22 Feb 2024 Kim Georgina STROUD · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to provide timely continence and personal hygiene care View source
This report raised 2 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Kim Georgina STROUD · 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
Kim Georgina Stroud was admitted to hospital for a bladder tumour procedure that had previously been cancelled five times, became unwell with a chest infection and later tested positive for covid, and died suddenly on 11 October 2022. Concerns included medication being left unsupervised despite delirium, with tablets signed for as administered, and inadequate personal care when she was found heavily soiled with urine and faeces.
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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 timely continence and personal hygiene care
Wider context from the report “Mrs Stroud’s care appears to have been non-compliant with both hospital policies and the Nursing and Midwifery Council regulations for the administration of medication.
Mrs Stroud’s relatives found pots with tablets in on several occasions just left on their mother’s bedside table. These had been signed for as given. On one occasion Mrs Stroud had concealed 9 tablets inside her incontinence pads because she thought she was being poisoned, clearly not supervised in taking these either. It was extremely unsafe to give tablets in this way. Mrs Stroud had delirium and could not be left to take them herself. There were other confused and mobile patients on the same ward who could have picked them up.
On several occasions Mrs Stroud was found in her bed so soaked in urine (I have seen photographs of this) that the urine was dripping off the edge of the bed and the family had to wash and change her themselves. Also wash faeces from her body.
” Source location Kim Georgina STROUD · Prevention of Future Deaths report
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24 Jul 2023 Alan Christopher NIPPARD · Prevention of Future Deaths report Avon
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Concerns raised 1
Failure to provide regular continence checks, toileting and personal care View source
This report raised 14 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.
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Alan Christopher NIPPARD · Prevention of Future Deaths report
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Report summary
Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.
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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 regular continence checks, toileting and personal care
Wider context from the report “I heard from the Trust’s Lead Tissue Viability Nurse, ████████ had reviewed the notes and provided ████████ opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with.
There were many concerns that she raised, she said in summary the pressure sore was preventable, that it’s basic nursing care and this wasn’t achieved. That once it had developed, if he’d had good skin care and the SSKIN bundle had been followed the damage would have been minimized. When asked how bad the care was ████████ said - it was shocking.
It was accepted that Mr Nippard did not have a sacral pressure sore when he was admitted to the RUH and that it was deemed hospital acquired.
That the first time that the sacral pressure sore was mentioned in the notes was on 2ⁿᵈ June 2022 when a Tissue Viability Nurse (TVN) referral was sent, stating - for suspected deep tissue injuries to buttocks with blistering, stating the area appeared overnight.
I was told that there were a number of areas of concern with regard to the risk assessment, management and care and treatment that Mr Nippard received including:
• That the screening tool completed on 31ˢᵗ May scored Mr Nippard as, not at risk of a pressure sore – this was wrong; he was at risk due to his immobility and diabetes which increased the risk of a pressure sore developing, in addition to his age and his medical history. He should have been scored high risk. Because of this - nothing happened and it should have. Mr Nippard should have been on an air mattress and he should have been re-positioned regularly.
• On the MAU he did not have his risk assessment done within 6 hrs as it should have been.
• It is recorded that he was on an air mattress on Pierce ward on 1ˢᵗ June but the time of this is unknown. This meant he probably went up to 2 days after his admission without an air mattress.
• Mr Nippard’s risk assessment was not carried out until 2 days post admission, (1ˢᵗ June) it did record his risk as high, this is a significant delay.
• Once recorded as high risk Mr Nippard should have been reassessed every week – this was not achieved.
• The SSKIN bundle, a nationally recognised tool with care plan was rarely completed and when it was it was poorly completed.
• Skin assessments should have been carried out daily, when they were carried out were ad hoc and inaccurate, sometimes skin was recorded as normal when it clearly wasn’t.
• On one occasion a body map was circled indicating the areas of concerns – sacrum and left heel but lacked information and categorisation
• Of significant concern is the fact Mr Nippard spent long periods of time on his back with little or no evidence of offloading of the sacrum or heels at all. He should have been repositioned every 2-3 hours during the day and between 2-4 hours at night. There was no structured re-positioning at all.
• It was estimated that every day he was in hospital he was on his back for 22 ½ hours and there was no sustained time off his sacrum and there should have been.
• When he was sat in his chair there is no evidence that he had an air cushion to sit on and when sat, he should have been stood hourly.
• It was raised that there was a query of his own compliance but there is only 2 occasions on 6ᵗʰ and 20ᵗʰ June when he declined to be moved
• There was no evidence of the use of 2 sliding sheets to assist with moving him.
• On 11ᵗʰ June it was a podiatrist who raised the new pressure sore on the right heel and completed an incident report – this should have been managed and picked up by the nurses in their daily checks. In addition he should have had repose boots to prevent this and there is no evidence they were used at all.
• Mr Nippard had a catheter and incontinence – he should have been checked regularly, offered the toilet, the commode, bed pans should have been a last resort . She could not see this was achieved at all . The fact Mr Nippard was left to soil the bed was not acceptable care and that the limited personal care described by the family was not acceptable .
• Fluid balance charts were poorly completed.
• He wasn’t weighed which would have assisted with managing his oedema.
• Appropriate nursing care was not achieved and pressure care was a fundamental part of nursing care.
I have been advised that The Trust have taken significant steps since Mr Nippard’s admission, however, I have not been reassured by those involved with Pierce Ward that this will not happen again. Specifically, I have been advised by The Lead Tissue Viability Nurse that she has ongoing concerns and indeed The Interim Deputy Divisional Director of Nursing for Surgery and The Divisional Director of Surgery have confirmed that there have been two pressure sore incidents on Pierce Ward this month (July 2023). I have been told that the reason for this could be the need for training of staff on Pierce Ward on : risk assessment, prevention care and treatment of pressure sores by the tissue viability team.
” Source location Alan Christopher NIPPARD · 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 Deliver face-to-face pressure-ulcer prevention and management training to substantive nursing, physiotherapy and occupational therapy staff.
Verbatim wording from the response “Since the inquest into Mr Nippard’s death, the Tissue Viability Nursing (TVN) Team have led a programme of face to face training for all substantive members of nursing staff on Pierce Ward. In addition, all Physiotherapists and Occupational Therapists have also received training.” Source location Response from Royal United Hospitals Bath 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 Complete and monitor staff workbooks assessing knowledge and skills in pressure-ulcer prevention and management.
Verbatim wording from the response “The training has focussed on addressing the learning from incidents which includes; consistently undertaking appropriate skin assessments, repositioning and the correct use of equipment. The training also incorporated training on the nationally recognised SKIN bundle which stands for ‘skin, surface, keep moving, incontinence, nutrition and hydration’ in addition to risk assessments, care planning, reporting and escalation. Staff knowledge and skills has been assessed using a workbook which has been distributed to and completed by each staff member. At the time of responding, 5 have not yet completed their work book which is being monitored and full compliance is expected.” Source location Response from Royal United Hospitals Bath NHS Foundation Trust
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5 Dec 2022 Richard Thomas SHANNON · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to provide required personal hygiene and catheter care during home visits View source
This report raised 8 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.
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Richard Thomas SHANNON · 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
Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.
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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 required personal hygiene and catheter care during home visits
Wider context from the report “6. When a district nurse arrived at the home the morning after discharge, she found that Professor Shannon’s catheter bag was so full it had become detached, and he had demonstrably and significantly soiled himself.
He had been in this condition when a Kapital carer had visited earlier that same morning, but the carer had not cleaned him or changed the catheter bag .
It took the district nurse three hours properly to take care of her patient’s needs. Carers from Kapital had been booked to visit Professor Shannon’s home for an hour four times each day by the City of Westminster. One of their specific tasks was to attend to the personal hygiene needs of this elderly and vulnerable man who was unable to attend to them himself.
The Kapital carer’s explanation for leaving him in this condition was that there was no soap or towel in the property. This excuse struck me as demonstrating an appalling lack of humanity and I was shocked to hear of it.
In fact, Professor Shannon was obviously dearly loved, and his friends had done everything they could to make his home ready for him, including stocking his bathroom with soap and towels readily found by the district nurse. Apparently, the Kapital carer had simply not opened the bathroom cupboard.
” Source location Richard Thomas SHANNON · Prevention of Future Deaths report
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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 Update home-held care-plan templates with clear carer instructions, escalation criteria and community nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
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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 Update home-held care-plan templates with clear carer instructions, escalation criteria and community-nurse contact details.
Verbatim wording from the response “• We have updated the care plans template for care plans that are held in the patients’ home to ensure that they contain clear instructions for the carers where required. This documentation now also includes clear escalation criteria and contact details for the community nurses.” Source location Response from Central London Community Healthcare
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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 Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Verbatim wording from the response “• The Central London Community Healthcare NHS Trust District Nursing Team has worked with University College Hospital NHS Trust and The City of Westminster to review and improve the quality of information we share with carers, prior to a vulnerable adult being discharged from hospital. This includes giving clear instructions regarding holistic care requirements and the equipment needed to reduce the risk of pressure damage.” Source location Response from Central London Community Healthcare
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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 Complete manual-handling, mobility-equipment and environmental assessments before or during the initial visit.
Verbatim wording from the response “• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.” Source location Response from Kapital Care
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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 Escalate equipment-related barriers to essential personal care and resolve them before staff leave the property.
Verbatim wording from the response “• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.” Source location Response from Kapital Care
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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 Complete manual-handling, mobility-equipment and environmental assessments during initial visits.
Verbatim wording from the response “• Kapital care will complete a robust manual handling assessment, including mobility equipment and environmental assessment are completed by the care coordinator prior/during the initial visit. This will ensure appropriate equipment, including items used to maintain the adults personal care is available within the property.” Source location Response from Kapital Care (UK) Limited
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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 Escalate equipment-related barriers to care coordinators and resolve them before staff leave the property.
Verbatim wording from the response “• All care staff will escalate their concerns to the care coordinator whilst at the adult’s home if they are unable to complete or deliver essential personal care tasks due to the lack of equipment in place. Kapital care will ensure the issue is resolved before the care staff leave the property and ensure the adults hygiene and dignity is always maintained. This action will prevent a reoccurrence of the identified concern.” Source location Response from Kapital Care (UK) Limited
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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 Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Verbatim wording from the response “We have reviewed and improved our local processes and education for staff to prevent further poor outcomes for patients. This is significantly strengthened by working collaboratively with our partners in the community and social care. We are confident this improved approach will enhance the quality and safety of the hospital discharge process and care outside of hospital. We are confident that we have addressed the concerns raised to ensure the care we provide to patients is safe and holistic. To assure ourselves and others, we have agreed to meet monthly as a newly formed partnership to review progress against these actions, share learning and collaborate on improvements.” Source location Response from University College London Hospitals
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Concerns raised 1
Failure to change incontinence pads regularly View source
This report raised 10 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Joan RICHARDSON · 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
Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.
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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 change incontinence pads regularly
Wider context from the report “(brief summary of matters of concern)
Joan had only started to receive care at home four times per day from lunch time of 29/04/2020, however when Joan failed to get up from her bed, refused food and fluids, complained of pain and generally started to deteriorate;-
1. The matter of Joan’s general deterioration was not escalated as it should have been to her GP/District Nurse/Commissioning Social Services etc.
2. When Joan complained of pain -the matter was not escalated as it should have been.
3. There was no comprehensive plan of care, risk assessment, pressure area care plan/risk assessment, falls assessment and care plan put in place following assessment by Litch care services. The manager/proprietor ████████ Registered manager informed the court they were still in the process of doing risk assessment/s etc because Joan was only receiving their care for 4.5 days before she was admitted to hospital.
4. Joan was admitted to hospital with Grade 4 pressure ulcers/tissue injuries to her sacrum, but because Joan had refused much of the personal care offered to her and she had remained largely immobile in bed the pressure sores/tissue injuries were not documented, assessed or managed as they should have been nor was the tissue viability nurse, GP, District nurse or social care team informed to enable them to commence/prescribe appropriate treatment.
5. There were no records/daily log making any mention of skin integrity/breakdown even though Joan was in bed, frail, immobile and incontinent in addition to which because Joan was refusing care her incontinence pad were not being changed regularly.
6. Training/education, support & supervision of care staff including the provision of clear escalation procedures was inadequate. Noting care staff attended upon Joan regularly as required.
” Source location Joan RICHARDSON · Prevention of Future Deaths report
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20 Mar 2020 John Francis GREGORY · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to provide consistent toileting and continence care View source
This report raised 8 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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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John Francis GREGORY · 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
John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.
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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 consistent toileting and continence care
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff .
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet ; on more than one occasion his family found him in wet bedclothes ; and he was put to bed at 7.30pm to fit in with nursing routine.
” Source location John Francis GREGORY · Prevention of Future Deaths report
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13 Aug 2018 Flora Marion BABER · Prevention of Future Deaths report Inner North London
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Concerns raised 2
Failure to provide requested toileting assistance View source Inaccurate recording of patients’ continence status View source
This report raised 8 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Action
Deliver a rolling HCA education programme covering nutrition, safe swallowing, continence care, toileting assistance and learning from the case.
Stated by Royal Free HospitalStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019. View source
Action
Remind Ward 8 West staff to assist incontinent patients to use a commode or toilet when requested and safe.
Stated by Royal Free HospitalStated completedThe respondent said that this action was complete when they made their response on 24 January 2019. View source
Action
Introduce an electronic care-plan system and update training for staff who review and update care plans.
Stated by Central & Cecil Housing Trust (C&CStated plannedThe respondent said that this action was planned when they made their response on 24 January 2019. View source
Action
Appoint a Director of Workplace and Culture to review policies, procedures and care-staff induction, including care-plan updating.
Stated by Central & Cecil Housing Trust (C&CStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019. View source
Action
Roll out enhanced refresher training on care-plan documentation, medication administration, and recording residents’ conditions and needs across C&C homes.
Stated by Central & Cecil Housing Trust (C&CStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019. View source
Action
Add regular Quality and Compliance Manager audits to monitoring of care planning and medication administration.
Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019. View source
Action
Strengthen induction controls by verifying completion within a strict timeframe before staff work with residents, including care-plan documentation demonstrations.
Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019. View source
Action
Implement rigorous checks for maintaining current care-plan and medication records, delete obsolete electronic care-plan forms, and roll these controls out across C&C homes.
Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019. View source
Action
Complete the Ward 8 West healthcare assistants’ care-certificate training, including continence care.
Stated by Royal Free HospitalStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019. View source See 6 more actions
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Flora Marion BABER · 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
Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.
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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 requested toileting assistance
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy , she was wearing an incontinence pad, and she should use that instead .
I was shocked to hear this.
” Source location Flora Marion BABER · Prevention of Future Deaths report
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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 Inaccurate recording of patients’ continence status
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy, she was wearing an incontinence pad, and she should use that instead.
I was shocked to hear this.
” Source location Flora Marion BABER · 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 Deliver a rolling HCA education programme covering nutrition, safe swallowing, continence care, toileting assistance and learning from the case.
Verbatim wording from the response “Furthermore the clinical practice educator will include nutrition, safe swallow, continence care, and assistance with toileting in the HCA study days, which will be a rolling programme of education. She will also discuss this case at the study days as an opportunity to raise awareness of the patient experience. Finally, our hospital quality governance manager will present the learning from this case at the next Health Services for Elderly People specialty governance meeting.” Source location 2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-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 Remind Ward 8 West staff to assist incontinent patients to use a commode or toilet when requested and safe.
Verbatim wording from the response “As previously mentioned, all staff on Ward 8 West have been reminded on Tuesday 14 August 2018 and on other dates since then, that even if patients are incontinent, they should be assisted to use the commode or a toilet if they request, and if it is safe to do so. Furthermore all staff are reminded of this through actions 2, 3 and 5 on the attached action plan.” Source location 2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-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 Introduce an electronic care-plan system and update training for staff who review and update care plans.
Verbatim wording from the response “v) It is C&C's intention to introduce an electronic care plan system, which will prompt staff to complete and update all relevant information in order to ensure that all questions are considered. C&C are in talks with potential suppliers for this new system, and we intend to introduce this, together with updating training for all staff tasked with reviewing and updating care plans, in the first quarter of next year.” Source location 2018-0299-Response-by-CC-Housing-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 Appoint a Director of Workplace and Culture to review policies, procedures and care-staff induction, including care-plan updating.
Verbatim wording from the response “viii) C&C have also appointed a new Director of Workplace and Culture who joined us in May 2018. She has been reviewing all the company policies and procedures and has been working with the care team, including our Quality & Compliance Manager to review staff our induction programme, including how care plans are reviewed and updated.” Source location 2018-0299-Response-by-CC-Housing-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 Roll out enhanced refresher training on care-plan documentation, medication administration, and recording residents’ conditions and needs across C&C homes.
Verbatim wording from the response “i) Since the incident at Compton Lodge, C&C have reviewed and increased the training given to staff across all of its Homes, around care plan documentation and medication administration, to ensure our residents' safety. Further training focuses upon good practice around recording and evidencing information about the residents' conditions and needs, which is discussed and demonstrated in full. This has been developed as part of staff refresher training, which is currently being rolled out throughout our Care Homes, by our Quality and Compliance Manager. This should be completed by the end of this year.” Source location 2018-0299-Response-by-CC-Housing-Trust
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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 Add regular Quality and Compliance Manager audits to monitoring of care planning and medication administration.
Verbatim wording from the response “ii) In addition to regular audits carried out by our Managers, C&C's care planning and medication administration system is now also monitored through additional, regular audits carried out by our Quality and Compliance Manager.” Source location 2018-0299-Response-by-CC-Housing-Trust
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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 Strengthen induction controls by verifying completion within a strict timeframe before staff work with residents, including care-plan documentation demonstrations.
Verbatim wording from the response “iii) Staff completion of the full induction programme is now checked and monitored more robustly, to ensure that induction is completed within a strict timeframe and staff are not able to commence working with residents until the full induction is complete. Induction includes demonstrations for new staff on how care plan documentation is to be completed and updated.” Source location 2018-0299-Response-by-CC-Housing-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement rigorous checks for maintaining current care-plan and medication records, delete obsolete electronic care-plan forms, and roll these controls out across C&C homes.
Verbatim wording from the response “ii) Since the new Home Manager at Compton Lodge was appointed in June 2018, more rigorous checks have been put in place to ensure that the procedures for care plans and medication records to be updated and maintained are followed consistently. The storage of old care plan forms on local computers have been deleted to ensure that new and relevant information only is added to the correct, up to date version of care plan documentation for each resident. These improvements and checks have also been rolled out across our other care Homes. Moving forward, this discipline will be closely monitored by the Quality and Compliance Manager and continued improvements made across all of C&C's Homes.” Source location 2018-0299-Response-by-CC-Housing-Trust
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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 the Ward 8 West healthcare assistants’ care-certificate training, including continence care.
Verbatim wording from the response “All HCAs on Ward 8 West are working towards completion of a care certificate, which includes continence care.” Source location 2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
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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 Because standing was considered unsafe and no regular bedpan requests were recorded, using incontinence pads was considered most appropriate.
Verbatim wording from the response “As the patient had been admitted with a subdural bleed, along with confusion, delirium, agitation, and visual hallucinations, it was not considered safe to encourage her to stand. The patient was assessed as being at a very high risk of falls. She was nursed in bed throughout her admission and was normally very confused. It was not felt that it would have been appropriate to assist her to a toilet, both for her own safety and for staff in terms of manual handling. However, a bed pan could have been an option. Due to the patient’s confusion, it was not felt to be appropriate to rely on her being able to call for staff when she needed the toilet, and there are no records of her regularly asking for a bedpan, so it was considered most appropriate to give her incontinence pads.” Source location 2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
Open published response
Concerns raised 1
Failure to maintain continence-related cleanliness before specialist assessment View source
This report raised 15 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.
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AI-generated summary
Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.
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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 continence-related cleanliness before specialist assessment
Wider context from the report “8. The deceased was incontinent and had required cleaning before Tissue Viability Nurses were able to examine her.
” Source location Janine Eugenie Pierrette KAISER · Prevention of Future Deaths 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 Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.
Verbatim wording from the response “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
24 Jun 2015 MR. ANTHONY GEERTS · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Failure to refer and plan for urinary incontinence View source
This report raised 18 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.
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. ANTHONY GEERTS · 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. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.
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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 refer and plan for urinary incontinence
Wider context from the report “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly.
In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for.
His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as
(a) There was insufficient physiotherapy staff to do so and
(b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th.
Neither Mr. GEERTS nor his family were involved in this decision.
Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th.
Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio.
For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection.
No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st.
Specifically at Princess Royal Hospital:
• Notes not completed.
• No nursing notes and no NEWS for 10th or 11th
• Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded.
• No plan for physiotherapy
• No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented.
• No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented.
• No referral of lack of urinary continence. Therefore no plan regarding this.
• Failed Trial without catheter on 3rd November 2014.
• Bowel monitoring chart not complete
• Discharge planning non-existent or inadequate
• Communication with patient and family virtually non-existent
• No senior review from 4th November 2014; possibility of chest infection not followed up.
• Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction.
• Discharge lounge information incorrect.
” Source location MR. ANTHONY GEERTS · Prevention of Future Deaths report
Open source report
11 Feb 2015 Rufjan BIBI · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to provide timely continence and personal care assistance View source
This report raised 2 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.
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AI-generated summary
Rufjan BIBI · 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
Rufjan Bibi, who had Parkinson’s disease and a previous subdural haematoma, fell at Mile End Hospital on 1 July 2014 and hit her head. The report raised concerns about inadequate nursing assistance and personal care, a suggestion that the family privately engage a nurse, and a five-hour delay before consultant review after the fall.
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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 timely continence and personal care assistance
Wider context from the report “1. Ms Bibi’s family told me at inquest that when they came to visit Ms Bibi, which they did daily, they often found her in need of changing (she was incontinent), and then had difficulty obtaining prompt nurse assistance .
They even found her with faeces in her hair.
Whilst this did not impact upon the outcome, it made me question the evidence I had been given about frequent nursing contact, in a way that I would not otherwise have done. (And of course, however busy staff are, it is not a situation that any of us would want for our loved ones.)
” Source location Rufjan BIBI · 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 Implement intentional rounding to monitor patients’ needs and safety.
Verbatim wording from the response “Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to” Source location 2015-0053-Response-by-Barts-Health-NHS-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 Carry out independent observations of care followed by reflective feedback with staff.
Verbatim wording from the response “Certain actions have already been taken. Intentional rounding has been implemented as have documentation audits as part of the Clinical Friday initiative which involves senior nurses carrying out a ward round every 1st and 3rd Fridays looking at safety and quality issues. Observations of care are also being carried out. This is an independent observation of the activity of a set team or ward area for a period of time which is then followed by a meeting between the observer and individual staff. The observation surveys a variety of things such as interactions between staff, patients and the public, telephone calls, 1:1 care and even practices such as infection prevention. The intention of the meeting afterwards is to allow the individual member of staff to reflect on their practice and on how they were perceived, allowing them to” Source location 2015-0053-Response-by-Barts-Health-NHS-Trust
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Includes failures of continence assessment, recording, referral, communication, toileting assistance, pad changing or continence-related personal care when they concern the patient’s continence needs.
