21 Oct 2025 Steven Roy Davidson · Prevention of Future Deaths report Essex
View report summary
Concerns raised 3 Inability to navigate System One records to find previous incidents of self-harm in prison View source Failure to search clinicians’ records from previous prison stays during Reception Health Screens or mental health needs reviews View source Insufficient training to understand and utilise System One records for previous history View source
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
Steven Roy Davidson · 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
Steven Roy Davidson died while in prison after a history of self-harm during a previous prison stay. The report identifies concerns that healthcare staff at HMP Chelmsford could not sufficiently navigate or search System One records, or did not sufficiently understand the importance of previous self-harm information when assessing his mental health and risk.
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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Inability to navigate System One records to find previous incidents of self-harm in prison
Wider context from the report “(1) Health Care Staff at HMP Chelmsford say that they are:
(i) not able to navigate the System One records sufficiently well to find information about previous incidents of self- harm in prison ; and/ or
(ii) not sufficiently aware of the importance of searching the records made by clinicians during previous prison stays when conducting Reception Health Screens and/ or reviews of a prisoner’s mental health needs.
(iii) May not be sufficiently trained to understand and utilise System One records to find previous history, including incidents of self- harm in custody.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to search clinicians’ records from previous prison stays during Reception Health Screens or mental health needs reviews
Wider context from the report “(1) Health Care Staff at HMP Chelmsford say that they are:
(i) not able to navigate the System One records sufficiently well to find information about previous incidents of self- harm in prison; and/ or
(ii) not sufficiently aware of the importance of searching the records made by clinicians during previous prison stays when conducting Reception Health Screens and/ or reviews of a prisoner’s mental health needs .
(iii) May not be sufficiently trained to understand and utilise System One records to find previous history, including incidents of self- harm in custody.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Insufficient training to understand and utilise System One records for previous history
Wider context from the report “(1) Health Care Staff at HMP Chelmsford say that they are:
(i) not able to navigate the System One records sufficiently well to find information about previous incidents of self- harm in prison; and/ or
(ii) not sufficiently aware of the importance of searching the records made by clinicians during previous prison stays when conducting Reception Health Screens and/ or reviews of a prisoner’s mental health needs.
(iii) May not be sufficiently trained to understand and utilise System One records to find previous history, including incidents of self- harm in custody .
” 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 Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
Verbatim wording from the response “SystmOne is the NHS electronic patient record system used in prison and custodial healthcare settings across the country. NHS North of England Commissioning Support (NECS) provides training and technical support for users of SystmOne, including system navigation, search functions and information retrieval. HCRG has amended its training provision so that all new staff will now receive structured SystmOne training as part of their induction, provided by NECS and recorded in the mandatory training schedule. This will include guidance on locating clinical information that may be stored in different parts of the system (see further below). Refresher training will also be provided to existing staff within three months and recorded in their personal training record.” Source location Response from HCRG 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 agency staff to confirm in writing that they understand how to navigate SystmOne clinical records and record confirmations.
Verbatim wording from the response “All agency staff will be required to confirm in writing that they understand how to navigate clinical records held in SystmOne and this will be recorded in the ShareDrive. Any long-term agency staff will also complete the same structured training as permanent staff.” Source location Response from HCRG 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 Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
Verbatim wording from the response “To ensure that records are being reviewed appropriately, the existing monthly audit of clinical notes will now include specific checks as to whether practitioners have accessed relevant historic information when assessing risk. Findings from the audit will feed into governance meetings and quality and performance monitoring available to NHS England commissioners.” Source location Response from HCRG 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 Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
Verbatim wording from the response “All Practitioners conducting clinical assessments should, as part of good practice, review relevant patient history when undertaking reception screenings, mental health reviews or risk assessments. In this case, it appears that practitioners focused primarily on Mr Davidson's current presentation rather than reviewing earlier records in depth. HCRG will reinforce through clinical governance that risk-related history should be considered when assessing patients, and that in some cases this may involve searching beyond the default summary record view.” Source location Response from HCRG 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 Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
Verbatim wording from the response “HCRG’s Performance and Quality teams are embedding SystmOne training into existing governance and supervision processes to ensure consistent and safe use of the platform. Staff may also contact the Performance and Quality Lead if further clarification is needed, either directly or via their line manager.” Source location Response from HCRG Care Group
Open published response
Concerns raised 9 Failure to formally request one-to-one supervision funding when necessary View source Failure to provide appropriate falls prevention for a resident with evolving dementia View source Failure to escalate a significant number of falls sustained by a frail older person View source Failure to provide organisational learning on accurate reporting and escalation View source Failure to provide training and development on falls prevention View source Failure to conduct appropriate risk assessment for a resident with evolving dementia View source Failure to meet the mobility needs of a resident with evolving dementia View source Failure to provide appropriate supervision for a resident with evolving dementia View source Failure to accurately and promptly report falls and complete falls-prevention referral forms View source See 6 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.
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AI-generated summary
Julia MURPHY · 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
Julia Murphy, known as Sheila, died in hospital on 9 April 2023 after a fall in her care home caused a hip fracture and her condition deteriorated. The report raises concerns about repeated falls, incomplete or inaccurate referrals to the falls prevention team, inadequate escalation, and failure to formally seek one-to-one supervision funding where appropriate.
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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to formally request one-to-one supervision funding when necessary
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate falls prevention for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate a significant number of falls sustained by a frail older person
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide organisational learning on accurate reporting and escalation
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide training and development on falls prevention
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct appropriate risk assessment for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to meet the mobility needs of a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility , supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate supervision for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 HCRG Care Group; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately and promptly report falls and complete falls-prevention referral forms
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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