Concerns raised 1
Failure to identify and communicate the commissioning service responsible for a resident View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
John Graham ALSTON · 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
Mr Alston, a 70-year-old man with dementia living in a specialist care home, was punched by another resident on 2 November 2022, suffered an unsurvivable brain bleed, and died in a hospice on 8 November 2022. The concerns relate to confusion over which commissioning body was responsible for the other resident, delays in finding a safer placement, and difficulties sharing discharge information; the report warns that similar delays could contribute to future deaths.
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 identify and communicate the commissioning service responsible for a resident
Wider context from the report “1. ████████ had been moved to the Lancashire ICB commissioning area by a Bolton (Greater Manchester) commissioning service due to the existence of care home with a place for him (care home one). His placement at that care home broke down and he was taken to the local accident and emergency department. ████████ remained in hospital for some time and was then discharged to care home two where the circumstances resulted in Mr Alston's death occurred.
It was quickly apparent that care home two could not meet ████████ needs and this was escalated to the Lancashire ICB. However the care home had first been directed to the Bolton (Greater Manchester) authorities by the local hospital. There was confusion as to which ICB was the commissioning body. This resulted in work being carried out by Lancashire ICB which ought to have been completed by the Bolton (Greater Manchester) ICB and a delay in commencing a search for an alternative and safe placement for ████████.
There were also difficulties in sharing information for discharge processes because it was unclear which area or from where ████████ had come.
This inquest concluded that due to the complexity of ████████ presentation, the delays due to confusion about ICB identification did not contribute to Mr Alston's death occurring at the time at which it did. However, I am concerned that there may be other cases where inaccurate or unknown information about which commissioning service is responsible for a resident can result in delays to accessing increased funding for support, services or more suitable placements.
I am concerned that these delays may result in future deaths and that a clearer system is necessary to identify at an early stage and appropriately communicate that to a home who accepts a resident.
I am concerned that determination of funding ICB arises on a reactive basis when additional care or changes are required and thus the time taken to resolve the issue causes necessary care or changes when proactive determination of the issue before problems arise ought to be possible.
” Source location John Graham ALSTON · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Information-sharing difficulties and clearer communication of commissioning responsibility should be addressed and implemented by the involved ICBs, rather than NHS England.
Verbatim wording from the response “The concerns raised in your Report around the difficulties in information sharing and the delays in identifying the responsible ICB would be best addressed by the ICBs involved, rather than NHS England. In particular, it would be for the ICBs to comment upon how they could implement a clearer system to appropriately communicate the position around commissioning responsibility to care homes, where a new resident has moved areas.” Source location Response from NHS England
Open published response
7 Nov 2025 Ernest Roy Gray · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 2
Failure to provide carers with guidance on recognising and responding to delirium symptoms View source Failure to communicate relevant delirium risks and behavioural history to carers View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East Kent Hospitals University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
East Kent Hospitals University NHS Foundation Trust
Review and make the Delirium leaflet accessible on the Trust intranet.
View source
East Kent Hospitals University NHS Foundation Trust
Share the Delirium leaflet with families and carers at discharge.
View source
East Kent Hospitals University NHS Foundation Trust
Request and develop IT record changes to distinguish carers from next of kin.
View source
East Kent Hospitals University NHS Foundation Trust
Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.
View source See 1 more action
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AI-generated summary
Ernest Roy Gray · 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
Ernest Roy Gray was admitted to hospital after a myocardial infarction and developed hyperactive delirium and heart failure, with episodes of agitation and aggression. He was discharged home while still confused and later became unwell, was admitted to hospital, developed pneumonia, and died on 24 November 2023. Concerns included failure to involve his partner in discharge planning, inadequate holistic discharge planning and communication, and insufficient information about the possible fluctuating and aggressive manifestations of his delirium and what to do if symptoms occurred.
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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 provide carers with guidance on recognising and responding to delirium symptoms
Wider context from the report “(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital, nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction. Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic . Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged
” Source location Ernest Roy Gray · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to communicate relevant delirium risks and behavioural history to carers
Wider context from the report “(3) Mr. Gray’s daughter was informed two days before the discharge that he had hyperactive delirium and that it would resolve itself but could take a few weeks. She was not made aware that Mr. Gray had at times been agitated and violent in hospital , nor was she told that although the hyperactive delirium was resolving it could fluctuate because it was likely triggered by a metabolic cause (renal function), heart failure or myocardial infarction . Neither she nor Mr. Gray’s partner were informed as to how symptoms may manifest or what to do if Mr. Gray was symptomatic. Had they known that Mr. Gray may become aggressive or violent to others particularly his carers, an early discharge would not have been encouraged
” Source location Ernest Roy Gray · 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 Review and make the Delirium leaflet accessible on the Trust intranet.
Verbatim wording from the response “1. Review of the existing Delirium leaflet will be shared as appropriate on patient discharge. This leaflet has been reviewed and is easily accessible on the Trust intranet. A hard copy will be handed out to families/carers for information.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Delirium leaflet with families and carers at discharge.
Verbatim wording from the response “1. Review of the existing Delirium leaflet will be shared as appropriate on patient discharge. This leaflet has been reviewed and is easily accessible on the Trust intranet. A hard copy will be handed out to families/carers for information.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request and develop IT record changes to distinguish carers from next of kin.
Verbatim wording from the response “1. We have requested IT record changes to correctly identify the carer(s) involved so they can be involved in appropriate discussions and decisions. Our current IT systems do not allow us to differentiate ‘carer’ from ‘next of kin’ (they can be different as was the case with Mr Gray). We recognise that this will be key in clearly identifying the carer for future discharge conversations so we have raised this urgently with the Sunrise team to investigate. The request has been made and is being prioritised.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish and operate a Carer Champion post supporting carer identification and involvement in discharge discussions.
Verbatim wording from the response “3. We have allocated an experienced discharge advisor to a new Carer’s Champion post. This individual has been identified, and they commenced their role in early January. They will support the ward multi-disciplinary teams to identify the patient’s carer and ensure that the carer themselves is involved in the discharge discussions from early in the admission.” Source location Response from East Kent Hospitals University NHS Foundation Trust
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 patient’s subsequent aggression was not predicted because there was no previous evidence of aggression.
Verbatim wording from the response “While a therapy assessment appointment had been arranged to attend Mr Gray’s home following discharge, this unfortunately did not take place in time to prevent the tragic death of his partner. It is a common occurrence that patients are discharged with ongoing confusion, and it is recognised that this will often be eased, by being in familiar surroundings. There had been no previous evidence of any aggression in Mr Gray, and the tragic events that followed were absolutely not predicted.” Source location Response from East Kent Hospitals University NHS Foundation Trust
Open published response
20 Dec 2024 Edith Theresa PYE · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2
Failure to report and stop repeated breaches of required care arrangements View source Failure of handover documents to communicate required personal-care staffing arrangements 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. 5
Care UK
Remind current Chandler Court colleagues of their duty and available mechanisms for reporting safeguarding and other concerns.
View source
Care UK
Complete individual moving-and-handling supervision in which senior staff observe junior colleagues’ compliance with care plans and policies.
View source
Care UK
Introduce key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
View source
Care UK
Review handover templates so they highlight key aspects of each resident’s care needs.
View source
Care UK
Review handover sheets weekly and update them when residents’ care needs change, under management supervision.
View source See 2 more actions
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AI-generated summary
Edith Theresa PYE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Edith Theresa PYE sustained a fracture after rolling from her bed at Chandler Court Care Home on 29 March 2024 while receiving personal care from one carer instead of the required two. She underwent an above-knee amputation, developed a chest infection and pulmonary emboli, and died at the care home on 28 April 2024. Concerns included ambiguous care-plan and handover information, inadequate staff awareness and compliance, lack of auditing, and weaknesses in the internal investigation.
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 report and stop repeated breaches of required care arrangements
Wider context from the report “2) The carer who provided personal care to Mrs. Pye on the occasion when she fell from her bed on 29.3.24 knew that he should have done so with a colleague, but would regularly do so on his own. He had never himself read Mrs. Pye’s care plan, and it became clear that two other members of staff who provided evidence at the inquest were also unaware of some key aspects of the care plan. Furthermore, other staff were aware that he would often provide care to Mrs. Pye on his own, but no-one had reported this to senior staff or taken any action to try to stop it happening ;
” Source location Edith Theresa PYE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of handover documents to communicate required personal-care staffing arrangements
Wider context from the report “3) At the inquest, I was shown a handover document which had been drafted by the home’s Deputy Manager, and was told that a nurse in charge would have gone through this document with all carers at the beginning of the relevant shift. The document was meant to highlight each resident’s care needs, based on their respective care plans. It did not make clear that Mrs. Pye required two carers for the provision of personal care, or that at least one of those carers should be female ;
” Source location Edith Theresa PYE · Prevention of Future Deaths report
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 Remind current Chandler Court colleagues of their duty and available mechanisms for reporting safeguarding and other concerns.
Verbatim wording from the response “Since this incident, there have been changes in personnel at Chandler Court, and current colleagues have been reminded of their duty to report concerns and the mechanisms available to progress any such concerns.” Source location 2024-0706 - Response from Care UK Ltd
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 Complete individual moving-and-handling supervision in which senior staff observe junior colleagues’ compliance with care plans and policies.
Verbatim wording from the response “Additionally, individual supervision has been completed for moving and handling whereby senior members of the care team observe junior colleagues to ensure correct compliance with Care Plans and policies. Refresher training on moving and positioning has also been carried out. This training is currently at 90% compliant and is expected to be 100% compliant by close of business tomorrow; 14 February 2025. This refresher training will further assist colleagues with understanding the importance of following individual care plans and reporting bad practices, or any other concerns that may pose a risk to a resident or colleague as per Care UK policy.” Source location 2024-0706 - Response from Care UK Ltd
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
Verbatim wording from the response “Additionally, Chandler Court now involves key workers who, along with the shift leads, are responsible for having a sound knowledge of the residents’ care needs and disseminating key information to their teams.” Source location 2024-0706 - Response from Care UK Ltd
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review handover templates so they highlight key aspects of each resident’s care needs.
Verbatim wording from the response “Care UK has reviewed our handover templates to ensure that they highlight the key aspects of each resident’s care needs.” Source location 2024-0706 - Response from Care UK Ltd
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review handover sheets weekly and update them when residents’ care needs change, under management supervision.
Verbatim wording from the response “At Chandler Court, handover sheets are now reviewed by the Deputy Manager at the weekly clinical review meetings to ensure accuracy. In addition, any changes to a resident’s care needs are reported during the daily morning meetings and the person in charge of the suite, which would either be the Team Leader and/or Registered Nurse, is directed to complete the relevant update under the supervision of either the Deputy Manager or the Home Manager.” Source location 2024-0706 - Response from Care UK Ltd
Open published response
3 Oct 2024 Mrs Gabrielle Sarah Anne Steel · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to convey home fire safety findings to responsible carers View source
This report raised 3 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. 4
London Fire Brigade
Review information-sharing processes, the data-protection impact assessment and third-party disclosure arrangements, consulting information-management specialists and the Information Commissioner.
View source
London Fire Brigade
Review Home Fire Safety Visit booking questions to identify in-home care and recommend that carers attend visits.
View source
London Fire Brigade
Scope options for leaving bespoke fire-safety information with residents, family members or carers, engaging other fire services to identify best practice.
View source
London Fire Brigade
Update Home Fire Safety Visit policy, guidance and staff training where necessary following the process review.
View source See 1 more action
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AI-generated summary
Mrs Gabrielle Sarah Anne Steel · 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 Gabrielle Sarah Anne Steel, who was bed bound and known to smoke in bed and drink alcohol, died after a fire on her bed at her home on 17 October 2023. The fire investigation identified the likely cause as unsafe disposal of smoking materials, and the flame-retardant duvet cover was not on the bed. The principal concerns were poor communication of the fire safety assessment and the absence of a shared written fire risk management plan for those caring for her.
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 convey home fire safety findings to responsible carers
Wider context from the report “1. The risk of fire, due to smoking in bed was recognised by a local authority occupational therapist. A request was made to the London Fire Brigade for a home fire safety visit. The assessment took place promptly, but neither the occupational therapist, nor the social worker enquired into the outcome of the home fire safety visit, so that a risk management plan could be put in place.
2. The findings of the home fire safety visit were shared only with Mrs Steel – a vulnerable, elderly lady. The findings were not conveyed to those with responsibility for caring for her .
3. A written risk assessment/risk management plan was completed by the London Fire Brigade. This was not left in the property or shared with Mrs Steel, her family, her carers or the agency who requested the fire safety check.
4. As a result of the poor communication from the LFB, there was no risk management plan in place to reduce the risk of fire harm to Mrs Steel. Had the findings of the fire assessor been communicated, carers would have been aware of the need to re-iterate the importance of stubbing out cigarettes in an ashtray and not leaving cigarettes to burn out; the need to dispose of all non-flame retardant bedding, to ensure that the safe bedding was in place at all times; the importance of keeping extraneous flammable materials away from the bed, as much as possible.
” Source location Mrs Gabrielle Sarah Anne Steel · 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 Review information-sharing processes, the data-protection impact assessment and third-party disclosure arrangements, consulting information-management specialists and the Information Commissioner.
Verbatim wording from the response “Noting HM Coroner's observations, we have started to review our processes and have engaged with our Information Management Team to discuss the data protection issues around sharing information with third parties where the resident has full mental capacity. LFB are reviewing the data protection privacy impact assessment and consulting the Information Commissioner to fully scope how we can best meet this need while ensuring privacy for the resident.” Source location Response from London Fire Brigade
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Home Fire Safety Visit booking questions to identify in-home care and recommend that carers attend visits.
Verbatim wording from the response “LFB are reviewing the questions asked at the point of booking the visit to ensure that information is gained regarding whether there is the provision of care in the home and recommend that the carer attends the visit. LFB are also considering the best ways of communicating with the carer or family member if they are not present, for example leaving guidance in the property including information about flame retardant bedding where appropriate.” Source location Response from London Fire Brigade
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 Scope options for leaving bespoke fire-safety information with residents, family members or carers, engaging other fire services to identify best practice.
Verbatim wording from the response “LFB are reviewing the questions asked at the point of booking the visit to ensure that information is gained regarding whether there is the provision of care in the home and recommend that the carer attends the visit. LFB are also considering the best ways of communicating with the carer or family member if they are not present, for example leaving guidance in the property including information about flame retardant bedding where appropriate.” Source location Response from London Fire Brigade
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 Update Home Fire Safety Visit policy, guidance and staff training where necessary following the process review.
Verbatim wording from the response “Following this review LFB will where necessary update the policy, guidance, and training to ensure all staff carrying out Home Fire Safety Visits fully understand this process.” Source location Response from London Fire Brigade
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 Existing policy authorises sharing advice only with a resident who can understand and retain it, so staff followed the correct process.
Verbatim wording from the response “Existing LFB policy, which follows national best practice, does not authorise staff to share findings with any other person. Providing staff are satisfied that the individual recipient is able to understand and retain the advice given, they share advice and observations face to face. During the booking of Mrs Steel's Home Fire Safety Visit it was confirmed that Mrs Steel was able to understand, process and retain the information provided – this was noted on our records and therefore the crews followed the correct process as outlined in the policy.” Source location Response from London Fire Brigade
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 Care providers are responsible for planning and delivering care based on risk assessments, including assessing and mitigating fire risk.
Verbatim wording from the response “The Fire Service's statutory role does not include responsibility for a resident's care plan or for making or contributing to a personalised risk management plan for an individual resident. Home Fire Safety Visits are not intended to be personal risk assessments but to be provision of fire safety advice to the resident. Care providers are regulated to plan and deliver care based on risk assessments, and this should include assessing risk from fire. A care provider should not need an HFSV to prompt attention on any of the points raised above. However, we accept that there is learning around communication with the carer about identified fire risk within the limitations of UK GDPR/Data Protection A 2018 and for the HFSV process to reinforce the need for care providers to have regard to fire safety. We have set out above that we are taking steps to explore improvements.” Source location Response from London Fire Brigade
Open published response
Concerns raised 2
Failure to inform accompanying carers of section 17 leave conditions View source Failure to provide section 17 leave forms to accompanying carers 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
Tees, Esk and Wear Valleys 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. 6
Tees, Esk and Wear Valleys NHS Foundation Trust
Include Section 17 leave and accompanying-role responsibilities in mandatory Trust-wide preceptorship for newly joining registered nurses.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Review, amend, approve and roll out the Section 17 leave policy, including signed leave documentation, accompanying-person confirmation and ward-held copies.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Develop and deliver targeted Section 17 leave training to Associate Directors of Nursing and Quality.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Use Section 17 leave folders, flowcharts, templates and contact cards to give staff, patients and accompanying persons accessible leave requirements and contact information.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Continue auditing clinical records to assess compliance with Section 17 leave procedures.
View source
Tees, Esk and Wear Valleys NHS Foundation Trust
Assess the impact of the amended Section 17 leave policy changes.
View source See 3 more actions
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AI-generated summary
Matthew Clive GALE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Clive Gale died on 19 March 2023 after being detained under the Mental Health Act and granted Section 17 leave. The conditions of his leave, including that he should not be left alone, were not properly recorded or communicated to his family. The report raised concern about inconsistent compliance with providing Section 17 leave forms and the removal of a requirement for the accompanying person to sign the form, creating a risk of future deaths.
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 inform accompanying carers of section 17 leave conditions
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form.
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her. The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave. That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024, with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system.
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken.
” Source location Matthew Clive GALE · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide section 17 leave forms to accompanying carers
Wider context from the report “At inquest, Matthew's mother gave evidence that she was never informed of the terms upon which Matthew's section 17 leave had been authorised by those responsible for his treatment and specifically that Matthew should never be left alone or unaccompanied whilst on section 17 leave nor was she provided with a copy of Matthew's section 17 leave form .
The Trust acknowledged and admitted that there was no evidence in any records available to it that such discussions had been had with Matthew's mother or that a copy of the section 17 leave form had been provided to her . The Trust gave evidence of changes implemented since Matthew's tragic death to avoid future recurrence and I requested additional evidence from the Trust in relation to audited compliance data.
Notwithstanding changes already implemented and envisaged and by its own admission, the Trust's compliance data is "inconsistent" generally but specifically in relation to the provision of the section 17 leave form to a carer/ person accompanying a patient subject to section 17 leave . That evidence demonstrated a 50% compliance rate in December 2023, a 52% compliance rate in March 2024 and a 76% compliance rate in May 2024 , with a compliance rate of 80% or above considered to be "good" by reference to the Trust's compliance criteria.
Additionally and in relation to changes already implemented, the Trust's evidence at inquest was that its revised section 17 leave policy for detained patients had removed the previous requirement that the section 17 leave form ought to be signed by the person accompanying the patient, the explanation for this being the Trust's roll-out of a new digitised system.
The inconsistent compliance audit data referenced above gives rise to a concern that there is risk that future deaths could occur consequent to this change unless action is taken.
” Source location Matthew Clive GALE · 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 Include Section 17 leave and accompanying-role responsibilities in mandatory Trust-wide preceptorship for newly joining registered nurses.
Verbatim wording from the response “As previously advised, following the May 2024 audit results the Trust implemented the following to improve Section 17 leave requirements:” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review, amend, approve and roll out the Section 17 leave policy, including signed leave documentation, accompanying-person confirmation and ward-held copies.
Verbatim wording from the response “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver targeted Section 17 leave training to Associate Directors of Nursing and Quality.
Verbatim wording from the response “The Associate Director of Nursing and Quality has developed and delivered targeted training to all Associate Directors of Nurses (ADONs) around Section 17 leave, including the changes to policy and procedures and the need to ensure that processes are being followed and documented. This training is currently being disseminated across the relevant parts of the Trust with oversight of the ADONs. Within the last three weeks, 957 (70%) of substantive ward staff within the Trust have been trained in the new Section 17 leave policy. In addition to this, Section 17 leave/time away from the ward training has been delivered to temporary workers, community staff, corporate services, and professional groups to ensure they are aware of the changes. Compliance with training continues to be closely monitored by the ADONs to ensure the Trust captures all relevant staff.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Section 17 leave folders, flowcharts, templates and contact cards to give staff, patients and accompanying persons accessible leave requirements and contact information.
Verbatim wording from the response “In order to further assist staff with the requirements of Section 17 leave, staff have been provided with leave folder templates and contact cards, which are now in use across the relevant parts of the Trust. At the front of the leave folders a flowchart that has been produced to remind staff of the requirements of Section 17 leave. The leave folder also contains a copy of the most recent Section 17 leave form and the leave/time away from the ward monitoring form to enable easy access. Contact cards are now also given to the patient and the accompanying person, which have details of the ward contact details, any conditions of leave, a check that a copy of the section 17 leave form has been provided and details of time and date which patient is due to return.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue auditing clinical records to assess compliance with Section 17 leave procedures.
Verbatim wording from the response “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess the impact of the amended Section 17 leave policy changes.
Verbatim wording from the response “The Trust continue to audit the clinical records to assess the Trust compliance with Section 17 leave procedures and an assessment will be made to determine the impact of the Section 17 leave policy changes, which was approved on 10 September 2024 by the Trust's Executive Team.” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Section 17 leave and monitoring forms will remain in paper format rather than being converted to electronic forms.
Verbatim wording from the response “The Section 17 leave policy has now been reviewed, amended and rolled out across the Trust, with a decision made that the Section 17 leave form and leave/time away from the ward monitoring form will remain in paper format, rather than going electronic. Section 17 leave forms are required to be signed by both the patient and accompanying person, to ensure they are aware of the conditions of leave and each person is provided with a copy, with a copy now also kept within a leave folder on the ward to ensure that a copy is always available prior to any leave. The leave/time away from the ward monitoring form, has been” Source location Response from Tees Esk and Wear Valleys NHS Foundation Trust
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4 Mar 2024 Sarah Rhiannon Keen · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to provide carers with relevant patient risks and care information View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sarah Rhiannon Keen · 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
Sarah Keen, who had a history of mental health difficulties and required support with daily activities, died after being discharged from hospital to supported accommodation. A post-mortem examination determined the medical cause of death to be multi-drug toxicity involving fluoxetine and dihydrocodeine in the presence of cocaine. The principal concerns were inadequate communication to carers about her risks and medication, insufficient guidance about discharge medication, and use of an abbreviation that was not universally understood.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide carers with relevant patient risks and care information
Wider context from the report “(1) The enhanced carer had not been told the reason that she was providing one to one care for Sarah, was not aware of any issues in relation to mental health, the fact of the deprivation of liberty order, or that Sarah was a risk of deliberate self harm including by overdosing on prescribed medications. She was not aware that Sarah had been discharged with seven days of medication or that her medication was being held on her behalf by another in the community. Although it was unusual for her to accompany a person with capacity to their address it was not unusual for her to accompany those without capacity. As a consequence the support worker who was on duty at the time that Sarah returned to her accommodation was not aware from an independent source that Sarah had been discharged with seven days of medication, Sarah lied to the support worker when she was asked whether she had been given any medication disclosing only the fact that she had been given ferrous sulphate which she handed over when her bag contained seven days of the medication which she subsequently ingested with fatal results. Even recognising medical confidentiality, those with a caring role who have not been provided with relevant information cannot meet the needs of the patient if they do not know what the risks are or know when it is appropriate to bring information to another professional charged with the care of the patient be it a nurse, doctor or support worker
” Source location Sarah Rhiannon Keen · 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 Record handovers to enhanced care nurses, including the risks of harm if they are not present.
Verbatim wording from the response “• Staff should record their handover to the enhanced care nurse to explain the risks to harm if they are not present.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record handovers between nursing staff and residence staff when escorting patients to their place of residence.
Verbatim wording from the response “• If a member of staff is required to escort a patient to their place of residence, the receiving person is informed and a handover between nursing staff and residence staff occurs. A note of this handover will be recorded in the patient record when the member of staff returns to the ward.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
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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 Speak with supported accommodation staff about patients’ medication and available discharge support, considering information sharing without consent where self-harm risk is significant.
Verbatim wording from the response “• If patients are living in supported or hostel accommodation, staff should make every effort to speak with supporting staff in relation to medication, and support available to the patient on discharge. This would preferably be done with the patient’s consent, but if the risk to self-harm is significant, must be considered without consent of the patient.” Source location Response from Darent Valley Trust and Kent & Medway NHS and Social Partnership
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18 Sep 2023 Anthony John Friend · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to discuss sling use with new carers View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Anthony John Friend · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to discuss sling use with new carers
Wider context from the report “In the course of the inquest, I heard evidence that:
1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property;
2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property;
3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided;
4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part;
5) ████████ also told the inquest that:
(a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and
(b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling ;
6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times.
” Source location Anthony John Friend · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.
Verbatim wording from the response “We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.” Source location Response from Herefordshire and Worcestershire Health and Care
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25 Aug 2022 Charles Evans · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to ensure staff know who else is on duty View source
This report raised 10 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
Charles Evans · 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
Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure staff know who else is on duty
Wider context from the report “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House.
1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid;
2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death);
3. There was no Registered First Aider at the premises;
4. There was no defibrillator on site;
5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements;
6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help;
7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves;
8. Staff did not know who else was on duty at any given time ;
9. There was no proper procedure in place for staff to report concerns about residents;
10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP);
11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan.
” Source location Charles Evans · Prevention of Future Deaths report
Open source report
20 May 2022 Robert Arthur Brown · Prevention of Future Deaths report North East Kent
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Concerns raised 1
Lack of a process to contact carers on discharge where no CPA is in place View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Robert Arthur Brown · 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
Robert Arthur Brown, who had a history of suicide attempts and suicidal ideation, was discharged from hospital after four days without his wife being contacted. On 9 September 2020, he was found fatally injured at cliffs close to his home address. The principal concerns were that “carer breakdown” might not be identified before discharge and that, without a process requiring contact with a carer where no CPA was in place, anticipated care might not be available.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of a process to contact carers on discharge where no CPA is in place
Wider context from the report “2. As there was no process in place to require contacting a carer on discharge where there is no CPA in place a patient could be discharged without notice to a carer and as such care that is anticipated to be in place on discharge may not be available .
” Source location Robert Arthur Brown · Prevention of Future Deaths report
Open source report
26 Jun 2019 Mr Charles Knapp · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to maintain complete identifying and contact information for responsible carers View source
This report raised 7 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
Mr Charles Knapp · 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
Mr Charles Knapp, who was paraplegic and dependent on care, developed necrotic pressure sores while living at home and later died in hospital on 24 February 2018 from aspiration pneumonia. The concerns included failures by Angel Solutions (UK) Ltd to maintain his hygiene, reposition him, seek medical attention, provide two carers as required, and maintain or supply complete care records; the Coroner was concerned that inadequate care and records could put other service users at risk of future deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain complete identifying and contact information for responsible carers
Wider context from the report “(iv) Angel Solutions (UK) Ltd failed to supply the court with the full name and contact details of the main carer who was responsible for Mr Knapp’s care and as such the court did not have the benefit of hearing from her. Further, her surname had been redacted from the records which were left at Mr Knapp’s house.
” Source location Mr Charles Knapp · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.