11 Apr 2022 Tracy Dawn WOOD · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 19 Failure to record important clinical events and patient discussions View source Failure to ensure accuracy of staff statements used in patient safety investigations View source Failure to investigate the source and nature of a hazardous item after an incident View source Failure to review hourly observations after a serious incident View source Failure to recover and check restricted items when patients return to the ward View source Insufficient ward staffing for required one-to-one patient support View source Inaccuracies in patient safety incident investigation reports View source Lack of clinical or management leadership supervision on the ward View source Inaccurate dates and times in clinical records View source Failure to interview relevant staff during patient safety investigations View source Delays in completing and providing patient safety incident investigation reports View source Delayed availability of emergency life-saving equipment at the patient’s room View source Failure to provide timely psychiatric doctor assessment when requested View source Incident investigations failing to establish the sequence of safety-critical events View source Patient safety investigations omitting relevant incident and record-keeping concerns View source Failure to document multidisciplinary observation decisions in clinical notes View source Failure to record administration of hazardous items and the rationale for overriding restrictions View source Failure to obtain clinical authorisation before overriding restrictions on hazardous items View source Ambiguous scope of restrictions on giving hazardous items to patients View source See 16 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
Tracy Dawn WOOD · 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
Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.
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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record important clinical events and patient discussions
Wider context from the report “8. Certain events are not included in the records , for example that a ████████ had been given to Tracy on 1 June 2021 on her going off ward , contrary to the instruction contained in the SBAR records and of 121 Talk times with Tracy. Evidence was heard that steps are being taken to improve record keeping. However this matter has been raised with NSFT previously and evidence from one witness at the inquest was that “every discussion” with a service user is recorded in the Clinical Record and that entries are made by one allocated person on a shift who will be told orally what to put by members of staff. This witness had had a 30 to 40 minute one to one meeting with Tracy the day prior to her ████████ on 1 June and talk time with Tracy on the day following her ████████ on 1 June, details of which may have been helpful to other staff and regarded of some importance to Tracy’s care
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accuracy of staff statements used in patient safety investigations
Wider context from the report “14. The PSII stated that statements of members of staff “for the Coroner” were reviewed. However many of these statements contained inaccurate dates and times including the date of death .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the source and nature of a hazardous item after an incident
Wider context from the report “5. Following Tracy ████████ on the evening of 1 June 2021, there was no investigation as to where she obtained the ████████ , despite there being a bold, red instruction in the SBAR records that Tracy was not to be given a ████████. By the date of the inquest some witnesses were still unaware as to how Tracy had come by the ████████ with. Some witnesses were still unaware as to what Tracy had used as a ████████
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to review hourly observations after a serious incident
Wider context from the report “6. Following Tracy ████████ on 1 June 2021, there was a review meeting and then a Multi Disciplinary Team Meeting. She had a meeting with the Psychologist later that day. No evidence was heard that there was a review of hourly observations
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recover and check restricted items when patients return to the ward
Wider context from the report “4. Part of the Risk Assessment for giving a ████████ to Tracy was that she was to hand the ████████ back on her return to the ward. Tracy did not return the ████████ and was not asked to return the ████████ . That Tracy had been given an ████████ was overlooked on her 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient ward staffing for required one-to-one patient support
Wider context from the report “1. Tracy Wood was placed on Yare Ward, an acute ward which was staffed in accordance with “Safer staffing levels”. We heard that additional staffing could be requested if necessary. The ward was described by witnesses as “busy” and at times “chaotic”. Staff were not always available to give Tracy one to one talk time which was recognised as being important to her and for her mental wellbeing, so much so a note was placed in red and bold on her SBAR records “If we are allocated to TW 1-1 we need to make sure we are doing it, she needs consistency”. Evidence was heard that steps are being taken to recruit more staff and also to retain existing staff and this is a national problem. The evidence was that the staffing levels are still not sufficient and that recruiting staff remains a problem
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in patient safety incident investigation reports
Wider context from the report “11. The PSII Report contains many inaccuracies including Tracy’s date of death, stating it to be 5 June 2021. The report refers to Tracy ████████ again at 21:00 on 3rd June 2021. The correct date is the 2 June 2021
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical or management leadership supervision on the ward
Wider context from the report “16. The first draft of the PSII Report contains a sentence “However, staff noted there was a lack of clinical or management leadership supervision on the ward at the time and they were often left to “firefight” with patients who they perceived carried a greater level of acute risk than Tracy.” This view of staff was not included in the final draft 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. The report was sent to Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Inaccurate dates and times in clinical records
Wider context from the report “7. Written records did not specify correct dates and times as to events , for instance the Event Date/Time of the ████████ incident on 1 June 2021 at 20:53 hours is recorded in the Clinical Notes as “02 Jun 2021 06:49”. Tracy’s date of death is recorded as 5 June 2021 and her date of birth in the SBAR records is recorded as 1 May 1981, when it is the 1 June 1981 .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to interview relevant staff during patient safety investigations
Wider context from the report “13. The PSII did not involve interviews with members of staff who had involvement with Tracy in the hours and days prior to her death , including staff who gave the ████████ to Tracy and a Nurse who had regular involvement with Tracy’s care and who knew her well
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in completing and providing patient safety incident investigation reports
Wider context from the report “10. A draft Patient Safety Incident Investigation Report (PSII) has been prepared. Evidence was heard that this is now used rather than a Serious Incident Requiring Investigation Report and has the advantage of being “more timely” and providing more learning. The report was still in draft form at the date of the inquest (nine months following Tracy’s death) and the draft was only available to me on the morning of the first day of the inquest , despite assurances at Pre Inquest Review Hearings that it would be available prior to the inquest.
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Delayed availability of emergency life-saving equipment at the patient’s room
Wider context from the report “9. On Tracy being found on the 2 June 2021 with a ████████ around her neck, emergency life-saving equipment was not brought immediately to Tracy’s room . Monitoring equipment was obtained by a member of staff who gave evidence they were unaware Tracy was not breathing . On return to Tracy’s room the emergency “crash bag” was then requested and obtained .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely psychiatric doctor assessment when requested
Wider context from the report “2. Following Tracy ████████ on the evening of 1 June 2021 the Duty Psychiatric Doctor was called to attend to see and assess Tracy, but did not attend . She was assessed by nursing staff but she was not seen by a Psychiatric Doctor as requested by them, until the next morning during a review meeting
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Incident investigations failing to establish the sequence of safety-critical events
Wider context from the report “12. The PSII report refers to the notes of the incident on 1 June 2021 that Tracy ████████ with a ████████ but goes on to say that in interviews a cord from her ████████ was used. Confusion remains as between the events on the 1 June 2021 and the 2 June 2021 . The report refers to the view of the MDT meeting on 2 June was to keep Tracy on hourly observations. There is no reference in the Clinical Notes to observations being discussed. Witnesses asked about observations at the inquest could not recall observations being discussed or that they were not discussed.
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Patient safety investigations omitting relevant incident and record-keeping concerns
Wider context from the report “15. The PSII does not make findings with regard to areas of concern raised at the inquest such as with regard to Tracy being given a ████████ on the morning of 1 June 2021 despite there being a bold red note contained in the records that Tracy should not be given a ████████, that this was not discussed with any other senior member of staff, no record was made of the decision and the rationale for the decision, nor that the ████████ was not returned on Tracy’s return. The PSII does not include reference to inaccurate record keeping and full records of important events 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document multidisciplinary observation decisions in clinical notes
Wider context from the report “12. The PSII report refers to the notes of the incident on 1 June 2021 that Tracy ████████ with a ████████ but goes on to say that in interviews a cord from her ████████ was used. Confusion remains as between the events on the 1 June 2021 and the 2 June 2021. The report refers to the view of the MDT meeting on 2 June was to keep Tracy on hourly observations. There is no reference in the Clinical Notes to observations being discussed . Witnesses asked about observations at the inquest could not recall observations being discussed or that they were not discussed .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record administration of hazardous items and the rationale for overriding restrictions
Wider context from the report “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward. There was no discussion with a Doctor or any other clinical staff when making this decision. There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain clinical authorisation before overriding restrictions on hazardous items
Wider context from the report “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward. There was no discussion with a Doctor or any other clinical staff when making this decision . There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Ambiguous scope of restrictions on giving hazardous items to patients
Wider context from the report “3. Tracy ████████ on 30 March 2021 and a note was placed on her SBAR records in red and bold “Do not give Tracy ████████”. On 1 June 2021 Tracy was given a ████████, at her request, before leaving the ward for a community visit. Evidence was heard that following a “risk assessment” it was acceptable for this decision to be made by a Band 6 Nurse when the ████████ was used off the ward and not on the ward where the original incident had occurred. The instruction not to give the ████████ did not specify whether this applied on or off the ward . There was no discussion with a Doctor or any other clinical staff when making this decision. There was no record of the ████████ being given to Tracy in the written records and no record of the rationale for the decision being made
” Open source report
15 Feb 2022 Theo Jude BRENNAN-HULME · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 2 Failure to conduct an immediate check or discussion before discharge from the Community Team following assessment View source Persistence of a bullying and harassment culture within the Crisis Resolution Home Treatment Team View source
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
Theo Jude BRENNAN-HULME · 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
Theo Brennan Hulme, a university student with Asperger’s Syndrome, a history of deliberate self-harm and suicidal thoughts, was found hanging in his room on 12 March 2019 and declared dead at the scene. The report identified concerns about the adequacy and timeliness of his mental health assessment, failure to make reasonable adjustments or involve his family, lack of follow-up after a missed appointment, a persistent culture within the Crisis Resolution Home Treatment Team, and the absence of an immediate review when a person is discharged after assessment.
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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an immediate check or discussion before discharge from the Community Team following assessment
Wider context from the report “2. Following an Assessment, a person is still discharged from the Community Team without any immediate “check” or discussion as to the correctness of this decision . It was heard that following Theo’s death immediate discharge from the Community Team following assessment is relatively rare. In these circumstances, such a discussion would not place an onerous burden on the Team and would enable a review of the discharging decision to be undertaken to ensure it is the correct decision.
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Persistence of a bullying and harassment culture within the Crisis Resolution Home Treatment Team
Wider context from the report “1. Evidence was heard of a historic culture of bullying and harassment within the Crisis Resolution Home Treatment Team which has led to a loss of compassion in some instances with the view that some suicides are ‘inevitable’ and some reluctance to recognise when cases should be referred to the Team . Work has been undertaken by the Trust to improve such cultural attitudes. However, it was recognised in evidence that there is “still a distance to go” and areas where the culture needs to change . It is of concern that this culture remains three years following Theo’s death
” Open source report
10 Feb 2022 Sheila Elizabeth Steggles · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Failure to recognise reduced mobility as a risk factor and take appropriate steps View source Failure to perform and document VTE risk assessments after reduced mobility from baseline View source Failure of junior staff to seek senior advice about anticoagulation interactions before administration View source Failure of staff to be aware of patients’ relevant past medical history View source Failure to record specific review plans in care plans View source Insufficient detail about patients in clinical notes View source Failure to document specific staff concerns in clinical notes View source See 4 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
Sheila Elizabeth Steggles · 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
Sheila Elizabeth Steggles, who had reduced mobility and several risk factors for thrombosis, collapsed on 5 November 2019 and died in an ambulance after suffering a cardiac arrest. The cause of death was recorded as acute pulmonary embolus arising from deep vein thrombosis. Concerns included the absence of a documented VTE risk assessment, insufficient consideration of reduced mobility and past DVT, inadequate staff training, and missed opportunities to provide prophylactic heparin.
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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise reduced mobility as a risk factor and take appropriate steps
Wider context from the report “Irrespective of the reason for a person’s mobility reducing, if it does so and this is a known risk factor then notice must be taken of it and appropriate steps taken .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to perform and document VTE risk assessments after reduced mobility from baseline
Wider context from the report “Medical staff should follow the Trust’s protocols and perform and document a VTE risk assessment when the reduction in mobility is reduced (from their baseline) even if it is not known if/ how long the reduction will continue.
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of junior staff to seek senior advice about anticoagulation interactions before administration
Wider context from the report “Junior staff should consult more senior staff if they are unsure of the effect that anti-coagulation will have on anti-psychotics or other medication and are thus concerned about administering 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to be aware of patients’ relevant past medical history
Wider context from the report “All staff should be aware of a patient’s relevant past medical 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to record specific review plans in care plans
Wider context from the report “If a patient is to be reviewed then a specific plan should be placed on to the care plan so that everyone knows what is needed to be done .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Insufficient detail about patients in clinical notes
Wider context from the report “All staff should raise concerns and if they have specific ones, document what these are in the clinical notes. Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to document specific staff concerns in clinical notes
Wider context from the report “All staff should raise concerns and if they have specific ones, document what these are in the clinical notes . Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts.
” Open source report
20 Oct 2021 Mary Jane BUSH · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 3 Failure to recruit, retain and resource suitably skilled staff View source Delays in access to psychological therapy View source Delays in mental health assessment following referral View source
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
Mary Jane BUSH · 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
Mary Jane BUSH, who had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, was found at her home on 6 August 2020; the inquest conclusion was suicide. The principal concerns were delays in her mental health assessment and psychological therapy, ongoing delays in providing therapy, and difficulties with recruitment and retention of suitably skilled staff.
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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit, retain and resource suitably skilled staff
Wider context from the report “5. However, there is the ongoing issue of recruitment and retention of suitably skilled staff by the Trust and the ability to resource this to enable the Trust to function effectively
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in access to psychological therapy
Wider context from the report “2. There was a delay in Mary receiving psychological therapy. She was still on the waiting list at the time of her death.
3. The evidence was that at the date of inquest, there continued to be a delay in service users receiving psychological therapy . Evidence was heard that balancing capacity and demand, which has increased, remains a challenge. The cases referred are of increasing complexity, as in Mary’s case
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Delays in mental health assessment following referral
Wider context from the report “1. Mary was referred to the mental health team in November 2019 and was assessed in January 2020, some three weeks later than should have been .
” Open source report
9 Sep 2021 Joshua SAHOTA · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1 Failure to communicate patient-specific restricted items to families and friends before ward visits View source
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
Joshua SAHOTA · 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
Joshua Sahota, a 25-year-old man, died on 9 September 2019 after being found with a plastic carrier bag over his head and a bed sheet around his neck while an inpatient on a mental health ward. The report raised concerns about ineffective communication to families and friends regarding items classified as restricted, including plastic carrier bags, and the inquest identified concerns including insufficient staffing, insufficient observations and one-to-one support, inadequate documentation, no psychologist availability, and an unclear restricted-items policy.
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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate patient-specific restricted items to families and friends before ward visits
Wider context from the report “relate to the communication of what are ‘restricted and contraband items’ to the family and friends of a patient, before those family and friends visit the mental health ward.
This would be particularly important for a family or friends first visit to the ward.
The court was told that there are signs up at the entrance of the ward detailing items that are ‘contraband’. These items are not allowed onto the ward in any circumstances.
This makes it clear to all visitors what cannot be taken onto the ward in any circumstances.
However, the court was told that a ‘restricted item’ regime also exists, under which patients are risk assessed, with some being allowed particular items (such as mobile phone charger leads, laptop leads, belts and lighters), whilst others are not.
From the evidence we heard in this case, we know that Josh’s clothes were taken onto the ward in a plastic carrier bag, which at the time was a restricted item.
We heard that the bag was emptied, the contents were searched, re-packed and then taken to Josh’s room.
From the investigation into this matter, it is apparent that firstly, that had the family known that a plastic carrier bag was a restricted item, it would not have been taken to the hospital in the first instance.
Secondly, that had the family been aware that a plastic carrier bag was a restricted item, even though they may have used one to deliver Josh’s clothes, they would have drawn staff attention to the bag when it was subsequently taken and left in Josh’s room.
During the evidence no clear system or procedure was identified, for a family to be notified of any particular items that have been deemed ‘restricted’ items for their loved one to have in their possession.
There was therefore no effective communication with the family regarding what items were, and what items were not, allowed onto the ward in Josh’s case.
I am therefore concerned that families and friends of current in-patients, may still inadvertently take a particular item onto ward, or be aware that their loved one has a particular item in their possession, yet be totally unaware that that particular item has been risk assessed as a restricted item for their loved one.
It is known that families and friends of in-patients can play a vital role in their care, treatment and recovery. However, without knowing what have been deemed ‘restricted items’ for their loved one, the ability to assist in keeping their loved one safe whilst an in-patient, is effectively removed from those family and friends.
” Open source report
9 Aug 2021 Terence Robert TUTTLE · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 7 Lack of early mental health review View source Lack of early dietician assessment View source Inability to care for mentally unwell patients with physical health problems who are refusing to eat View source Failure to adequately assess under the Mental Capacity Act View source Failure to act on recorded weight loss View source Lack of recognition of serious harm View source Failure to include family members in care View source See 4 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
Terence Robert TUTTLE · 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
Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.
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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of early mental health review
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of early dietician assessment
Wider context from the report “1.Lack of proper dietician assessment and mental health review at an early stage .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Inability to care for mentally unwell patients with physical health problems who are refusing to eat
Wider context from the report “4.Inability to care for a mentally unwell patient with physical health problems , including gastric problems, who is refusing to eat .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess under the Mental Capacity Act
Wider context from the report “3.Ability to assess Mr Tuttle adequately under the Mental Capacity Act .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to act on recorded weight loss
Wider context from the report “2.Inaction when Mr Tuttle was losing weight even though his intake was recorded no-one acted upon 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of serious harm
Wider context from the report “6. Apparent lack of recognition that serious harm did occur for this patient who was described as appearing cachexic .
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to include family members in care
Wider context from the report “5.Refusal to include family members in caring for (after over 20 years in a care home) a patient who was in unfamiliar surroundings and their better knowledge of his usual presentation.
” Open source report
11 Sep 2014 ANN MARY WELLS · Prevention of Future Deaths report Norfolk
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Concerns raised 2 Unsafe positioning of light switches beside beds View source Lack of risk assessment for room placement View source
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
ANN MARY WELLS · 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
Ann Mary Wells, a resident of Julian Hospital, fell in her room on 21 November 2013 while attempting to access the wall beside her bed, sustaining a fractured pelvis and later dying on 28 December 2013. The concerns identified were the positioning of the light switch beside her bed and the absence of a risk assessment for placing her in that room.
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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Unsafe positioning of light switches beside beds
Wider context from the report “(1) A light switch was positioned on the wall beside Mrs Wells’ bed (see attached a photograph). Mrs Wells was 77 years of age, frail with scoliosis, osteoarthritis and a history of falls. In light of the fact that she had been diagnosed with dementia and had a sitting position in bed, it could have been reasonably foreseen that she might attempt to reach for the light switch . Her fall resulted in a fractured pelvis and subsequent complications.
” 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 Hellesdon Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for room placement
Wider context from the report “(2) No risk assessment had been carried out with regard to Mrs Wells being placed in this particular room .
” 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