7 Apr 2026 Mark Robert Smith · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to ensure truthful observation records View source
This report raised 8 other concerns. 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
Mark Robert Smith · 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 Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure truthful observation records
Wider context from the report “(5) I am concerned there were numerous missed and falsified observation entries in Mark’s case and how similar incidents can be prevented given the reliance on handwritten sheets being scanned onto the system at a later stage . I appreciate the efforts made with training and audits. (Practice Plus Group)
” Source location Mark Robert Smith · Prevention of Future Deaths report
Open source report
8 Feb 2026 Elise Kay Louise Sebastian · Prevention of Future Deaths report Essex
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Concerns raised 2
Falsification of patient observation records View source Falsification of observation logs View source
This report raised 29 other concerns. 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
Elise Kay Louise Sebastian · 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
Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.
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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 Falsification of patient observation records
Wider context from the report “4. Mental Health Trust staff falsified Elise’s observation records and this was not identified by the Trust post-death investigation despite the availability of timings from Oxevision imaging. This matter arose in an inquest that significantly post-dated Elise’s death and there is concern that lessons had not been learned. The Trust internal investigation does not refer to this and these matters are arising with scrutiny within the inquest hearing.
” Source location Elise Kay Louise Sebastian · 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 Falsification of observation logs
Wider context from the report “7. Oxevision imaging showed Elise entering her bedroom alone at approximately 18:10 hours and she remained in her room until she was found unresponsive at approximately 18:29. Elise’s observation logs for 17:30-18:30 on 17 April were falsified recording that Elise was in the communal area with checks completed at 17:30 17:40 17:50 18:00 18:10 and 18:20 recorded that Elise was present in the communal area. Elise was required to be on constant eyesight observations whilst in her bedroom.
” Source location Elise Kay Louise Sebastian · Prevention of Future Deaths report
Open source report
18 Jul 2024 Anna Vivien Elliott · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Falsification of safe and supportive observation records View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East London 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. 7
East London NHS Foundation Trust
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
View source
East London NHS Foundation Trust
Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
View source
East London NHS Foundation Trust
Deliver face-to-face Honesty in Documentation training across inpatient services.
View source
East London NHS Foundation Trust
Continue work promoting honesty in documentation.
View source
East London NHS Foundation Trust
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
View source
East London NHS Foundation Trust
Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
View source
East London NHS Foundation Trust
Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
View source See 4 more actions
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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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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Falsification of safe and supportive observation records
Wider context from the report “Concern 4
In Anna’s case, observation records were backfilled despite the observations not having been conducted . All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done ”. As the spot checks described to me only look at the quality and timings of the written observations, I am not reassured that records are not still being falsified or about how this is being identified and addressed.
” Source location Anna Vivien Elliott · 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 Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Verbatim wording from the response “19. The Trust is currently developing a new E-observations (e-obs) platform which has in-built prompts to ensure staff capture the location of a patient, what they observe and their interactions with a patient. Daily spot checks will be undertaken by the clinical nurse manager or the most senior nurse on shift out of hours. It is hoped that this will be in place in the coming six months.” Source location Response from ELFT
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 Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
Verbatim wording from the response “The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.” Source location Response from ELFT
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 Deliver face-to-face Honesty in Documentation training across inpatient services.
Verbatim wording from the response “Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.” Source location Response from ELFT
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 Continue work promoting honesty in documentation.
Verbatim wording from the response “Continued work on honesty in documentation.” Source location Response from ELFT
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 Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Verbatim wording from the response “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.” Source location Response from ELFT
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 Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
Verbatim wording from the response “Communication
To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.” Source location Response from ELFT
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 Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
Verbatim wording from the response “Standardised processes
To develop a consistent approach to supporting staff to learn from their observations practice through reflection, personal accountability and if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.” Source location Response from ELFT
Open published response
10 Jul 2024 Mahamoud Hussain Ali · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to accurately record required observations View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
East London 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. 14
East London NHS Foundation Trust
Implement the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
View source
East London NHS Foundation Trust
Develop and deliver Honesty in Documentation training face to face across all inpatient services.
View source
East London NHS Foundation Trust
Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
View source
East London NHS Foundation Trust
Implement observation board relay to reduce missed observations and improve handover between staff.
View source
East London NHS Foundation Trust
Test and pilot a Microsoft PowerApps application for documenting observations before planned inpatient-wide scaling.
View source
East London NHS Foundation Trust
Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
View source
East London NHS Foundation Trust
Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
View source
East London NHS Foundation Trust
Conduct senior-staff night visits with spot-check audits and observation of practice.
View source
East London NHS Foundation Trust
Continue work on honesty in documentation.
View source
East London NHS Foundation Trust
Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
View source
East London NHS Foundation Trust
Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
View source
East London NHS Foundation Trust
Continue Trust-wide communications discouraging falsification, encouraging honest reporting and clarifying missed-observation reporting requirements.
View source
East London NHS Foundation Trust
Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
View source
East London NHS Foundation Trust
Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
View source See 11 more actions
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AI-generated summary
Mahamoud Hussain Ali · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mahamoud Hussain Ali fell twice in the street on 19 August 2020 and was later detained under the Mental Health Act and transferred to Lea Ward. On 21 August 2020 he was found unresponsive and died in hospital on 26 August 2020. The principal concern was that required 15-minute observations were not conducted or were falsely recorded, and that subsequent Trust action had not been sufficient to ensure observations were conducted and recorded as required.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to accurately record required observations
Wider context from the report “(1) Although Mr Ali was meant to be under 15-minute observations, a registered mental health nurse on Lea Ward gave evidence that on 21 August 2020 at around 1740 she saw that the observations board had not been completed for 1700, 1715 and 1730. She then completed it as if she had conducted those observations, recording that Mr Ali was asleep.
East London NHS Foundation Trust (the Trust) has acknowledged that the deliberate falsification of observation records is not acceptable .
Evidence has been provided by the Trust that since Mr Ali’s death on 26 August 2020, there have been 11 fatal incidents where observation records may have been filled in when observations have not been conducted . One of these, in May 2023, was in Lea Ward, the same ward where Mr Ali was detained.
Whilst the date and name of the hospital and/or ward connected with each of these deaths have been provided to me, evidence has not been given by the Trust as to the specific circumstances of each death, nor the subsequent individual investigation and findings and any consequential action taken. Nor has this issue been addressed in the Trust’s Action Plan as part of its internal investigation.
The Trust has stated that the majority of the 11 deaths pre-date the work that it has been doing to improve practice around observations that has been progressing since Autumn 2022.
I have been provided with evidence that in October 2023, the Trust wrote to staff about ‘Falsification of Observation Records’, stating: “We commenced a Trust wide QI project in September 2022 in response to prevention of future death (PFDs) notices from the coroners. The PFDs highlighted concerns about the quality and consistency of engagement and observation practice. This work has engaged all Directorate’s in enhancing our appreciation and understanding of the importance and impact of therapeutic engagement and observation. Directorates have been doing work using QI methodology to look at how we can improve standards to ensure consistency and quality in undertaking these…”
Further, that “Despite this work, we have seen an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done. ”
Given the above, I am concerned that action undertaken thus far by the Trust has not been sufficient to ensure that observations are being conducted and/or recorded as required which in my opinion gives rise to a concern that future deaths will occur.
” Source location Mahamoud Hussain Ali · Prevention of Future Deaths report
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 the live Inpatient Safety Suite as essential training for inpatient nursing staff, including observation and honesty-in-documentation training, with compliance oversight.
Verbatim wording from the response “Staff competency | The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.” Source location Response from ELFT
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 Develop and deliver Honesty in Documentation training face to face across all inpatient services.
Verbatim wording from the response “Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.” Source location Response from ELFT
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 Facilitate weekly directorate safety discussions for inpatient staff to review observation data, identify practice gaps and disseminate learning.
Verbatim wording from the response “Safety discussion sessions are facilitated weekly in directorates for all inpatient staff to review observation data, reflect on gaps in practice and disseminate learning.” Source location Response from ELFT
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 Implement observation board relay to reduce missed observations and improve handover between staff.
Verbatim wording from the response “Quality improvement | A Trust-wide Quality Improvement programme which involved all 54 wards, their staff teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:” Source location Response from ELFT
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 Test and pilot a Microsoft PowerApps application for documenting observations before planned inpatient-wide scaling.
Verbatim wording from the response “A digital application to document observations (using Microsoft PowerApps) has been developed and is in the testing phase. It is planned that this will be piloted from October 2024 on four wards and then scaled across all inpatient units.” Source location Response from ELFT
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 Communicate and regularly update staff on accountability, accurate observation records, honesty and procedures for missed observations.
Verbatim wording from the response “Standards of professional practice | Expected standards of practice have been communicated to staff, with frequent updates on improvement work since 2021 to date. In 2023, this specifically addressed accountability and responsibility for accurately documenting observations. It included the importance of honesty in documentation and gave guidelines for staff to follow for occasions when observations were missed. The Trust-wide Quality Improvement programme described above has introduced the observation relay board to reduce incidents of observations being left or not handed over.” Source location Response from ELFT
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 Use the Standard Observation Measurement tool to oversee observation completion and support ward and directorate improvement.
Verbatim wording from the response “Audit and monitoring
The Standard Observation Measurement (SOM) Tool was developed for oversight of rates of completion of all observations. Individual ward teams and directorates can access and use their data to drive continued improvement.” Source location Response from ELFT
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 Conduct senior-staff night visits with spot-check audits and observation of practice.
Verbatim wording from the response “Night visits are undertaken by senior staff in directorates to monitor practice through spot check audits and observing work as it happens.” Source location Response from ELFT
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 Continue work on honesty in documentation.
Verbatim wording from the response “Continued work on honesty in documentation.” Source location Response from ELFT
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 Explore non-CCTV assurance tools for detecting falsified observations and review relevant national improvement workstreams.
Verbatim wording from the response “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.” Source location Response from ELFT
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete external Human Factors and Patient Safety analysis of inpatient observation practice to identify redesign opportunities.
Verbatim wording from the response “Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed,” Source location Response from ELFT
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 Continue Trust-wide communications discouraging falsification, encouraging honest reporting and clarifying missed-observation reporting requirements.
Verbatim wording from the response “Communication
To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.” Source location Response from ELFT
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design internal governance for reviewing missed-observation cases and learning, with reporting to Patient Safety and Quality Assurance committees.
Verbatim wording from the response “To design an internal governance process for the review of reported cases of missed observations and learning that arises from this, that will report into the Patient Safety and Quality Assurance committees.” Source location Response from ELFT
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 Develop a consistent process for staff learning from poor observation practice through reflection, accountability and regulatory referral where indicated, alongside disciplinary procedures.
Verbatim wording from the response “Standardised processes
To develop a consistent approach to supporting staff to learn from incidents involving poor observations practice through reflection, personal accountability and, if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.” Source location Response from ELFT
Open published response
19 Jul 2022 Beryl Simcock · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 1
Falsification of records to indicate completed care plan and risk assessment reviews View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Beryl Simcock · 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
Beryl Simcock, who lived in a care home because of dementia, suffered several falls, including a fall on 10 June 2021 that caused an impacted fractured neck of femur and led to a severe deterioration in her health. The concerns included inadequate care-plan and risk-assessment reviews, potentially inaccurate records, insufficient oversight, and inadequate information for her family when she was deprived of her liberty.
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 Falsification of records to indicate completed care plan and risk assessment reviews
Wider context from the report “I was concerned about the lack of written policies for care planning and review. I was concerned that reviews of care plans and risk assessments were either not done (and the records falsified to suggest that they were ) or that they were done by someone unsuited to the task. This was not identified despite audit activity during the relevant period.
I was also concerned that at times when Mrs Simcock was deprived of her liberty the care home did not ensure that her family were given adequate and timely information to enable them to provide independent scrutiny of the care and restrictions in place.
” Source location Beryl Simcock · 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 Evaluate shortlisted digital care planning systems to improve linked risk assessment, trend analysis and point-of-care record keeping.
Verbatim wording from the response “A summary of the report is attached. (The full report contains details of the care plans of a number of residents from which they could be identified.) The main thrust of the report is that the paper-based care plan system currently used by the Home makes the identification of risk and progression to mitigation difficult, and this has not been helped by the fact that risk assessment procedures have been adapted from various sources. The two major recommendations of the report are:” Source location Response from Radcliffe Manor House
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 Fully implement the selected digital care planning system for all residents.
Verbatim wording from the response “• In order to improve care planning and record keeping, the Home should introduce a digital care planning system which will enable the linking of care plans to risk assessments; this digital system should also be capable of providing good quality trend analysis and facilitating point-of-care-delivery record keeping.” Source location Response from Radcliffe Manor House
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 Improve management oversight of care plan documentation.
Verbatim wording from the response “Where the home is now
The original safeguarding was taken very seriously by the trustees and management team, and several initiatives (with the active involvement of the CQC and the GP) were immediately implemented to improve safety. These included:” Source location Response from Swift Management services
Open published response
30 Apr 2021 Rohan Dayal Singh · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to maintain accurate records of clinical observations View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Rohan Dayal Singh · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain accurate records of clinical observations
Wider context from the report “2. Mr Singh was subject to intermittent observations at 15 minute intervals during his admission. The records of these observations were found to be unreliable , staff accepted that they had failed to undertake observations and made false records , further they had done so in such circumstances that their peers were aware of the falsehood. A culture of impunity existed where inaccurate and misleading recording of clinical records was tolerated.
” Source location Rohan Dayal Singh · Prevention of Future Deaths report
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 Provide medical-record-keeping training to Borough Lead Nurses and cascade the learning to staff during induction and away days.
Verbatim wording from the response “Two half day training sessions will be provided to the Borough Lead Nurses on medical record keeping by the Trust’s external solicitors within the next 6 months. The training will focus on the legal standard expected for documenting medical practice (especially in relation to observations) and will ensure staff understand when retrospective entries are and are not appropriate and what comprises a misleading record.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
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 Develop and roll out an electronic observations system enabling real-time recording of patient observations in RIO.
Verbatim wording from the response “The Trust is developing an e-observation (e-obs) recording system to replace the current paper-based system. The intention is that, staff will carry an iPad with direct links to RIO so they can enter patient records in real time. It is expected that this will improve the timeliness and accuracy of observations. A full project plan will be completed by the end of July with anticipated roll out throughout each hospital site from early Autumn 2021.” Source location 2021-0134-Response-from-East-London-NHS-Foundation-Trust_Published
Open published response
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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 Professional concerns about nurses’ conduct and registration are for the NMC to investigate and sanction.
Verbatim wording from the response “The Nursing and Midwifery Council (NMC) have informed the Department it will be providing a separate response to you in relation to this case. The NMC code of practice² sets out the professional standards that nurses, midwives and nursing associates must uphold in order to be registered to practise in the UK.” Source location 2021-0134-Response-from-Department-of-Health-Social-Care_Published
Open published response
Concerns raised 1
Falsification of pressure sore repositioning records View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Janine Eugenie Pierrette KAISER · 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
Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing 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 Falsification of pressure sore repositioning records
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” Source location Janine Eugenie Pierrette KAISER · 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 Share investigation learning with New Park House and recommend improvements to recording practices.
Verbatim wording from the response “Some turns had been missed but Mrs Kaiser was known to regularly refuse to comply with the turn regime in place. It was acknowledged that such refusals were not always documented and the home took this away as a recommendation from the investigation for further work with the staff.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
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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 investigation found no evidence that the pressure-sore management plan was inadequately followed or that records had been falsified.
Verbatim wording from the response “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
5 Mar 2014 Neil James Carter · Prevention of Future Deaths report London (West)
View report summary
Concerns raised 1
Deliberate falsification of nursing records View source
This report raised 5 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
Care Quality Commission
Use information about alleged nursing-record falsification to inform planning and delivery of the next inspection.
View source
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AI-generated summary
Neil James Carter · 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 James Carter took his own life on 20 November 2012 by jumping in front of a train while he was an inpatient at Priory Hospital Roehampton. The report identified repeated failures to perform basic nursing observations, inadequate staffing and skill mix, poor ward layout and discipline, management failures, and deliberate falsification of the nursing record. The inquest concluded that these failures led to missed opportunities to realise he was missing, search for him early, and offer life-saving interventions.
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 Deliberate falsification of nursing records
Wider context from the report “(3) There was a deliberate falsification of the nursing record .
” Source location Neil James Carter · 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 Use information about alleged nursing-record falsification to inform planning and delivery of the next inspection.
Verbatim wording from the response “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.” Source location 2014-0103-Response-by-Care-Quality-Commission
Open published response
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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 No evidence of deliberate nursing-record falsification was identified during inspections.
Verbatim wording from the response “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.” Source location 2014-0103-Response-by-Care-Quality-Commission
Open published response
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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 Deliberate record falsification is difficult to identify through routine monitoring or inspections unless reported by staff, patients or relatives.
Verbatim wording from the response “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.” Source location 2014-0103-Response-by-Care-Quality-Commission
Open published response
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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 Alleged deliberate record falsification may require referral to the relevant professional regulatory body, such as the NMC or GMC.
Verbatim wording from the response “The Commission would also respectfully suggest that if it has not been done so already this may be a matter which would require referral to the relevant professional regulatory body, whether NMC, GMC or otherwise.” Source location 2014-0103-Response-by-Care-Quality-Commission
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.