10 Mar 2026 Ruariri Thomas STEWART · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 14 Fragmented storage of clinical records without a central access point View source Failure to notify the CQC of periods of absence without leave View source Investigations failing to identify and report safety issues View source Failure to include recent drug-use information in shift handovers View source Failure to hand over information about intended continued cocaine use View source Failure to assign individual accountability for planned drug testing View source Failure to fully consider recent substance misuse history in unescorted-leave decisions View source Failure to document and formalise leave reinstatement decisions View source Leave management by a non-s12 doctor during responsible-clinician absence View source Failure to create and complete required care plans View source Failure to investigate suspected drug use during leave suspension View source Failure to disclose relevant medical records View source Failure to enable named-nurse participation in MDTs View source Inaccurate named-nurse reporting to MDTs View source See 11 more concerns
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 this recipient says it has done, is doing, or plans to do in response to the concern raised. 16
Action
Monitor task completion during daily handovers, escalate outstanding work and audit compliance monthly through a senior practitioner.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Allocate every clinical task to a named individual and record the allocation in the DSR system.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Document all clinical and Mental Health Act decisions in patient files, the DSR system and relevant meeting minutes.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Implement MDT scheduling that enables named-nurse attendance or requires an appropriate alternative clinician to attend and prepare with the patient.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Record named-nurse or alternative-clinician MDT attendance and monitor compliance through monthly senior-practitioner audits.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Operate a monthly clinician-led quality and practice development forum to coach and mentor nurses in care-plan best practice.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Revise MDT documentation to include a current risk summary and the patient’s perspective, informed by review of patient documentation and interactions.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Require relevant patient information, including externally generated clinical documents, to be recorded, stored and uploaded through the expected DSR process.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Require admission care plans, 72-hour manager review, at least monthly named-nurse updates, and monthly audits of care-plan reviews and accuracy.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Implement a structured Disclosure Control Toolkit and governance process for mapping, searching, collating, reviewing and disclosing records.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Update the search policy, document required searches and drug tests in DSR, and provide refresher search training.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Submit general safeguarding concerns to the CQC and clarify staff statutory reporting requirements, including safeguarding duties.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Use a standardised DSR MDT reporting template completed before meetings, with automated compliance checks and senior-practitioner clinical supervision.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Require material disclosures in handovers and MDTs, using an updated handover template with monthly senior-practitioner and registered-manager audits.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source
Action
Review all future serious incidents in accordance with the PSIRF framework.
Stated plannedThe respondent said that this action was planned when they made their response on 12 March 2026. View source
Action
Reissue section 17 guidance and use separate escorted/emergency and unescorted leave forms for each patient.
Stated completedThe respondent said that this action was complete when they made their response on 12 March 2026. View source See 13 more actions
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AI-generated summary
Ruariri Thomas STEWART · 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
Ruariri Thomas Stewart, aged 29, died from fatal cocaine toxicity at Weaver Lodge Independent Hospital on 31 July 2025 after a period of unescorted leave during which he probably obtained cocaine. The report identifies concerns about failures in documentation, communication, information sharing, leave decision-making, substance-misuse management, record keeping, and the quality of post-incident investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Fragmented storage of clinical records without a central access point
Wider context from the report “11. Over the course of the inquest there were multiple, serious, disclosure issues relating to non-disclosure of medical records. It appears that at the time medical records were kept across a variety of locations and programmes, electronic and in paper . Staff therefore would not have had a central place to go to find all relevant clinical information about a patient . I am informed that there are plans to implement an electronic record keeping system but I do not have information about the nature, scope or timeframes for this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the CQC of periods of absence without leave
Wider context from the report “10. The CQC were not notified of periods when the patient went absence without leave
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Investigations failing to identify and report safety issues
Wider context from the report “12. The post event reflective practice report from AFG does not identify any of these issues . The "summary of issues / concerns highlighted" are wholly positive . Post incident reflection and investigation is an important tool to improve practices and prevent future deaths. Similar concerns about the quality of investigations by AFG were raised in a Regulation 28 report issued by the Manchester City Coroner in 2022 in relation to a death in 2019 (Shona Campbell).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to include recent drug-use information in shift handovers
Wider context from the report “6. On multiple occasions information about recent drug use was not part of the shift handover notes
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over information about intended continued cocaine use
Wider context from the report “8. Information from the patient that he intended to carry on taking cocaine was not handed over to the staff who made the final decisions about leave and checked the patient on return
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to assign individual accountability for planned drug testing
Wider context from the report “3. The MDT made plans for a patient to have drug tests. These were not allocated to an individual to be accountable and were instead allocated to "staff" . These tests were not carried out as planned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to fully consider recent substance misuse history in unescorted-leave decisions
Wider context from the report “7. Decisions were made to grant unescorted leave to a patient with a known and recent history of cocaine use whilst on unescorted leave, without a full appreciation of their recent substance misuse history
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document and formalise leave reinstatement decisions
Wider context from the report “4. When the responsible clinician was away for an extended period, leave was managed by a non s12 doctor. There is no contemporaneous documentary evidence of the decision making process by that doctor to reinstate leave as decisions were made outside the formal s17 MHA framework .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Leave management by a non-s12 doctor during responsible-clinician absence
Wider context from the report “4. When the responsible clinician was away for an extended period, leave was managed by a non s12 doctor . There is no contemporaneous documentary evidence of the decision making process by that doctor to reinstate leave as decisions were made outside the formal s17 MHA framework.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to create and complete required care plans
Wider context from the report “9. Care plans that should have been in place were either not created at all or were not fully completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate suspected drug use during leave suspension
Wider context from the report “5. On at least one occasion leave was suspended due to suspected drug use but no drug test was taken and no search carried out , and there was no documentation indicating that consideration had been given to undertaking these acts .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to disclose relevant medical records
Wider context from the report “11. Over the course of the inquest there were multiple, serious, disclosure issues relating to non-disclosure of medical records . It appears that at the time medical records were kept across a variety of locations and programmes, electronic and in paper. Staff therefore would not have had a central place to go to find all relevant clinical information about a patient. I am informed that there are plans to implement an electronic record keeping system but I do not have information about the nature, scope or timeframes for this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to enable named-nurse participation in MDTs
Wider context from the report “1. The timing of the shifts of the named nurse for the patient meant that she was not able to attend any MDT for the patient over many months and her input was therefore only in writing
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Inaccurate named-nurse reporting to MDTs
Wider context from the report “2. The named nurse written reports provided inaccurate information to the MDT , giving a reassuring picture of compliance which is not reflected by the written records
” 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 Monitor task completion during daily handovers, escalate outstanding work and audit compliance monthly through a senior practitioner.
Verbatim wording from the response “• Task completion by the assigned individual is monitored daily during shift handovers by oncoming staff, with any outstanding action either being completed by the incoming staff or escalated to senior management. Ongoing compliance is monitored via monthly handover form audit by a senior practitioner, which also enables early identification of trends and implementation of remedial action where appropriate.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate every clinical task to a named individual and record the allocation in the DSR system.
Verbatim wording from the response “• All clinical tasks are now clearly and unequivocally allocated to a named individual and recorded within the DSR system, to ensure clear accountability and ownership.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Document all clinical and Mental Health Act decisions in patient files, the DSR system and relevant meeting minutes.
Verbatim wording from the response “• All clinical decision-making, including that relating to MHA matters, is now documented within each patients’ file, both within the DSR system as well as additionally in any relevant minutes – for example within MDT meeting minutes, where a clinical decision has been taken during the course of that meeting.” Source location Response from Alternative Futures 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 Implement MDT scheduling that enables named-nurse attendance or requires an appropriate alternative clinician to attend and prepare with the patient.
Verbatim wording from the response “• An updated standard operating procedure has been implemented requiring MDT scheduling to take account of named nurse availability.” Source location Response from Alternative Futures 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 Record named-nurse or alternative-clinician MDT attendance and monitor compliance through monthly senior-practitioner audits.
Verbatim wording from the response “• Attendance at MDTs by a patient’s named nurse, or an alternative in their place, is formally recorded, with ongoing compliance monitored through routine monthly audits by a senior practitioner.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a monthly clinician-led quality and practice development forum to coach and mentor nurses in care-plan best practice.
Verbatim wording from the response “• There is also a clinician-led quality and practice development forum in place to coach and mentor nurses on care plan best practice, which meets monthly.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise MDT documentation to include a current risk summary and the patient’s perspective, informed by review of patient documentation and interactions.
Verbatim wording from the response “• MDT documentation has been revised and updated to require inclusion of a clear and current risk summary, and staff have been reminded to consider all the patient’s documentation including interactions with the patient. The patient’s perspective is included as part of the MDT preparation documents.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require relevant patient information, including externally generated clinical documents, to be recorded, stored and uploaded through the expected DSR process.
Verbatim wording from the response “• Staff have been reminded that relevant person/patient information, including externally generated clinical documents received by a property, must be recorded, stored and uploaded in line with the expected DSR process.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require admission care plans, 72-hour manager review, at least monthly named-nurse updates, and monthly audits of care-plan reviews and accuracy.
Verbatim wording from the response “• Before a new service user is accepted into a service, an admission care plan is carried out, and this is uploaded to the DSR system. Within 72 hours of admission, the registered manager reviews the admission care plan to ensure that the correct care plan is in place and meets the individual’s needs. Following admission and initial review, the DSR system creates a prompt, assigned to a patient’s named nurse, to review and where necessary update the care plan on an at least monthly basis. Care plans will also be updated on a shorter timescale if there is a clinical need, for example an adverse event or change in a patient’s presentation/ risk profile. Care plan reviews and updates are audited on a monthly basis to ensure continuing compliance, so that any remedial actions can be taken swiftly if required.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a structured Disclosure Control Toolkit and governance process for mapping, searching, collating, reviewing and disclosing records.
Verbatim wording from the response “• In response to the Coroner’s concern, AFG has reviewed its approach to record collation and disclosure and has taken action to strengthen the consistency and auditability of this process.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the search policy, document required searches and drug tests in DSR, and provide refresher search training.
Verbatim wording from the response “• The search policy has been updated and where a search or drug test is required, this is documented within the DSR system. Staff have received refresher training in conducting searches as part of the compliance process, and reminded of the importance of documenting all such actions.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Submit general safeguarding concerns to the CQC and clarify staff statutory reporting requirements, including safeguarding duties.
Verbatim wording from the response “• Following the Inquest, a safeguarding submission was made by AFG to the CQC as regards the general concerns raised at the hearing, and AFG has in addition clarified and reminded all staff of their statutory reporting requirements, including in respect of safeguarding.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a standardised DSR MDT reporting template completed before meetings, with automated compliance checks and senior-practitioner clinical supervision.
Verbatim wording from the response “• A standardised MDT reporting template has been introduced into the Digital Support Record (DSR) system, AFG’s electronic patient record software. The named nurse (or an alternative individual, as detailed in response to Concern 1) is sent the template attached to the MDT invite, and is required to complete this form seven days prior to the MDT meeting. The completion of this form triggers other processes within the DSR system, including monthly compliance checks and clinical supervision by a senior practitioner.” Source location Response from Alternative Futures 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 material disclosures in handovers and MDTs, using an updated handover template with monthly senior-practitioner and registered-manager audits.
Verbatim wording from the response “• Staff are required, and have been reminded to record in handover notes and MDT meetings, all material disclosures. To help with this process, the handover template has been reviewed and updated, to ensure it adheres to national standards and guidance. The adequacy of handover notes, and sufficiency of information provided, is reviewed monthly by a senior practitioner, and are also audited by a service’s registered manager to ensure appropriate completion and provision of information.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all future serious incidents in accordance with the PSIRF framework.
Verbatim wording from the response “• All future serious incidents will be reviewed in accordance with PSIRF framework.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reissue section 17 guidance and use separate escorted/emergency and unescorted leave forms for each patient.
Verbatim wording from the response “• Specifically in respect of s.17 MHA decision-making, AFG has updated and reissued to staff guidance as to the process to be followed. In addition, AFG has moved to a system of two leave forms for each patient: one that covers all escorted and emergency arrangements; and a second which covers unescorted leave, to minimise the impact to restriction and recovery.” Source location Response from Alternative Futures Group
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Medical information may legitimately remain across multiple appropriate sources; a structured collation and disclosure process can address this without a single central record.
Verbatim wording from the response “Over the course of the inquest there were multiple, serious, disclosure issues relating to non-disclosure of medical records. It appears that at the time medical records were not kept across a variety of locations and programmes, electronic and in paper. Staff therefore would not have had a central place to go to find all relevant clinical information about a patient. I am informed that there are plans to implement an electronic record keeping system but I do not have information about the nature, scope or timeframes for this.” Source location Response from Alternative Futures 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 AFG was not legally required to report unauthorised absences to the CQC because Weaver Lodge did not meet the prescribed security-unit categories.
Verbatim wording from the response “The CQC were not notified of periods when the patient went absence without leave.” Source location Response from Alternative Futures Group
Open published response
1 Jul 2022 Shona Christine Michaela Campbell · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 14 Failure of serious incident investigations to obtain relevant information and make additional enquiries View source Patient access to ligatures and other objects usable for self-harm or against others View source Failure to prevent repeated access to and use of ligatures View source Lack of appropriate contemporaneous clinical record keeping by support workers View source Lack of appropriate clinical supervision of nurses and support workers View source Lack of a clear clinical assessment and plan for repeated self-harm attempts View source Lack of an auditing process for care plans and risk assessments View source Inadequate communication of self-harm information, observation completion and records between nurses in charge and support workers View source Failure to complete patient observations as directed View source Failure to complete and update care plans and risk assessments after MDT meetings or ward rounds View source Failure to keep accurate records of patient observations View source Lack of appropriate contemporaneous clinical record keeping by nurses View source Lack of regular training in automated external defibrillator use View source Lack of regular training on applicable policies and procedures View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shona Christine Michaela Campbell · 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
Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to obtain relevant information and make additional enquiries
Wider context from the report “10. The opportunities missed by the Safety Matters Ltd Serious Incident Investigation report process to obtain other relevant information and/or make additional enquiries which could affect the overall findings and recommendations for learning, improving practice and procedures as well as patient safety . This will also help improve other investigations that the authors of the report may do in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Patient access to ligatures and other objects usable for self-harm or against others
Wider context from the report “5. That patients could obtain ligatures and other objects that could be used for self-harm/suicide and/or used against other patients and staff members .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent repeated access to and use of ligatures
Wider context from the report “9. The lack of a clear clinical assessment and plan to investigate and deal with repeated self-harm attempts that could result in serious injury or death as well as the repeated access to and use of ligatures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate contemporaneous clinical record keeping by support workers
Wider context from the report “2. The lack of appropriate contemporaneous clinical record keeping by the Support Workers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate clinical supervision of nurses and support workers
Wider context from the report “8. The need for appropriate clinical supervision of nurses and support workers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear clinical assessment and plan for repeated self-harm attempts
Wider context from the report “9. The lack of a clear clinical assessment and plan to investigate and deal with repeated self-harm attempts that could result in serious injury or death as well as the repeated access to and use of ligatures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of an auditing process for care plans and risk assessments
Wider context from the report “7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of self-harm information, observation completion and records between nurses in charge and support workers
Wider context from the report “4. There was inadequate communication between the Nurse in Charge and Support Workers about important clinical information relating to self-harm as well as completion of observations and the records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete patient observations as directed
Wider context from the report “3. Patient observations were not being completed as directed and accurate records were not being kept.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and update care plans and risk assessments after MDT meetings or ward rounds
Wider context from the report “7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate records of patient observations
Wider context from the report “3. Patient observations were not being completed as directed and accurate records were not being kept .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate contemporaneous clinical record keeping by nurses
Wider context from the report “1. The lack of appropriate contemporaneous clinical record keeping by the nurse in charge as well as other nurses .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of regular training in automated external defibrillator use
Wider context from the report “6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Alternative Futures Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of regular training on applicable policies and procedures
Wider context from the report “6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations