24 Apr 2026 Kenneth John Morris · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Failure to provide required one-to-one nursing care View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kenneth John Morris · 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
Kenneth John Morris, aged 78, died at Hull Royal Infirmary on 10 December 2025 after a second unwitnessed ward fall caused intracranial haemorrhage, brain damage and early post-traumatic epilepsy. The principal concern was that he did not receive required one-to-one nursing care because of understaffing and more pressing cases, and evidence indicated that similar deaths may occur while resources remain critically stretched.
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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 one-to-one nursing care
Wider context from the report “This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care . Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur.
” Source location Kenneth John Morris · 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 Publish a new 10 Year Workforce Plan to support appropriate NHS staffing and workforce distribution.
Verbatim wording from the response “In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan. The plan, which will be published this year, will help ensure the NHS has the right people in the right places to deliver the best care for patients.” Source location Response from Department of Health and Social Care
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 Individual NHS trusts and employers are responsible for determining staffing levels and workforce composition.
Verbatim wording from the response “I have carefully considered the situation. Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect Hull University Teaching Hospitals NHS Trust and all other NHS Trusts to ensure that their staffing arrangements, are appropriate following the tragic death of Mr Morris.” Source location Response from Department of Health and Social Care
Open published response
8 Feb 2026 Elise Kay Louise Sebastian · Prevention of Future Deaths report Essex
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Concerns raised 1
Failure to provide required key-nurse one-to-one sessions View source
This report raised 30 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation Trust
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AI-generated summary
Elise Kay Louise Sebastian · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.
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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 key-nurse one-to-one sessions
Wider context from the report “9. Elise’s key nurse was working nights and was not having the required 1:1 with Elise and key documents were not completed for Elise’s care. Inaccuracies and inconsistencies in record-keeping remains a concern.
” Source location Elise Kay Louise Sebastian · 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 Existing monitoring by charge nurses, record review and reallocation processes is considered sufficient to address gaps in patients’ weekly key-nurse one-to-ones.
Verbatim wording from the response “Response
By way of assurance on this, the Court is advised that all staff are part of internal rotation, which includes nursing staff being rostered to work night and day duties. The night shifts start at 7pm; this enables staff to have 1:1 with patients during the course of the evening. This is often preferable for the young person depending on activities during the day. During the day, the unit provides a full education programme and therapeutic programme outside of education hours. Therefore, spending time with key nurse outside of these hours often means this is quality, uninterrupted time with patients.” Source location 2026-0078 - Response from Essex University Partnership Trust
Open published response
18 Jun 2025 Margaret Elizabeth DOUGLAS · Prevention of Future Deaths report Cheshire
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Concerns raised 3
Failure of one-to-one carers to understand individuals’ complex needs View source Failure of one-to-one carers to communicate effectively with individuals who have speech difficulties View source Failure to ensure provision of required one-to-one care before accepting care responsibilities View source
Linked response
Minster Care Management Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Minster Care Management Limited
Provide clinical nurse and director support to managers managing residents with complex needs.
View source
Minster Care Management Limited
Require staff engaged by the service to complete the IELTS exam before working on site.
View source
Minster Care Management Limited
Include agency-worker induction in routine internal monitoring through a documented monthly area-manager audit.
View source
Minster Care Management Limited
Provide written care descriptions and relevant care-plan information during handovers to irregular staff, alongside verbal handover and electronic access.
View source
Minster Care Management Limited
Assess overseas agency workers’ spoken and written English at each shift and exclude those with inadequate proficiency from working on site.
View source
Minster Care Management Limited
Remind managers to escalate refusals of required one-to-one care to Head Office and the oversight team.
View source
Minster Care Management Limited
Assess and provide interim one-to-one care using the organisation’s workforce while external funding is pursued.
View source See 4 more actions
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AI-generated summary
Margaret Elizabeth DOUGLAS · 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
Margaret Elizabeth Douglas suffered recurrent falls, a subdural haemorrhage, worsening stroke symptoms and increasing frailty while receiving care, and died after a further deterioration at Holcroft Grange. Concerns included accepting her into care despite being unable to provide the required one-to-one supervision, and using carers whose understanding of her complex needs and ability to communicate effectively were questioned, particularly given her risk of aspiration.
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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 of one-to-one carers to understand individuals’ complex needs
Wider context from the report “ii) In the course of the Inquest I heard evidence from the individual who was caring for Elizabeth on the morning of her death and in the course of that evidence it became apparent that the carer had little understanding of Elizabeth’s needs and had difficulty communicating and understanding information in English. The evidence given by those at Holcroft Grange was that they outsourced the provision of the one to one carers to a company, '1st Care 4 U Ltd' who had been approved for use by their parent company 'Minster Care Group'. At the time the care was provided, it was known by those responsible for sourcing the care, that there were difficulties with Elizabeth’s communication and complex needs. This evidence gives rise to significant concerns in respect of the ability of those providing one to one care to understand an individual’s complex needs and their ability to communicate with those who themselves have difficulties with their speech. The concerns were heightened in the context of this case given that Elizabeth was at high risk of aspiration and if carers are unable to understand the complexities of an individual’s needs and communicate effectively with them, it poses a risk to their life.
” Source location Margaret Elizabeth DOUGLAS · 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 one-to-one carers to communicate effectively with individuals who have speech difficulties
Wider context from the report “ii) In the course of the Inquest I heard evidence from the individual who was caring for Elizabeth on the morning of her death and in the course of that evidence it became apparent that the carer had little understanding of Elizabeth’s needs and had difficulty communicating and understanding information in English . The evidence given by those at Holcroft Grange was that they outsourced the provision of the one to one carers to a company, '1st Care 4 U Ltd' who had been approved for use by their parent company 'Minster Care Group'. At the time the care was provided, it was known by those responsible for sourcing the care, that there were difficulties with Elizabeth’s communication and complex needs. This evidence gives rise to significant concerns in respect of the ability of those providing one to one care to understand an individual’s complex needs and their ability to communicate with those who themselves have difficulties with their speech . The concerns were heightened in the context of this case given that Elizabeth was at high risk of aspiration and if carers are unable to understand the complexities of an individual’s needs and communicate effectively with them , it poses a risk to their life.
” Source location Margaret Elizabeth DOUGLAS · 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 ensure provision of required one-to-one care before accepting care responsibilities
Wider context from the report “i) In the course of the Inquest I heard evidence that by the 5th September 2024, Holcroft Grange had already identified that they were unable to meet Elizabeth's needs, considering that she required one to one care. Despite being aware that they were unable to meet Elizabeth's needs and that they were unable to provide one to one care , Holcroft Grange accepted Elizabeth back into their care , following which she suffered a further fall. Agreeing to provide care for an individual in circumstances where it is known that the level of care that person requires to keep them safe cannot be provided , creates a risk that future deaths could occur as a consequence of inadequate care and supervision.
” Source location Margaret Elizabeth DOUGLAS · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinical nurse and director support to managers managing residents with complex needs.
Verbatim wording from the response “We understand that costs should not be a factor which determines the necessity of providing 1-1 care. Within the Croftwood Care portfolio of homes, any manager can contact me to seek support with navigating the difficulties in securing funding for clients such as Elizabeth.” Source location Response from Minster Care Group
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 Require staff engaged by the service to complete the IELTS exam before working on site.
Verbatim wording from the response “In order to ensure that any staff engaged by Holcroft Grange have an appropriate understanding of residents’ care needs, we ensure that they have completed the International English Language Test (IELTS) exam. This forms part of our introductory checklists and paperwork prior to staff members working on our premises.” Source location Response from Minster Care Group
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 Include agency-worker induction in routine internal monitoring through a documented monthly area-manager audit.
Verbatim wording from the response “2) Our induction policy for agency workers will now form part of our compliance test undertaken by our routine internal monitoring teams. A monthly audit is carried out by area managers and the induction policy for agency workers will form a specific section within the audit documentation. This will provide assurances to our monitoring team that all agency staff have had sufficient opportunity to engage and read the relevant care plans for each resident they are caring for. Each agency carer will also have an induction through their own agency, before they are given an induction to the site and to the residents to be cared for, which will include time allocated to read specific care plans.” Source location Response from Minster Care Group
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 Provide written care descriptions and relevant care-plan information during handovers to irregular staff, alongside verbal handover and electronic access.
Verbatim wording from the response “3) Handover of care between staff will be enhanced to ensure that any irregular staff ie Agency carers, have a written description of the issues and conditions that a person may exhibit. In addition to verbal handovers from the relevant staff members, written descriptions of the care plans will now be provided at the start of the shift. Information contained in the handover is also provided on handheld electronic devices that are given to all staff, and this information can also be easily updated at any given time.” Source location Response from Minster Care Group
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 Assess overseas agency workers’ spoken and written English at each shift and exclude those with inadequate proficiency from working on site.
Verbatim wording from the response “1) Our organisation will ensure that all overseas workers that attend our services via agencies have a competent understanding of the English language, both spoken and written. This will now be assessed by the person in charge of each shift to ensure that the command of the English language is good. Where it is deemed “inadequate” the staff member will not be allowed to work on site.” Source location Response from Minster Care Group
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 Remind managers to escalate refusals of required one-to-one care to Head Office and the oversight team.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
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 Assess and provide interim one-to-one care using the organisation’s workforce while external funding is pursued.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
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 suggestion that providers can fund one-to-one care and reclaim costs from local authorities does not reflect the provider’s experience.
Verbatim wording from the response “I note in court, that the local authority stated that as a provider we could have put a 1-1 in place and then claimed back the monies later down the line. However, this suggestion is just not my experience or our company’s experience of working with local authorities and I can highlight several cases whereby we are pursuing funds for such cases via the courts.” Source location Response from Minster Care Group
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 One-to-one care cannot continue indefinitely without local-authority funding; if funding is refused, the resident may need to leave the home.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
Open published response
2 May 2025 Raihana Oluwamidalo Awolaja · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2
Insufficient staff training on what one-to-one care means in practice View source Failure to provide children requiring one-to-one care with sufficiently intensive care and supervision 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. 7
The Children's Trust
Provide mandatory training on monitoring, observation, and one-to-one care requirements.
View source
The Children's Trust
Require one-to-one carers to confirm care requirements and obtain approval before stepping away or ending shifts.
View source
The Children's Trust
Provide a 24-hour floating staff role to supply additional care and supervision when needed.
View source
The Children's Trust
Maintain 24-hour on-site clinical oversight through a Clinical Site Manager.
View source
The Children's Trust
Conduct and systematically review routine overnight clinical care and observation audits.
View source
The Children's Trust
Embed an evidence-based staffing model aligned with national standards and individual children’s needs.
View source
The Children's Trust
Convene a multi-agency Risk Summit to improve specialist NHS access and review monitoring and observation policies.
View source See 4 more actions
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AI-generated summary
Raihana Oluwamidalo Awolaja · 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
Raihana Oluwamidalo Awolaja, who was tracheostomy-dependent and required one-to-one nursing care, was left unsupervised at her residential care home for approximately fifteen minutes. Secretions blocked her tracheostomy, causing respiratory compromise and cardiac arrest; she was later resuscitated but died of hypoxic ischaemic brain injury. The principal concerns included inadequate supervision and staffing, possible shortcomings in training and communication, and concerns about the care provider’s investigation and handling of concerns raised by next of kin.
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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 Insufficient staff training on what one-to-one care means in practice
Wider context from the report “4. That there may be staff training issues in relation to what one to one care means in practice .
” Source location Raihana Oluwamidalo Awolaja · 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 children requiring one-to-one care with sufficiently intensive care and supervision
Wider context from the report “1. That children such as Raihana requiring one to one care are still at times receiving less intensive care and supervision than they require .
” Source location Raihana Oluwamidalo Awolaja · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory training on monitoring, observation, and one-to-one care requirements.
Verbatim wording from the response “• Mandatory Training: All care giving staff now receive mandatory, specific training on our monitoring and observation policy, including clear guidance on what one-to-one care entails at The Children’s Trust. This training covers essential aspects such as proximity, engagement, and supervision.” Source location Response from The Children’s 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 Require one-to-one carers to confirm care requirements and obtain approval before stepping away or ending shifts.
Verbatim wording from the response “• Delegation Policy: As part of our revised Delegation Policy, The Children’s Trust now requires that every staff member allocated to provide one-to-one care for a child or young person, formally sign at the start of each shift to confirm their understanding of that individual’s care, monitoring, and observation needs; furthermore, they must seek approval from the shift leader before stepping away at any time during the shift, including for breaks, and must obtain permission to leave at the end of their shift to ensure safe and continuous care with no gaps during handovers.” Source location Response from The Children’s 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 Provide a 24-hour floating staff role to supply additional care and supervision when needed.
Verbatim wording from the response “• Floating Staff Role Introduced: We have introduced a flexible “floating” staff role available 24 hours a day. This role ensures that additional support can be provided promptly whenever needed, guaranteeing that children and young people consistently receive the appropriate level of care and supervision without interruption.” Source location Response from The Children’s 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 Maintain 24-hour on-site clinical oversight through a Clinical Site Manager.
Verbatim wording from the response “• Clinical Site Management: A Clinical Site Manager, a senior nurse, is now present on site 24 hours a day. This role allows immediate response to any clinical issues or escalations, enhancing clinical oversight and quality of care.” Source location Response from The Children’s 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 Conduct and systematically review routine overnight clinical care and observation audits.
Verbatim wording from the response “• Routine Audits: In addition to regular monitoring and observation audits, Clinical Site Managers conduct routine overnight audits. These are systematically reviewed to maintain high standards of care.” Source location Response from The Children’s 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 Embed an evidence-based staffing model aligned with national standards and individual children’s needs.
Verbatim wording from the response “• We are in the process of embedding a revised evidence-based staffing model aligned with national standards. This model aims to continue to ensure the appropriate number and mix of staff are available according to the individual needs of each child.” Source location Response from The Children’s 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 Convene a multi-agency Risk Summit to improve specialist NHS access and review monitoring and observation policies.
Verbatim wording from the response “• Risk Summit: In November 2024, we convened a Risk Summit involving NHS England, regulatory bodies, health and social care partners, and commissioners. This summit” Source location Response from The Children’s Trust
Open published response
14 Jan 2020 John David Long · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 1
Failure to provide safe break and relief arrangements during 1:1 care View source
This report raised 3 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
John David Long · 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 David Long suffered an unwitnessed fall from his bed in Benjamin Weir Ward at St. George’s Hospital on 4 May 2019, sustaining a head injury that led to his death. The concerns identified relate to the design and suitability of bed rails, the definition and administration of one-to-one care, provision of breaks without leaving the patient alone, and training for one-to-one care.
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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 safe break and relief arrangements during 1:1 care
Wider context from the report “2. A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means. In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient. Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and how they are relieved from their duties in such circumstances but ensuring the Patient is not left alone at any time .
” Source location John David Long · Prevention of Future Deaths report
Open source report
22 Dec 2016 Edwina Rose Moses · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Failure to clearly allocate responsibility for requesting and securing additional nursing cover for one-to-one support 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
Edwina Rose Moses · 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
Edwina Rose Moses was admitted to hospital after a fall at home that fractured her left hip. While in hospital, she fell from her bed at a time when she should have been receiving one-to-one nursing care, fractured her right hip, and later died following an upper gastrointestinal bleed; concerns included poor systems for arranging additional nursing cover and inadequate staffing when such cover was unavailable.
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 clearly allocate responsibility for requesting and securing additional nursing cover for one-to-one support
Wider context from the report “1. The evidence revealed that there was a poor system in place for requesting additional nursing cover to provide one to one support . There was confusion by front line staff as to who was responsible for identifying, booking and ensuring that such help was provided .
” Source location Edwina Rose Moses · 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 Establish daily staffing monitoring that identifies patients requiring enhanced observation, includes out-of-hours handover, and checks Nurse Bank availability.
Verbatim wording from the response “The Princess of Wales Hospital Managed Unit has reviewed its process around enhanced observation. The review included the standard of completion of Risk Assessments and introducing a process to monitor staffing levels across the site which will include the identification of all patients requiring enhanced observation. There is daily monitoring of staffing levels in place which is subsequently handed over to the Out of Hours team for evenings and weekends. All staff have been made aware of the process to check the Nurse Bank system. This work will link into the Health Board Falls Management group as prevention of falls is one of the main criteria for requesting enhanced observation.” Source location 2016-0462-Response-by-University-Health-Board.pdf
Open published response
3 Oct 2016 Amy El-Keria · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Inadequate staffing levels for one-to-one care in inpatient CAMHS units View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Amy El-Keria · 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
Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.
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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 Inadequate staffing levels for one-to-one care in inpatient CAMHS units
Wider context from the report “(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan . It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued. There is currently no national guidance on staffing levels for inpatient CAHMS
” Source location Amy El-Keria · 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 Existing staffing reviews, multidisciplinary support, on-call arrangements and staff redeployment are considered sufficient to determine appropriate staffing levels.
Verbatim wording from the response “We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.” Source location 2016-0347-Response-by-Priory-Group
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 staffing guidance, continual staffing reviews, multidisciplinary support and escalation arrangements are considered sufficient to determine appropriate staffing levels.
Verbatim wording from the response “We note your comments in relation to the QNІC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.” Source location 2016-0347 - Response from Priory
Open published response
Concerns raised 1
Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls View source
This report raised 2 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
Howell Glyndwr Fisher · 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
Howell Glyndwr Fisher fell at home, sustained a fractured hip, and later died in hospital on 9 December 2014 after developing an ischemic leg, pneumonia and other health problems. The concerns included at least five falls while he was assessed as being at high risk, insufficient staffing to provide required one-to-one nursing, and inadequate handover and falls-risk assessments between and within hospitals.
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 Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls
Wider context from the report “(1) Within the space of a month the deceased had at least 5 falls whilst being deemed as high risk of falls. He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that this could not be delivered.
” Source location Howell Glyndwr Fisher · Prevention of Future Deaths report
Open source report
10 Apr 2015 Maurice Camfield · Prevention of Future Deaths report West Yorkshire (East)
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Concerns raised 1
Failure to provide one-to-one nursing care in accordance with the agreed care plan View source
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
Maurice Camfield · 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
Maurice Camfield suffered a traumatic brain injury in a road traffic collision in Bangkok, was repatriated to the United Kingdom, and later died in an ambulance after becoming unresponsive during transfer to hospital. The substantive concern was that the agreed care plan requiring one-to-one nursing care at all times was not followed.
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 provide one-to-one nursing care in accordance with the agreed care plan
Wider context from the report “I heard evidence at this Inquest from ████████ a Consultant in Neurological Rehabilitation who expressed the view that it was important that in Mr Camfield's case that those involved in his care and treatment should do so strictly in accordance with the agreed plan which dictated that he should have one to one nursing care at all times . ████████ stressed the importance of doing what was in our care plan which did not happen in Mr Camfield's case .
” Source location Maurice Camfield · Prevention of Future Deaths report
Open source report
1 Apr 2015 John Lowe · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 1
Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs View source
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
John Lowe · 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 Lowe was an inpatient receiving mental health assessment and care after suffering a stroke. After a series of falls, his final fall on 18 February 2014 caused a fractured left neck of femur, which materially contributed to his death from bronchopneumonia on 26 February 2014. Concerns related to nursing staff beliefs that 1:1 nursing could not be provided solely for falls risk or physical care needs.
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 Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs
Wider context from the report “1. That there was a belief amongst members of the Trust’s nursing staff that they were unable as a matter of policy to provide 1:1 nursing care for a patient in respect of that patient’s falls risk assessment alone, no matter what that assessment might be.
2. That there was a belief amongst members of the Trust’s nursing staff that 1:1 nursing could only be provided on the basis of a patient’s particular mental health needs, and not in respect of his or her physical care needs.
” Source location John Lowe · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.