Recurring concern

Unreliable access to equipment for contemporaneous clinical-observation recording

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First reported 21 Aug 2020•Latest report 8 Jun 2022

Definition

What this concern includes

Includes failures to provide, maintain or make accessible suitable equipment that staff need to record clinical observation results contemporaneously during care, including mobile recording devices, computers and comparable point-of-care recording equipment.

Not included

Excludes failures to perform, interpret, communicate or act on clinical observations when suitable recording equipment was available and the recording-equipment process was reliable.
Excludes general clinical-equipment shortages, maintenance or serviceability failures that are not specifically tied to contemporaneous recording of clinical observations.
Excludes general electronic-record access, documentation-quality and information-transfer failures where the problem is not unavailable or inaccessible equipment for recording observations.
Excludes equipment used solely to measure observations, such as thermometers or pulse oximeters, unless the asserted deficiency concerns recording the resulting observations.

Reports: 2
Individual concerns: 2
Date range: 2020–2022
Stated actions: 4

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Downham Grange1

Kingsley Care Homes Limited1

Royal Free Hospital1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

8 Jun2022
Norfolk
Concerns raised1
1. Unavailability of mobile recording devices for recording observation results
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Train Deputy Managers to rebuild handheld-device software when devices become inoperable.
  Stated by Kingsley Care Homes LimitedStated completed
2. Action
  Increase Downham Grange recording capacity by purchasing three handheld devices and enabling PCS access on medication devices for nurses.
  Stated by Kingsley Care Homes LimitedStated completed
Respondent positions 1
1. Position
  The Company considers computer access at nearby nursing stations sufficient for nurses to record PCS entries without assigned mobile devices.
  Stated by Kingsley Care Homes LimitedExisting arrangements considered sufficient
AI-generated summary

Lilian Bernadette BEHRENDT · 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

Lilian Bernadette Behrendt, aged 91, deteriorated at her care home on 28 November 2021 and died later that evening after being taken to hospital, where she was diagnosed with chest sepsis. The report raised concerns about an incorrectly graded ambulance call, records describing her as “content” despite deterioration, missing observation results, uncertainty about DNACPR and ReSPECT documentation, and unclear responsibility and accountability within the care home.

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
Unavailability of mobile recording devices for recording observation results
Wider context from the report
“2) The evidence was that the Nurse taking the observations on 28 November 2021 did not have access to a mobile recording device, which staff are given to use at the Home specifically to record results, although she did have access to a computer on the Unit to input the information. Evidence was heard that the number of mobile recording devices has now increased to 12, which “should be adequate”, but that “they do get lost and broken”. As at the day of the inquest 10 were available to staff to use. ”
Source location
Lilian Bernadette BEHRENDT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Train Deputy Managers to rebuild handheld-device software when devices become inoperable.

Verbatim wording from the response
“On occasion the mobile recording devices do become inoperable, as a result of software issues, and the Company does arrange for repair and replacement of them when required. The Company has also now provided training to its Deputy Managers so that they have the skills and knowledge to re-build the software within each handheld device should they become inoperable.”

Source location
Response from Kingsley Healthcare
Page 4 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase Downham Grange recording capacity by purchasing three handheld devices and enabling PCS access on medication devices for nurses.

Verbatim wording from the response
“Downham Grange has purchased three additional devices for use following the recent inquest request. In addition, the Company has also uploaded the PCS App onto its medication handheld devices, so that registered nurses are now able to access both the PCS and medication software on one device. The medication devices are in addition to the handheld devices and laptops for use by the nurses. The Company considers that the number of units available in the Home is sufficient for the number of staff on duty at any given time.”

Source location
Response from Kingsley Healthcare
Page 4 · response
Published 16 September 2022
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Company considers computer access at nearby nursing stations sufficient for nurses to record PCS entries without assigned mobile devices.

Verbatim wording from the response
“The mobile recording devices are allocated to care assistants during each shift for their use and ease of recording entries within service users’ care records. In addition, the Company provides separate computers for each nurse within every home, for their specific use. Nurses are not assigned a mobile recording device as they are expected, and are directed during their initial training, to record their entries within the PCS software via the computers. The computers are located within the nursing stations. Although the NIC was not expected to have personal access to a mobile recording device, access to the PCS was available via the computers. Mrs Behrendt’s room was located a few yards from the nurse’s station and the Company is satisfied that this system is sufficient in the circumstances.”

Source location
Response from Kingsley Healthcare
Page 3 · response
Published 16 September 2022
Open published response
21 Aug2020
Inner North London
Concerns raised1
1. Unavailability of a computer in the delivery suite for contemporaneous observation recording
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review Labour Ward workstations on wheels to confirm computer availability in every labour room and identify required actions.
  Stated by Royal Free London NHS Foundation TrustStated completed
2. Action
  Instruct staff to keep workstation-on-wheels carts in delivery rooms and report equipment problems through coordination, IT and incident-reporting channels.
  Stated by Royal Free London NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The Labour Ward had an appropriate number of workstations; the issue was staff removing workstation carts from labour rooms.
  Stated by Royal Free London NHS Foundation TrustDisputes the concern
AI-generated summary

Malyun Habib KARAMA · 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

Malyun Karama died at the Royal Free Hospital from a uterine rupture after misoprostol was administered in doses exceeding national guidelines to induce labour following an intrauterine death. Abnormal observations were relayed to a senior registrar, but the doctor did not attend immediately. Concerns included the need for national learning about the increased risk of rupture in multigravida mothers and the lack of a computer in the delivery suite for contemporaneous recording of observations.

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
Unavailability of a computer in the delivery suite for contemporaneous observation recording
Wider context from the report
“Also, one of the midwives looking after Malyun Karama explained that there was no computer in the delivery suite and so she could not record her observations contemporaneously or without leaving the room. This is sub optimal. ”
Source location
Malyun Habib KARAMA · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review Labour Ward workstations on wheels to confirm computer availability in every labour room and identify required actions.

Verbatim wording from the response
“The Action required is for a review to take place of the workstations on wheels (WOW) on the Labour Ward to ensure that all Labour rooms possess a computer for staff use.”

Source location
2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020
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
Instruct staff to keep workstation-on-wheels carts in delivery rooms and report equipment problems through coordination, IT and incident-reporting channels.

Verbatim wording from the response
“This review was completed on 2 September 2020 and it identified that there were the appropriate number of workstation on wheels for the Labour rooms. However it was identified that staff were removing the Wow carts from the Labour rooms. This gave rise to recommendations being sent out via email on 2 September 2020 that:”

Source location
2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 2 · response
Published 26 October 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Labour Ward had an appropriate number of workstations; the issue was staff removing workstation carts from labour rooms.

Verbatim wording from the response
“Review completed – The review identified that there were the appropriate number of workstation on wheels for the Labour rooms – however it was identified that staff were removing the WOW carts from the Labour rooms.”

Source location
2020-0162-Response-from-Royal-Free-London-NHS-Foundation-Trust_Redacted.pdf
Page 6 · response
Published 26 October 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Unavailability of mobile recording devices for recording observation results

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

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

Concerns raised1

Unavailability of a computer in the delivery suite for contemporaneous observation recording

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

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

Actions described in response 2

Respondent positions 1

Actions described in response 2

Respondent positions 1