Recurring concern

Failure to provide effective on-duty clinical leadership

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First reported 30 Aug 2013•Latest report 8 Feb 2024

Definition

What this concern includes

Includes failures of on-duty clinical leadership in clinical or care settings, including absent or unclear leadership, inability of the available leader to provide clinical direction or support, and inadequate leadership of ward or immediate-care operations.

Not included

  • Excludes generic organisational leadership or governance deficiencies that do not concern leadership of clinical care or clinical teams.
  • Excludes failures of senior review, consultant attendance, clinical supervision or staffing capacity where on-duty clinical leadership is not the shared unsafe condition.
  • Excludes leadership failures in non-clinical settings, such as race control, event management or custody operations, unless the assertion explicitly concerns leadership of clinical care.
  • Excludes isolated poor clinical decisions where no deficiency in the availability, clarity or effectiveness of on-duty clinical leadership is identified.
Reports
15

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
12

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England4
Department of Health and Social Care3
Birmingham and Solihull Mental Health NHS Foundation Trust1
Care Quality Commission1
CSC Computer Sciences Limited1
Cwm Taf Morgannwg University Local Health Board1
Cygnet Health Care Limited1
General Medical Council1
Hellesdon Hospital1
Hull University Teaching Hospitals NHS Trust1
Isle of Wight NHS Trust1
James Paget University Hospitals NHS Foundation Trust1
Leeds and York Partnership NHS Foundation Trust1
Milton Keynes University Hospital1
NHS Surrey and Sussex 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. East Riding and Hull

    AI-generated summary

    Ethel Doreen Reed · 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

    Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.

    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 visible ward leadership and a clear escalation pathway

    Wider context from the report

    “(1) H130 is on the 13th floor of Hull Royal Infirmary. It has an East and a West wing and spans the full floor. It was opened in response to winter pressures. At that time, in January 2023, Hull Royal Infirmary was placed under significant pressure in terms of admissions and staffing. The ward been open only a matter of some two weeks by the time Mrs Reed was transferred to that ward. Despite being medically fit for discharge upon arrival on that ward Mrs Reed’s condition worsened and family raised concerns as best they could but they reported that the ward was chaotic and that staff would tell them they had only just found out they were working on the ward before their shift started and there was no consistency of nursing staff on the ward. Mrs Reed was dehydrated and family report that there was a paucity of personal care afforded on that ward. There was a risk of cross infection as patients’ personal effects such as toiletries were not with the right patients and had to be located by family. There was no established cohort of permanent staff on the ward at that time and no signposting to the ward sister or matron and therefore no way of patients, their friends, or their families being able to have a clear escalation pathway to ventilate concerns. Although HUTH now have an established team and leadership chain on Ward H130 there is a real concern that wards opened in response to winter pressures in the future in any busy hospital may give rise to the same peripatetic staffing regime, that is to say, agency staff and no fixed team in place and a lack of visible leadership. This could lead to the deterioration of patients not being recognised if there is no continuity of care by the same team of nursing staff. ”

    Source location

    Ethel Doreen Reed · 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

    Establish permanent ward teams and leadership, with daily Ward Sister presence and clear escalation signposting.

    Verbatim wording from the response

    “The Trust can confirm that there is now a very well established team on the 13th floor, including leadership, nursing and medical teams. The Ward Sisters are present on the wards on a daily basis with clear signposting for patients, relatives and carers if they need it. The Ward Sisters have set up ‘relative clinics’, which provides dedicated time for patients or relatives to meet the Ward Sisters to ask questions, seek advice or raise concerns. The wards promote patient feedback via Friends and Family Test (FFT) and displays feedback, results and actions taken by the areas. The wards also have volunteer presence, activity champions and visits from the therapy dogs.”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 3 · response
    Published 21 February 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

    Provide Ward Sister relative clinics for patients, relatives and carers to raise questions or concerns.

    Verbatim wording from the response

    “The Trust can confirm that there is now a very well established team on the 13th floor, including leadership, nursing and medical teams. The Ward Sisters are present on the wards on a daily basis with clear signposting for patients, relatives and carers if they need it. The Ward Sisters have set up ‘relative clinics’, which provides dedicated time for patients or relatives to meet the Ward Sisters to ask questions, seek advice or raise concerns. The wards promote patient feedback via Friends and Family Test (FFT) and displays feedback, results and actions taken by the areas. The wards also have volunteer presence, activity champions and visits from the therapy dogs.”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 3 · response
    Published 21 February 2024

    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

    Established H130 staffing, leadership, escalation arrangements and a planned methodology are considered sufficient to safely open additional winter capacity.

    Verbatim wording from the response

    “The Trust can confirm that there is now a very well established team on the 13th floor, including leadership, nursing and medical teams. The Ward Sisters are present on the wards on a daily basis with clear signposting for patients, relatives and carers if they need it. The Ward Sisters have set up ‘relative clinics’, which provides dedicated time for patients or relatives to meet the Ward Sisters to ask questions, seek advice or raise concerns. The wards promote patient feedback via Friends and Family Test (FFT) and displays feedback, results and actions taken by the areas. The wards also have volunteer presence, activity champions and visits from the therapy dogs.”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 3 · response
    Published 21 February 2024

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Chelsea Blue Louise Mooney · 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

    Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.

    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 clear CPR leadership and task structure

    Wider context from the report

    “8. Whilst in evidence I have heard about the practice exercises using the 'Red Bag' it is clear that there was limited confidence and clarity around the CPR needed for Chelsea. There was not a clear structure of one person leading and others knowing exactly what and how to do tasks. ”

    Source location

    Chelsea Blue Louise Mooney · Prevention of Future Deaths report
    Page 4 · 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

    Provide monthly unannounced resuscitation drills, assess response times, record responders and retrain staff where issues are identified.

    Verbatim wording from the response

    “70. In addition the Hospital has a schedule of resuscitation drills that are carried out monthly at an unannounced time and part of the drill includes staff response times. The resuscitation drills are completed by the Resuscitation Lead for Cygnet Hospital Sheffield and the local Quality Manager. The resuscitation drills are assessed and a compliance percentage is generated. The Staff members’ names that respond are also logged. If there is an identified issue raised regarding a specific staff member or any practice then they are put on the next BLS or ILS course as a refresher. The resuscitation lead is also a BLS trainer which allows for quick turnaround of training and also allows for in depth discussion and analysis following the drills.”

    Source location

    Response from Cygnet Health Care
    Page 17 · response
    Published 3 October 2022

    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 nurse drop-in sessions with the ILS lead, including practical refresher training on emergency equipment.

    Verbatim wording from the response

    “71. The resuscitation lead has also been nominated to complete the ILS train the trainer course which allows her to then teach the ILS course. This is currently completed by an external trainer.”

    Source location

    Response from Cygnet Health Care
    Page 17 · response
    Published 3 October 2022

    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 ILS train-the-trainer qualification for the resuscitation lead.

    Verbatim wording from the response

    “71. The resuscitation lead has also been nominated to complete the ILS train the trainer course which allows her to then teach the ILS course. This is currently completed by an external trainer.”

    Source location

    Response from Cygnet Health Care
    Page 17 · response
    Published 3 October 2022

    Open published response

  3. Norfolk

    AI-generated summary

    Tracy Dawn WOOD · 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

    Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.

    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 clinical or management leadership supervision on the ward

    Wider context from the report

    “16. The first draft of the PSII Report contains a sentence “However, staff noted there was a lack of clinical or management leadership supervision on the ward at the time and they were often left to “firefight” with patients who they perceived carried a greater level of acute risk than Tracy.” This view of staff was not included in the final draft Report ”

    Source location

    Tracy Dawn WOOD · 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

    Maintain a permanent Consultant Psychiatrist and increase senior nursing capacity through Deputy Lead Nurse, Matron and Clinical Nurse Specialist appointments.

    Verbatim wording from the response

    “At the time of Tracy’s stay on this ward the ward did not have a permanent Consultant Psychiatrist, this has since changed and a permanent medic is in situ, this appointment supports the multi-disciplinary team in providing consistency which in turn brings stability to the ward environment. Equally the senior nursing presence has been increased with the recruitment of a Deputy Lead Nurse to support the Lead Nurse and enhancing the Matron and Clinical Nurse Specialist cohort across the hospital site.”

    Source location

    Response from Hellesdon Hospital
    Page 1 · response
    Published 26 April 2022

    Open published response

  4. West Yorkshire Eastern

    AI-generated summary

    Neil Peter Bastock · 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

    Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

    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

    Absence of ward management leadership for care provision

    Wider context from the report

    “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system. ”

    Source location

    Neil Peter Bastock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The ward was not without a ward manager; leadership continuity was maintained through handover and support from the outgoing manager.

    Verbatim wording from the response

    “2. Mr Bastock’s treatment in the Newsam Centre lacked continuity. The responsible clinician was a locum who had recently taken over from another locum psychiatrist. There was no ward manager on the ward to provide leadership for the care being provided. There was no psychologist on the ward to contribute to care planning. The nursing records were incomplete, possibly due to teething problems associated with the recently introduced electronic recording system.”

    Source location

    2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 4 November 2021

    Open published response

  5. Norfolk

    AI-generated summary

    Ifeoma Onwuka · Prevention of Future Deaths report

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

    Report summary

    Mrs Onwuka was admitted for induction of labour and developed severe bleeding and disseminated intravascular coagulopathy after delivering her baby. She underwent a hysterectomy after a delay, and an expert concluded that the delay in surgery to control the bleeding contributed to her death. The principal concerns were apparent lack of confidence in performing emergency hysterectomy, inadequate investigation of the cause of the coagulopathy, and lack of leadership and overview of her care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of clinical leadership and oversight of care

    Wider context from the report

    “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present. 2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this. 3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present. That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team. ”

    Source location

    Ifeoma Onwuka · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of ability to work in or lead a clinical team

    Wider context from the report

    “1. Apparent lack of confidence/ability on part of on-call consultant to perform an emergency total abdominal hysterectomy without another consultant present. 2. Lack of professional curiosity about cause of DIC, the haemorrhage was not enough to cause this. 3. Lack of leadership and overview of Mrs Onwuka’s care. Reluctance on the part of the on-call consultant to consider anything other than conservative measures until another obstetric consultant was present. That pregnant women in the area served by this hospital may be at risk if emergency surgery is needed and this consultant has these apparent difficulties, continues with an apparent lack of professional curiosity and displays no evidence of the ability to work in a team or head a team. ”

    Source location

    Ifeoma Onwuka · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Brighton and Hove

    AI-generated summary

    Bethany Tengquist · 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

    Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.

    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 ward management and matron leadership

    Wider context from the report

    “5. Staffing levels. It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time, in conjunction with a 50% reduction of substantive staff. There was a reliance on bank and agency staff, and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk of future deaths. ”

    Source location

    Bethany Tengquist · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  7. South Wales Central

    AI-generated summary

    Calary Fern Davis · 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

    Calary Fern Davis was delivered by emergency Caesarean Section on 31st December 2017 after fetal bradycardia caused hypoxic ischaemic encephalopathy and very serious brain damage, and she later died from that condition. The report identified concerns about failures in the induction pathway, including a lack of planned obstetric review, delay in artificial rupture of membranes, insufficient staffing and leadership, poor communication and safety briefings, and a culture against performing artificial rupture of membranes at night.

    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 band 7 midwife and obstetric team leadership

    Wider context from the report

    “(9) There was a lack of band 7 midwife and obstetric team leadership. ”

    Source location

    Calary Fern Davis · 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

    Undertake two leadership study days to improve clinical leadership and team working within the department.

    Verbatim wording from the response

    “8. There was a lack of Band 7 Midwife and Obstetric Team leadership. The Organisational Development Action Plan and two planned leadership study days in June and July 2019 are being undertaken to improve clinical leadership and team working within the department. The Organisational Development Plan will focus on multidisciplinary team working and clinical leadership. Our mandatory training includes communication, documentation and escalation as part of the yearly updates.”

    Source location

    2019-0043-Response-by-University-Health-Board
    Page 3 · response
    Published 24 May 2019

    Open published response

  8. Southampton and New Forest

    AI-generated summary

    Owen Richard Widlake · 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

    Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.

    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 nursing staff empowerment and leadership

    Wider context from the report

    “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU. (1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift. (1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff. 2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph. 3) The nursing staff do not appear able to escalate concerns either i) due to lack of clear care plans and escalation markers ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN ii) a lack of empowerment indicating a lack of leadership. 4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves. 5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this. 6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm. 7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover. ”

    Source location

    Owen Richard Widlake · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Liverpool and the Wirral

    AI-generated summary

    Linsay Bushell · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of senior clinical challenge and guidance in ward management

    Wider context from the report

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

    Source location

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

    Open source report

  10. Manchester City

    AI-generated summary

    Mrs Kathleen Cooper · Prevention of Future Deaths report

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

    Report summary

    Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Poor ward-level leadership and supervision of nurses

    Wider context from the report

    “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026