex Partnership University Foundation Trust (EPUT) consider establishing a mechanism and process for a formal structured handover between care coordinators. The service manager took this recommendation on board and has been working with colleagues and departments to produce a purposeful template that will form part of the Patient Electronic Record specific to the care coordinators’ handover. This document has been approved, for implementation Trust wide, following a process of consultation and with comments gathered from all community services.” Source location Response from Essex Partnership University NHS Fondation Trust
Open published response
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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 Attempt prompt recruitment and arrange at least two weeks’ overlap when a care coordinator gives notice, supporting effective handover and continuity of care.
Verbatim wording from the response “In addition, where notice has been given by any care coordinator (of their departure from the Trust) the team will promptly make an attempt to recruit another member of staff with an aim of ensuring an overlap of at least two weeks, to allow for effective handover and continuity of care, again Trust wide.” Source location Response from Essex Partnership University NHS Fondation Trust
Open published response
Concerns raised 1
Failure to pass injury information on at handover or document its transfer View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Sequoia CH Group Ltd
Strengthen staff communication by requiring documented concerns, daily records, written handovers, shift briefings and review of relevant resident records.
View source
Sequoia CH Group Ltd
Require the Manager to review and sign off handover records daily for completeness and inclusion of key information.
View source
Sequoia CH Group Ltd
Implement a Referral for Medical Attention policy requiring prompt clinical referral, documented professional guidance, care-plan updates and recorded follow-up.
View source
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AI-generated summary
June Peel · 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
June Peel, a resident at Belle Green Court Care Home, sustained a displaced distal femur fracture that was not identified or medically assessed promptly. She underwent surgery after admission to hospital and did not recover, dying on a palliative care pathway. The principal concerns were failures to follow her care plan, record and hand over information about her knee injury, and seek timely medical attention.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to pass injury information on at handover or document its transfer
Wider context from the report “1. There was a failure to record the injury from the body map in the daily communication records both on 3rd June and 6th June, and a failure to pass that information on at handover (or to document that the information had been passed on ). This led to a period in which June was being turned on a 2 hourly basis with a displaced femur fracture.
” Source location June Peel · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen staff communication by requiring documented concerns, daily records, written handovers, shift briefings and review of relevant resident records.
Verbatim wording from the response “Action Taken
We have taken the following action to ensure information is effectively communicated across the team;” Source location Response from Belle Green Court Care Home
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require the Manager to review and sign off handover records daily for completeness and inclusion of key information.
Verbatim wording from the response “6. The Manager reviews the handover record every day to ensure that the records are robust and key information is included. The Manager signs off the report to evidence that it has been reviewed.” Source location Response from Belle Green Court Care Home
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Referral for Medical Attention policy requiring prompt clinical referral, documented professional guidance, care-plan updates and recorded follow-up.
Verbatim wording from the response “Action Taken
We have implemented a new policy ‘Referral for Medical Attention’. Staff must not exercise their judgement as to whether urgent referral/ treatment is required or whether assessment can be delayed. The policy requires that” Source location Response from Belle Green Court Care Home
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28 Jan 2022 Mark Anthony Athias · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Failure to preserve handover records View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Exemplar Health Care
Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
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AI-generated summary
Mark Anthony Athias · 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
Mark Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to preserve handover records
Wider context from the report “3. The handover record for 2 July 2021 was missing, having allegedly been overwritten . The managers in the nursing home did not appreciate this until an Adult Safeguarding Investigation was underway.
” Source location Mark Anthony Athias · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
Verbatim wording from the response “You heard evidence from Ms ████████ that Exemplar Health Care had changed its system to use word templates across the entire organisation. It is therefore no longer possible for documents such as handovers to be overwritten. In addition, each handover is now saved electronically in a specific month document file and a copy is printed off and retained in the management office at Copperfields in paper form with a date tracker.” Source location 2022-0024-Response-from-Exemplar-Health-Care_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic storage, printed copies and monthly checks ensure handovers cannot be overwritten and remain accessible.
Verbatim wording from the response “You heard evidence from Ms ████████ that Exemplar Health Care had changed its system to use word templates across the entire organisation. It is therefore no longer possible for documents such as handovers to be overwritten. In addition, each handover is now saved electronically in a specific month document file and a copy is printed off and retained in the management office at Copperfields in paper form with a date tracker.” Source location 2022-0024-Response-from-Exemplar-Health-Care_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
Verbatim wording from the response “I have detailed above the relevant management structure changes and quality assurance systems in place to ensure that all record keeping is appropriate and accurate. In summary:” Source location 2022-0024-Response-from-Exemplar-Health-Care_Published
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4 Oct 2021 Caden Stewart · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to communicate healthcare waiting status during handover View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Caden Stewart · 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
Caden Stewart, aged 16, became unwell after weightlifting in custody and was later found collapsed and unresponsive in his cell. He was diagnosed with a brain haemorrhage, underwent surgery, and died at King’s College Hospital. The principal concerns were inadequate reporting and recording procedures and insufficient communication between prison officers and healthcare staff, resulting in healthcare failing to attend his requests to be seen.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate healthcare waiting status during handover
Wider context from the report “3. The wing officer in charge did not check whether Caden had been seen by healthcare at any stage over the following hours nor did he inform his successor on handover that Caden was waiting to see healthcare and had not been seen
” Source location Caden Stewart · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use daily residential roll books, guidance prompts and NOMIS records to capture healthcare requests, follow-up actions and relevant wellbeing information for staff sharing.
Verbatim wording from the response “To ensure improved and effective information sharing regarding a prisoner’s well-being, in September 2021 the Young People Services Team introduced daily roll books onto the residential areas which record the amount of time each young person spends in various activities. The logs provide for comments to be added and ‘guidance prompts’ are now in place which outline the importance of providing this information so that it is available to all staff. The guidance prompts also explain the type of information staff should record, including where a young person has made a request to see healthcare. A Notice to Staff detailing the use of the roll books was issued to ensure all staff are aware of the need to record information about a young person in custody.” Source location 2021-0328-Response-from-HMPPS_Published
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.