29 Jul 2019 Mr Alex Blake · Prevention of Future Deaths report Inner South London
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Concerns raised 3 Failure to perform required patient observations View source Failure to maintain accurate and truthful patient observation records and reports View source Failure to conduct timely and adequate observations of patients whose condition is uncertain View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Mr Alex Blake · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Alex Blake died from a self-administered heroin overdose while a sectioned in-patient at Lambeth Hospital, sometime before 04.13 on 24 June 2018. The jury found that inadequate observations, unsuitable record sheets, ineffective observations and poor communication meant his death went unnoticed for several hours. Concerns were also raised about unreliable or potentially false accounts and records by staff regarding observations of him before he was found dead.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to perform required patient observations
Wider context from the report “The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.
The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court.
” 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 NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate and truthful patient observation records and reports
Wider context from the report “The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used. She chose to wait until 06.00 to conduct a proper observation. She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead. Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible .
The evidence of these three witnesses cannot be said to be reliable . The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court .
” 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 NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct timely and adequate observations of patients whose condition is uncertain
Wider context from the report “The first was RMN T, who gave evidence that the deceased was half out of bed, wearing pyjamas and assumed to be asleep at 05.00. When asked whether he could have been dead, the nurse said she did not know, but it was too dark to see and no torch was used . She chose to wait until 06.00 to conduct a proper observation . She could not answer the question why she had not gone to get a torch or returned before 06.00. When found in the same position an hour later, she says she was concerned and asked Health Care assistant K if he was breathing as he had been in the same position for an hour. HCA K denies that this conversation took place before he was found dead. RMN T on finding the deceased said that it still did not occur to her that he might be dead . Her evidence to the court that he was wearing pyjamas at 05.00 is in contrast to the electronic patient journal, which confirms that when he was found dead he was topless.
The second was RMN E, whose evidence was read due to his unavailability. He made an entry in the electronic journal at 05.59, which is about the time which he was found dead, that “he went to his bedroom and was observed asleep from 23.00 hrs. Alex remains asleep and was observed breathing regularly at the time of this entry (05.52).” The deceased was already dead at the time this entry claims to have been written. RMN T told the court that she had no communication with RMN E about his observations and RMN E was not one of those who found him dead at about 06.10 hours. This raises concern about what prompted the unusual entry at 05.59.
The third was health care assistant K, whose evidence in court was that the deceased was observed at 03.00 and he held his phone in his hand which was lit up, and so assumed to be watching a film. The witness was unable to answer why he had then recorded the deceased as being asleep, as it would be likely then that the light of the phone would not be visible.
The evidence of these three witnesses cannot be said to be reliable. The evidence of the two nurses would seem to go beyond that of poorly conducted observations. It would be reasonable to suspect that either the two nurses did not perform the observations at all or that they have provided false evidence to the Trust and to the court.
” 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 Conduct ongoing investigations into concerns arising from the case.
Verbatim wording from the response “I can confirm that the concerns raised were acted upon immediately and are currently the subject of ongoing investigations. I would therefore wish to assure all concerned that action will be taken to remedy any identified organisational or individual deficits arising from this process in the interests of patient safety.” Source location 2019-0259-Response-from-NHS-Professionals-Redacted-1
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include evidence of completed and updated observation competency assessments in the whole-systems review actions.
Verbatim wording from the response “In addition to statutory and mandatory training, individual Client Trusts may have specific additional training requirements for bank staff who are provided via NHS Professionals and, where this is the case, NHS Professionals works in partnership with a Client Trust to support delivery of this additional training. The Trust Engagement and Observation Policy Version 6.1 (July 2017) includes a Nursing Verification of Competence proforma which requires a competency assessment prior to any ‘nurse’ undertaking any level of observation. This is undertaken at ward level.” Source location 2019-0259-Response-from-NHS-Professionals-Redacted-1
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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 Client Trusts complete performance assessments and directly manage staff compliance with Trust policies, guidelines and record-keeping requirements.
Verbatim wording from the response “NHS Professionals uses an online performance review and monitoring system that helps to resolve concerns informally at an early stage. It identifies Bank Members who are performing well and also highlights any lack of skills or knowledge development. Performance assessment is completed by the client Trust. NHS Professionals will put in place improvement measures for Bank Members where poor performance or skill deficit has been identified by a Trust.” Source location 2019-0259-Response-from-NHS-Professionals-Redacted-1
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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 Client Trusts deliver substantive staff training, and ward staff undertake competency assessments before nurses perform observations.
Verbatim wording from the response “Substantive Registration is the primary registration route, which is available to applicants who hold a substantive post within a Client Trust. The substantive registration process allows substantive staff, referred to as Multi Post Holder Bank Members, to work back at the Trust where they are substantively employed and in an area of work that has been authorised by a Trust Manager. All training requirements for substantive staff are delivered by the Trust.” Source location 2019-0259-Response-from-NHS-Professionals-Redacted-1
Open published response
18 Oct 2018 Anne Roberts · Prevention of Future Deaths report Berkshire
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Concerns raised 5 Failure to manage choking risk during bedroom meals alongside risks of harm to patients and others View source Failure to disseminate information relating to choking risk View source Failure to maintain full, accurate, and up-to-date hospital records about choking risk View source Lack of front-line ward staff training on the interaction between mental disorders and choking risks View source Lack of training for bank staff in caring for patients at risk of choking View source See 2 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
Anne Roberts · 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
Anne Roberts died at Prospect Park Hospital, Reading, on 28 September 2017 after choking on a bolus of food consisting of a sandwich and chocolate brownie cake. The report raised concerns about bank-staff training, dissemination and recording of choking-risk information, management of patients eating in bedrooms, and frontline staff training on the interaction between mental disorders and choking risks.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to manage choking risk during bedroom meals alongside risks of harm to patients and others
Wider context from the report “3. Concerns about how risk of choking is managed when patients eat in their bedrooms in conjunction with managing risk of harm to themselves and others at the same time.
” 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 NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate information relating to choking risk
Wider context from the report “2. Concerns about the dissemination of information relating to risk of choking particularly with respect to ensuring that hospital records are full, accurate, and up to date.
” 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 NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain full, accurate, and up-to-date hospital records about choking risk
Wider context from the report “2. Concerns about the dissemination of information relating to risk of choking particularly with respect to ensuring that hospital records are full, accurate, and up to date .
” 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 NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of front-line ward staff training on the interaction between mental disorders and choking risks
Wider context from the report “4. Training of front-line ward staff (including nurses and healthcare assistants/support workers) around the interaction between mental disorders and choking risks , as distinct from choking risks caused by dysphagia
” 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 NHS Professionals Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of training for bank staff in caring for patients at risk of choking
Wider context from the report “1. Concerns about the training of Bank Staff in relation to the care of patients at risk of choking, including patients who are mentally ill.
” 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