Recipient

Northside House

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First report 28 Mar 2013•Latest report 28 Mar 2013

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Northside House linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Norfolk

    AI-generated summary

    SEBASTIAN VAUGHAN DAVIES · 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

    Sebastian Vaughan Davies was a detained patient at the Norvic Clinic who became unresponsive after returning from unescorted leave and later died in hospital. The concerns related to whether hourly night-time observations adequately identified patients who had remained immobile or provided continuity between staff carrying out observations.

    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 Northside House; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check whether patients have moved or remained immobile for an extended period during hourly observations

    Wider context from the report

    “Evidence was given at the Inquest that there was a system of hourly observation checks on patients in their rooms during the course of a night shift. These consisted of shining a torch through the window in the door to the room and looking and listening for signs of breathing. However it was not routinely part of such observations to check whether the patient had moved or appeared to have remained immobile for an extended period unless there was a particular concern which there was not in Sebastian’s case. The observations were done in pairs and shared between the staff nurse on duty and the three support staff. However the same individuals did not carry out all the observations on any particular patient. There was therefore a lack of continuity. It was confirmed it was possible for a patient to be breathing but unconscious. Sebastian was heard to be snoring. Sebastian when found to be unresponsive at around 08:30 hours had a crush injury to his right arm. It was therefore apparent that he had been lying immobile on his arm for some extended period of time. Notwithstanding the Jury’s conclusion that the procedures at the Norvic Clinic could not have prevented Sebastian’s death I am nevertheless concerned that a failure to specifically check whether a patient has moved or rather remained immobile for an extended period on hourly observations (thereby indicating that perhaps they may have fallen unconscious) could in the future give rise to a preventable death and therefore there is a risk of future deaths occurring and that therefore a review may need to be undertaken of the procedure for night time hourly observations to specifically include whether a patient has moved or remained immobile for an extended period and whether a system can be devised to give better continuity of those undertaking observations of individual patients. ”
    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 Northside House; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of continuity among staff undertaking observations of individual patients

    Wider context from the report

    “Evidence was given at the Inquest that there was a system of hourly observation checks on patients in their rooms during the course of a night shift. These consisted of shining a torch through the window in the door to the room and looking and listening for signs of breathing. However it was not routinely part of such observations to check whether the patient had moved or appeared to have remained immobile for an extended period unless there was a particular concern which there was not in Sebastian’s case. The observations were done in pairs and shared between the staff nurse on duty and the three support staff. However the same individuals did not carry out all the observations on any particular patient. There was therefore a lack of continuity. It was confirmed it was possible for a patient to be breathing but unconscious. Sebastian was heard to be snoring. Sebastian when found to be unresponsive at around 08:30 hours had a crush injury to his right arm. It was therefore apparent that he had been lying immobile on his arm for some extended period of time. Notwithstanding the Jury’s conclusion that the procedures at the Norvic Clinic could not have prevented Sebastian’s death I am nevertheless concerned that a failure to specifically check whether a patient has moved or rather remained immobile for an extended period on hourly observations (thereby indicating that perhaps they may have fallen unconscious) could in the future give rise to a preventable death and therefore there is a risk of future deaths occurring and that therefore a review may need to be undertaken of the procedure for night time hourly observations to specifically include whether a patient has moved or remained immobile for an extended period and whether a system can be devised to give better continuity of those undertaking observations of individual patients. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026