Recurring concern

Unreliable intentional-rounding systems

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First reported 29 Aug 2014•Latest report 5 Feb 2026

Definition

What this concern includes

Includes failures in intentional-rounding systems, including defining required checks, conducting them at the required frequency, recording or retaining evidence of completion, and assuring through review or audit that rounding is robust and reliable across hospital, care and comparable settings.

Not included

  • Excludes generic patient observations, welfare checks or monitoring where intentional rounding is not the identified process.
  • Excludes failures in clinical care or escalation after intentional rounding was reliably completed and recorded.
  • Excludes generic documentation, staffing, training or audit deficiencies unless they directly impair the intentional-rounding system.
  • Excludes other named observation systems, such as ACCT, enhanced care supervision or physiological early-warning systems, unless the assertion explicitly concerns intentional rounding.
Reports
4

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Manchester University NHS Foundation Trust2
Barts Health NHS Trust1
Care Quality Commission1
Department of Health and Social Care1
NHS England1
North Cumbria Integrated Care NHS Foundation Trust1
Royal London 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.

  1. Manchester South

    AI-generated summary

    His Honour Bruce Caulfield · 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

    His Honour Bruce Caulfield died at Trafford General Hospital on 19 August 2025 from complications arising from coronary artery disease, against a background including an acute on chronic subdural haematoma requiring surgery, hypertension and frailty. Concerns included the delay between a family member requesting medical review and the review taking place, whether nursing practices ensured vulnerable patients received adequate hydration and nutrition, and whether measures relating to communication about sitting-out recommendations were in place across the Trust.

    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 of intentional rounding and nursing practices to ensure adequate hydration and nutrition for vulnerable ward patients

    Wider context from the report

    “2. Having considered all of the evidence before the inquest with the utmost care, I am concerned that the approach to intentional rounding at Wythenshawe hospital in conjunction with other relevant nursing practices is insufficient to ensure vulnerable patients (such as those with cognitive impairment or the inability to eat or drink without assistance) receive adequate hydration and nutrition whilst on the wards; ”

    Source location

    His Honour Bruce Caulfield · 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

    Continue enhanced auditing of appropriate food-chart commencement for three months to assure consistent nutrition monitoring across WTWA hospitals.

    Verbatim wording from the response

    “Following His Honour’s admission to Doyle Ward on 23 July 2025, he was placed on food charts on 24 July 2025. This measure allowed staff to track his nutrition status closely and respond promptly to any emerging concerns. An audit of 49 patient records at Wythenshawe Hospital, completed in February 2026, found that 89% of relevant patients had food charts commenced appropriately. This enhanced audit will continue for the next three months to provide further assurance of consistent practice across WTWA hospitals. As part of His Honour’s nutrition and hydration management, he was placed on the ‘red tray system’ on 24 July 2025. The red tray is a visible prompt for staff, indicating that the patient is at high risk of malnutrition and requires assistance with eating or drinking. During his admission, His Honour required encouragement and support with both eating and drinking.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 4 · response
    Published 10 February 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide additional nutrition and hydration monitoring through quality and safety walk rounds led by nursing directors, with real-time feedback.

    Verbatim wording from the response

    “• Additional monitoring is being provided through quality and safety walk rounds led by the Director or Deputy Director of Nursing with feedback provided in real time.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 8 · response
    Published 10 February 2026

    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

    Formalise Ward Manager and Matron walkarounds to increase assurance of mealtime preparedness and real-time patient feedback.

    Verbatim wording from the response

    “• Ward Manager and Matron walk arounds are in place and are now being formalised as part of increased assurance mechanisms to focus on mealtime preparedness and patient feedback in real time.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 8 · response
    Published 10 February 2026

    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 the volume and frequency of peer dining audits from March 2026, reporting results through senior nursing and nutrition governance.

    Verbatim wording from the response

    “• Increased volume and frequency of peer audits from March 2026 reporting into the weekly Senior Nurse Huddle chaired by ████████ and oversight into the WTWA Nutrition and Hydration Group.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 8 · response
    Published 10 February 2026

    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 Trust considers its comprehensive care approach, including nutrition and hydration support for vulnerable patients, sufficient to address the concern.

    Verbatim wording from the response

    “As you may be aware, ‘intentional rounding’ is a term used to describe a practice in care delivery to patients during their hospital admission; it is a structured proactive nursing process where staff check on patients at regular intervals to address any key needs such as pain, communication and placement of items such as a call bell. Although the terminology ‘intentional rounding’ was used with regards to care provided on Doyle Ward, it is not a term that is widely used across WTWA Hospitals to describe what is a more comprehensive approach to care delivery, which includes assessment and implementation of care. This approach is provided to all patients, including those patients who require support with nutrition and hydration, and those patients with a cognitive impairment.”

    Source location

    Response from Manchester University NHS Foundation Trust
    Page 3 · response
    Published 10 February 2026

    Open published response
  2. Cumbria

    AI-generated summary

    Gordon Bernard Hendley · 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

    Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a robust A&E intentional-rounding system

    Wider context from the report

    “4) At the inquest into the death of Nicholas Dietzold (who died in the A&E department) which I heard last September I was assured that a system of “Intentional Rounding” would take place in A&E when a senior doctor and nurse would go round the department to look at patients & assure themselves that appropriate actions were in hand (I am aware the design of the department is less than ideal). The consultant gave evidence assuring me that this did take place but there were no notes to confirm this and I question whether it is a robust system. ”

    Source location

    Gordon Bernard Hendley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester South

    AI-generated summary

    Mr William Ivan McKibbin · 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 William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from 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

    Lack of documentation checks confirming bed brakes are on

    Wider context from the report

    “2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position, and the bed brakes are on. ”

    Source location

    Mr William Ivan McKibbin · 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

    Update falls documentation and policy to require immediate scene checks, bed-brake and bed-rail checks, falls-risk review, and appropriate care planning during intentional rounding.

    Verbatim wording from the response

    “The intentional rounding core documentation (attached at appendix 4) was adapted alongside the Trust’s Inpatient Falls Management Policy, Falls Care Plan, and Falls Investigation Template, with changes publicised via the Trust’s iNews communication on 9ᵗʰ September 2020 which included a spotlight on falls prevention and management. The updates to documentation were also circulated by the Group Deputy Chief Nurse on 11ᵗʰ September 2020. The changes were also highlighted specifically at Trafford General Hospital via the site Falls Specialist Nurse, with a poster and publicity campaign.”

    Source location

    2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
    Page 6 · response
    Published 19 November 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

    Review nursing documentation and its effectiveness in supporting individualized care plans through a Trust Task and Finish Group with academic partners.

    Verbatim wording from the response

    “The Falls Collaborative Research Sub-Group, co-chaired by the Trust’s Group Deputy Chief Nurse and international expert Professor ████████, Director of the National Institute for Health Research’s Older People & Frailty Policy Research Unit, has reviewed and approved the Trust’s Intentional Rounding documentation. The evidence base for rounding was considered at the Falls Collaborative meeting on 21ˢᵗ September 2020. Subsequently, a Task & Finish Group has been established within the Trust with support from academic partners to review the current nursing documentation and its effectiveness in contributing to the delivery of an individualised care plan for patients. A high-level literature review has been conducted on intentional rounding to inform this work programme.”

    Source location

    2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
    Page 7 · response
    Published 19 November 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 Trust disputes that managers knew the bed brakes were not applied, stating the unwitnessed fall and absent contemporaneous checks prevented that conclusion.

    Verbatim wording from the response

    “I share your concern that the assessment of the brakes was not undertaken immediately post Mr McKibbin’s fall. I also accept in full your findings in relation to the report completed, it was not of the quality I would expect and lacked some key questions and lines of enquiry. Those failings acknowledged; it is not accepted that the Managers from the Trust therefore knew the brakes could not have been on. Sadly, Mr McKibbin’s fall was unwitnessed and, as confirmed, the brakes were not checked at the time. The Trust position on this was that it could not be ascertained as to whether the brakes were on and that the bed rails were applied. I would draw your attention to page 4 of the report where it is noted that “Upon entering the room Mr”

    Source location

    2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
    Page 5 · response
    Published 19 November 2020

    Open published response
  4. Inner North London

    AI-generated summary

    Irshad 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

    Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.

    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 record intentional rounding checks

    Wider context from the report

    “1. The nursing staff should have checked on Mr Ali every two hours through the night, but there was no record of intentional rounding on 24/25 March. There was a record of the night before and a record of the night after, but not the night that Mr Ali fell. The chart appears to have gone missing. ”

    Source location

    Irshad ALI · 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

    Conduct monthly senior nursing audits of medical-record filing, with spot checks of intentional-rounding compliance and correct filing.

    Verbatim wording from the response

    “During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did take place. The intentional rounding chart for this night remains missing. Evidence has been adduced that this is because the medical notes had been filed incorrectly. This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients’ notes and spot checks for intentional rounding compliance and correct filing of medical notes.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 29 August 2014

    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

    Intentional rounding occurred despite the missing chart, which resulted from medical notes being filed incorrectly.

    Verbatim wording from the response

    “During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did take place. The intentional rounding chart for this night remains missing. Evidence has been adduced that this is because the medical notes had been filed incorrectly. This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients’ notes and spot checks for intentional rounding compliance and correct filing of medical notes.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 29 August 2014

    Open published response
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Data last updated 7 September 2026