Recipient

Northumbria Healthcare NHS Foundation Trust

First report 28 May 2019•Latest report 29 Jul 2025

Recipient record

Reports, concerns and published responses

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

Reports: 6
Published responses: 117%
Concerns addressed: 28
Stated actions: 67

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.

117%published responses found

67stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Northumbria Healthcare NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

29 Jul2025
Northumberland
Concerns raised8
1. Failure to conduct speech and language therapy assessment using referral information, eating observation and care records
2. Failure to ensure staff have current Basic Life Support and First Aid at Work training
3. Lack of staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment
1. Failure to refer residents identified as high nutritional risk to appropriate clinical services
2. Failure to ensure food provided conforms to residents' identified diet plans
3. Failure to provide pertinent referral information to speech and language therapy
4. Failure to ensure agency staff receive and have verified induction
5. Delays in care assistant intervention when a resident shows signs of choking
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement revised electronic SALT referral form questions, mandatory detail fields, and mandatory Next of Kin or LPA information.
  Stated planned
2. Action
  Complete and approve a SALT standard operating procedure requiring clarification documents, specified face-to-face assessment triggers, family liaison, and confirmation of recommended IDDSI levels.
  Stated in progress
Respondent positions 2
1. Position
  Existing dysphagia guidance and referral thresholds were considered sufficient to determine that face-to-face assessment was not required.
  Existing arrangements considered sufficient
1. Position
  The referral information did not indicate or corroborate dysphagia, swallowing difficulty, coughing or choking requiring face-to-face assessment.
  Disputes the concern
AI-generated summary

Joan WHITWORTH · 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

Joan Whitworth, a resident of Oaks Care Home with advanced dementia and a DNACPR order, died there on 3 March 2023 after choking caused by massive aspiration. Concerns included the adequacy of the speech and language assessment, staff training and induction, delayed intervention when she showed signs of choking, and food being prepared contrary to her diet plan.

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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct speech and language therapy assessment using referral information, eating observation and care records
Wider context from the report
“1. Whilst pertinent information was not provided to SALT, I am concerned that at assessment on 21 February 2023 there was no reliance upon the information provided in the referral to SALT which identified a concern for her swallow, coughing, weight loss choking. Instead the assessment was based on the verbal account of a member of care home staff. There was no observation of the deceased eating and there was no inspection of her care records. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure staff have current Basic Life Support and First Aid at Work training
Wider context from the report
“2. Basic Life Support and First Aid at Work I am concerned that a Registered General Nurse and a Senior Care Assistant were not in date with their training in Basic Life Support and First Aid at Work. I am further concerned that it could not be confirmed if an Agency Care Worker was up to date with their training in Basic Life Support and First Aid at Work. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment
Wider context from the report
“3. Training I am concerned that a Senior Care Assistant could not recall having received any formal training in the preparation of Care Plans, no training on MUST or calculating BMI yet was completing care plans and documents. I am further concerned than when the Senior Care Assistant completed the Nutritional Risk Assessment, on three dates the deceased was identified as high risk yet there was no referral to the GP, dietician or consideration of referral to SALT. I am concerned that in the absence of training there was not an understanding of the assessment. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer residents identified as high nutritional risk to appropriate clinical services
Wider context from the report
“3. Training I am concerned that a Senior Care Assistant could not recall having received any formal training in the preparation of Care Plans, no training on MUST or calculating BMI yet was completing care plans and documents. I am further concerned than when the Senior Care Assistant completed the Nutritional Risk Assessment, on three dates the deceased was identified as high risk yet there was no referral to the GP, dietician or consideration of referral to SALT. I am concerned that in the absence of training there was not an understanding of the assessment. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure food provided conforms to residents' identified diet plans
Wider context from the report
“5. Normal Diet IDDSI L7 easy chew and to avoid difficult textures. I am concerned that a chef in evidence at the inquest was not aware that breaded fish was not a suitable food stuff in the diet identified for the deceased. I am concerned that other residents could be fed inappropriate food stuffs that are not in line with their identified diet plans. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide pertinent referral information to speech and language therapy
Wider context from the report
“1. Whilst pertinent information was not provided to SALT, I am concerned that at assessment on 21 February 2023 there was no reliance upon the information provided in the referral to SALT which identified a concern for her swallow, coughing, weight loss choking. Instead the assessment was based on the verbal account of a member of care home staff. There was no observation of the deceased eating and there was no inspection of her care records. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure agency staff receive and have verified induction
Wider context from the report
“4. Agency staff - induction I am concerned that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord. The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. I am further concerned that it could not be confirmed if the agency staff had undergone an induction. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Delays in care assistant intervention when a resident shows signs of choking
Wider context from the report
“4. Agency staff - induction I am concerned that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord. The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. I am further concerned that it could not be confirmed if the agency staff had undergone an induction. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement revised electronic SALT referral form questions, mandatory detail fields, and mandatory Next of Kin or LPA information.

Verbatim wording from the response
“Following the death of Ms Whitworth and extensive discussion within the wider SALT team, it is acknowledged that changes could be made to the electronic referral form, to encourage more detailed information from the referrer. These changes, which were referred to during the inquest, are due to come into effect in October 2025.”

Source location
Response from Northumbria Healthcare NHS Foundation Trust
Page 2 · response
Published 30 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Complete and approve a SALT standard operating procedure requiring clarification documents, specified face-to-face assessment triggers, family liaison, and confirmation of recommended IDDSI levels.

Verbatim wording from the response
“Following Ms Whitworth's death and discussion of the learning from this case, in relation to discrepancies in referral information versus verbal reports, a Standard Operating Procedure (SOP) is in development by the SALT department, which is due for sign off and completion by October 2025. This SOP will guide staff to seek clarification of any discrepancies, through requesting key documents from Care Home staff. In these instances, SALT staff will ask the Care Home staff to provide the following:”

Source location
Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 30 July 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing dysphagia guidance and referral thresholds were considered sufficient to determine that face-to-face assessment was not required.

Verbatim wording from the response
“The current expectation and guidance on dysphagia assessments within the Trust and/or nationally is set out in the Royal College of Speech and Language Therapists guidance, and all SALT staff have undergone robust dysphagia training, which is a post-graduation qualification.”

Source location
Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 30 July 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The referral information did not indicate or corroborate dysphagia, swallowing difficulty, coughing or choking requiring face-to-face assessment.

Verbatim wording from the response
“prioritised by the Trust SALT team as ‘low priority’ (according to Northumbria Healthcare Foundation Trust (NHCT) SALT departmental prioritisation criteria) due to the description provided of Ms Whitworth’s eating and drinking difficulties and associated risk level. The referral stated that she did not want to swallow lumpy food and that she spat out food and drinks. These are common, often behavioural, issues associated with advanced dementia and not an indication of Oro-pharyngeal dysphagia. The referral also states that there had been no episodes of choking. In addition, there had been no direct correspondence from care home staff to raise concerns, seek advice or request an urgent appointment.”

Source location
Response from Northumbria Healthcare NHS Foundation Trust
Page 2 · response
Published 30 July 2025
Open published response
23 Jun2025
Northumberland
Concerns raised10
1. Failure to escalate care or make onward referral
2. Lack of in-person dietetic assessment recording weight and clinical observations
3. Insufficient staff understanding of Medical Emergencies in Eating Disorders guidelines
1. Confusion and delayed cascading of Consultant-to-Consultant referral guidance
2. Lack of physical face-to-face monitoring of weight
3. Lack of scrutiny of reluctance to engage and attend appointments
4. Lack of one accessible system for weights, heights and BMI
5. Lack of clear accountable oversight of outpatient care
6. Failure to provide face-to-face or direct contact before CAMHS discharge
7. Failure to share clinically significant eating and weight information with an appropriate body
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 21
1. Action
  Implement Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.
  Stated completed
2. Action
  Require CAMHS MDT discussion before discharging non-attending young people, including review of measurements, physical assessment needs and wider risks.
  Stated completed
3. Action
  Operate the MEED Oversight Group to review policies, processes and high-risk patient pathways with executive oversight.
  Stated completed
1. Action
  Discuss and implement improved information sharing between primary and secondary healthcare pathways through the NENC GP/provider interface group.
  Stated planned
2. Action
  Adopt and communicate the NENC consultant-to-consultant referral policy as local Trust policy following consultation and ratification.
  Stated planned
3. Action
  Offer face-to-face appointments to all higher-risk patients, using telephone contact only when needed for timely intervention and followed by in-person review.
  Stated planned
4. Action
  Deliver eating-disorder and disordered-eating identification and management training to Nutrition and Dietetics staff, including mental-health input and resource dissemination.
  Stated planned
5. Action
  Develop a Dietetics SOP for managing patients who do not attend or are not brought, subject to Trust-wide agreement on tolerances for very low-weight patients.
  Stated planned
6. Action
  Develop, implement and cascade an administrative SOP covering Dietetics non-attendance, cancellations, telephone substitutions and discharge without review.
  Stated in progress
7. Action
  Implement documented clinical supervision for Dietetics staff and Nutrition MDT support, including escalation review for very low BMI patients.
  Stated completed
8. Action
  Routinely offer face-to-face Dietetics appointments as first contact for patients referred for nutritional support or weight loss, with in-person follow-up after necessary telephone assessment.
  Stated completed
9. Action
  Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.
  Stated in progress
10. Action
  Capture the child or young person’s voice during assessment and reassess care plans and risks after cancellations or non-engagement.
  Stated completed
11. Action
  Update CAMHS non-engagement guidance to address frequent cancellations, low weight or restricted intake, MDT discussion and safeguarding escalation.
  Stated completed
12. Action
  Embed the MEED assessment tool in outpatient consultation records and direct staff to use MEED and ARFID guidance when assessing patients aged 16 and over.
  Stated completed
13. Action
  Review CAMHS non-attendance and cancellation rates through caseload-management meetings, including checks of risk assessments and care plans.
  Stated completed
14. Action
  Cascade safety messages on accurate height and weight measurement, assessment frequency and documentation through Trust communications and policy.
  Stated completed
15. Action
  Continue reviewing clinical systems and digital platforms to streamline central reporting and interoperability of height and weight measurements.
  Stated in progress
16. Action
  Offer home visits to higher-risk patients who cannot or will not attend an in-person Trust appointment.
  Stated completed
17. Action
  Implement SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.
  Stated completed
18. Action
  Introduce a documented SOP for triaging and assessing suspected eating-disorder and disordered-eating referrals.
  Stated completed
Respondent positions 2
1. Position
  The service cannot guarantee that every first appointment will be face-to-face because patient choice may prevent this.
  Unable to act
1. Position
  A return to face-to-face appointments as standard requires additional resources and a commissioning review, preventing immediate universal implementation.
  Unable to act
AI-generated summary

REDACTED Deceased · 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

The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.

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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate care or make onward referral
Wider context from the report
“4.There was no in person assessment by dietetics or escalation of care The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations. At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17. On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4. The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red. Red or high risk would be a BMI less than 13. The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9 I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of in-person dietetic assessment recording weight and clinical observations
Wider context from the report
“4.There was no in person assessment by dietetics or escalation of care The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations. At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17. On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4. The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red. Red or high risk would be a BMI less than 13. The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9 I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff understanding of Medical Emergencies in Eating Disorders guidelines
Wider context from the report
“4.There was no in person assessment by dietetics or escalation of care The deceased was assessed via telephone on all occasions. I am concerned that whilst telephone assessments expedited contact there was no in person face to face assessment to record weight or to take and record clinical observations. At assessment on 2 January 2024, the deceased was not aware of her current weight. A weight history from the 20 November 2023 and a 2022 weight were noted. Her BMI was calculated as 17. On 5 March 2024 the deceased was reviewed by a specialist dietitian again by telephone. The deceased self-reported her weight to be 33kg with a calculated BMI of 13.4. The Medical Emergencies in Eating Disorders (MEED) guidelines are used to identify at the earliest stage possible the appropriate care and treatment to be provided. It identifies BMI calculators in the green, amber and red. Red or high risk would be a BMI less than 13. The next specialist dietitian review took place on 26 April 2024, 2 weeks later than planned again by telephone. The self-reported weight was 31.8kg with a calculated BMI of 12.9 I am concerned that there was no escalation of care or onward referral, and I am concerned about staff’s understanding of the Medical Emergencies in Eating Disorders (MEED) guidelines. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Confusion and delayed cascading of Consultant-to-Consultant referral guidance
Wider context from the report
“2.There was no referral to gastroenterology I am concerned there is confusion as to the guidance on Consultant-to-Consultant referrals. The Consultant Physician wrote to the GP saying, "please monitor weight loss and refer into gastroenterology services for further assessment". The GP was aware of guidance regarding Consultant-to-Consultant Referrals that had been updated in October 2023 so that Consultants could and should be directly referring patients themselves to another speciality if there was a clinical reason to do so, rather than passing that task back to the GP. The Consultant Physician told me the guidance was not cascaded down to trust level until December 2023 after the Consultant Physician saw the deceased and that the final guidance has not yet been received. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of physical face-to-face monitoring of weight
Wider context from the report
“1.The deceased’s weight was not adequately monitored from November 2023. I am concerned there was no physical or face to face monitoring of the deceased’s weight from November 2023. I heard about the importance of physical eye to eye contact and examination on a face-to-face basis so that one can see evidence of the skin, properly see the patient’s face and when doing the height and weight asking for the removal some of their clothing to assess muscle mass. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of scrutiny of reluctance to engage and attend appointments
Wider context from the report
“3.The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed The second referral to CAMHs was following the Consultant Physician’s letter dated 20 November 2023. The request was “I would be grateful if you could see this young girl urgently for advice with regards to oral intake. She has lost weight over a number of months and clinical history as outlined above”. The deceased was offered an appointment in keeping with the 4-week national waiting timescale for CYP with an eating disorder. Contact was made with mum on 24 November and an appointment offered for 13 December 2023. During the call Mum told staff the deceased “hated CAMHS so might kick off and refuse to come”. Mum cancelled the appointment on 11 December 2023. CAMHS contacted mum by telephone on 12 December 2023. Mum said that the deceased was not aware that she had been referred to CAMHs, was not willing to attend. Again, there was no exploration as to why that was the case and no direct contact with the deceased. (a) I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly. (b) I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of one accessible system for weights, heights and BMI
Wider context from the report
“6.One records system - weights, heights and Body Mass Index (BMI) I heard that patient care records are held on different care record systems within the NHS which are not universally accessible to healthcare organisations, healthcare professionals or patients. I heard good examples of accessible records such as the Great North Care Record (GNCR) and SystmOne operated by some in Primary Care. I am concerned there is not one accessible system for weights, heights and BMI. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear accountable oversight of outpatient care
Wider context from the report
“6.Oversight of care in an Outpatient setting There is a lack of clarity regarding oversight of care in an outpatient setting. The Patient Safety Incident Investigation report identified that there was a lack of oversight of care. The early help assessment team were stepped down in 2022 and they may have been the appropriate team to maintain oversight of care. The SI report comments that the referrals between services were all appropriate but it was unclear who had oversight of all the care and that the investigation team felt that oversight was unclear and that arrangements around risk assessment escalation safeguarding and GP involvement could have been better through improved communication. I heard that in an inpatient setting there are key NHS standards set around what was described as “the name at the end of the bed” which healthcare professionals work within. I am concerned that in an outpatient setting there is no specific guidance regarding oversight of care within the NHS. No one department or clinician has overall responsibility or accountability. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide face-to-face or direct contact before CAMHS discharge
Wider context from the report
“3.The deceased was discharged from CAMHS in December 2023 without being seen in person, spoken to or weighed The second referral to CAMHs was following the Consultant Physician’s letter dated 20 November 2023. The request was “I would be grateful if you could see this young girl urgently for advice with regards to oral intake. She has lost weight over a number of months and clinical history as outlined above”. The deceased was offered an appointment in keeping with the 4-week national waiting timescale for CYP with an eating disorder. Contact was made with mum on 24 November and an appointment offered for 13 December 2023. During the call Mum told staff the deceased “hated CAMHS so might kick off and refuse to come”. Mum cancelled the appointment on 11 December 2023. CAMHS contacted mum by telephone on 12 December 2023. Mum said that the deceased was not aware that she had been referred to CAMHs, was not willing to attend. Again, there was no exploration as to why that was the case and no direct contact with the deceased. (a) I am concerned the deceased was discharged from CAMHs on 12 December 2023 without being seen face to face or spoken to directly. (b) I am concerned there was no scrutiny as to why the deceased was reluctant to engage and not attend appointments. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to share clinically significant eating and weight information with an appropriate body
Wider context from the report
“5.The Passage of information/communication Communication: I heard about the importance of the passage of information. During the course of the inquest a witness was taken to the SEN chronology and an entry dated 1 March 2024 which refers to a conversation with the deceased’s mother on 29 February 2024 where she described the deceased having significant problems with her eating habits, losing weight and refusing to eat foods that would be good for her and put weight on her. I am concerned that this information was not shared to an appropriate body. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.

Verbatim wording from the response
“2. Internal management re-structure within Dietetics Service to introduce, and empower, a Community Team Lead to oversee and manage all the outpatient work from triage and clinic capacity to reporting, monitoring and planning. This facilitates the provision of alternative outpatient offers, including home visits where concern is raised regarding”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 1 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require CAMHS MDT discussion before discharging non-attending young people, including review of measurements, physical assessment needs and wider risks.

Verbatim wording from the response
“25. Prior to a decision being made relating to discharge if a child or young person will not attend for a CAMHS assessment, a discussion within the CAMHS MDT will take place and every effort made to discuss with the referring clinician. Clarification will be undertaken at the MDT case discussion with regard to dates when height and weight measurements were taken, and by who, to support the decision-making process. These discussions focus on the potential risks and wider factors impacting on the health and wellbeing of the young person, including consideration as to whether a physical assessment has been completed or is needed.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 5 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate the MEED Oversight Group to review policies, processes and high-risk patient pathways with executive oversight.

Verbatim wording from the response
“6. Implementation of the Medical Emergencies in Eating Disorders (MEED) Oversight Group; this group has been meeting every 6 weeks since August 2024. This Group includes colleagues from the mental health Trust to monitor and review policies, processes and high-risk patient pathways and includes Executive Director oversight from both Trusts. The function of the Oversight Group is to agree and formalise operational policies and processes rather than for clinical discussions. However, it has provided opportunity for discussing specific, existing, cases whilst the joint clinical MDT is established.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss and implement improved information sharing between primary and secondary healthcare pathways through the NENC GP/provider interface group.

Verbatim wording from the response
“38. We are fully committed in working with our CCG colleagues to ensure that any information that is shared between primary and secondary healthcare pathways and communication is implemented as part of the learning and actions from this case. This will be discussed, for action, at the NE NC GPP Provider interface group by October 2025.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 7 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Adopt and communicate the NENC consultant-to-consultant referral policy as local Trust policy following consultation and ratification.

Verbatim wording from the response
“19. During the inquest, the Trust gave oral evidence regarding the implementation and cascading of the new consultant to consultant referral guidance. The Trust has adopted the Northeast North Cumbria (NENC) Consultant team to Consultant team referral policy via the Northumberland and North Tyneside GP/Provider interface group organised via NENC ICB. This will be adopted as a local policy and communicated to all clinicians within Northumbria by the Trust Policy group on behalf of the Executive Medical Director by the end of October 2025, following consultation/ratification at the Trust’s CPG (Clinical Policy Group). Primary Care colleagues also have access to the Trust’s Advice and Guidance service across the acute secondary care specialties to request advice and guidance on clinical cases, in this case including Gastroenterology.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 4 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Offer face-to-face appointments to all higher-risk patients, using telephone contact only when needed for timely intervention and followed by in-person review.

Verbatim wording from the response
“30. All higher risk patients will be offered a face-to-face appointment going forward and if a telephone contact is required to facilitate a timely intervention it will be followed by an in-person appointment to ensure accurate weight and height is recorded. Face-to-face appointments for all patients who are not triaged as ‘higher risk’ are offered where possible and would be based on individual clinical need and may require further commissioning discussions.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 6 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver eating-disorder and disordered-eating identification and management training to Nutrition and Dietetics staff, including mental-health input and resource dissemination.

Verbatim wording from the response
“10.3 Training is to be delivered to the Nutrition and Dietetics team CNTW dietetic colleagues, to support identification and management of eating disorders/disordered eating. There are a series of bookable webinars arranged for staff: 18 September 2025; 15 January 2026; 23 April 2026 and 16 July 2026. In addition, a colleague from the mental health Trust will be attending the Nutrition and Dietetics department meeting on 15 October 2025 to give an update and training to all staff in the department. A register will be taken, and the training resources will be supplied to any front-line staff member not in attendance. The Adult Dietetics team meeting on 26 August 2025, has been specifically allocated for mental health training.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a Dietetics SOP for managing patients who do not attend or are not brought, subject to Trust-wide agreement on tolerances for very low-weight patients.

Verbatim wording from the response
“14. Introduction of a Standard Operating Procedure (SOP) for management of patients referred to the Nutrition and Dietetics department that do not attend (DNAs) or are not brought to appointments. The SOP will be in line with Trust's framework for non-attendance and the Outpatient Steering Group recommendations. Referrals for patients with a very low weight and BMI who do not attend appointments require further discussion to agree acceptable tolerances Trust-wide. This action will be raised via the Outpatient Steering Group for consideration at the September 2025 meeting.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop, implement and cascade an administrative SOP covering Dietetics non-attendance, cancellations, telephone substitutions and discharge without review.

Verbatim wording from the response
“31. The service is working on a SOP which will provide further assurance that patients are appropriately managed by the Dietetics Admin team. This SOP will include pathways to manage patient DNA’s, cancellations and patient/carer requests to change to a telephone call instead of an in-person contact, or to be discharged without further review. The Admin team will be able to task the clinicians via SystmOne with requests by patients to change appointments and clinicians will need to review the patient record to confirm and agree in writing that the changes are acceptable. This SOP will be cascaded and implemented following the Department meeting in October 2025.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 6 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement documented clinical supervision for Dietetics staff and Nutrition MDT support, including escalation review for very low BMI patients.

Verbatim wording from the response
“4. Introduction of robust, documented clinical supervision was launched formally at the Nutrition and Dietetics Department meeting on 1 April 2025, within the Dietetics staffing structure and also with the Nutrition Team MDT from July 2025.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Routinely offer face-to-face Dietetics appointments as first contact for patients referred for nutritional support or weight loss, with in-person follow-up after necessary telephone assessment.

Verbatim wording from the response
“9. From August 2025, face to face appointments are now routinely offered by the Dietetics service as first contact for any patient referred for nutritional support and weight loss (irrespective of the cause). If telephone contact is required for timeliness, then an in-person review appointment will then be offered after the initial telephone assessment.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.

Verbatim wording from the response
“5. Development of a Nutrition Multi-disciplinary Team (MDT) meeting which includes medical oversight from Gastroenterologists for complex and vulnerable Dietetic outpatients and mental health oversight from colleagues from the mental health Trust. The first meeting took place on 15 July 2025, scheduled to meet fortnightly and is on track with scheduling. The initial meetings were held with Dietetics and the Trust Gastroenterology consultants to review the current caseloads. Concerns may also be raised to this group outwith the scheduled meetings. This MDT will include mental health colleagues from going forward. The terms of reference are currently being established and will be in place for joint meetings to be scheduled from September 2025.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Capture the child or young person’s voice during assessment and reassess care plans and risks after cancellations or non-engagement.

Verbatim wording from the response
“26.1 An initial awareness raising training session has been delivered to 41 CAMHS Staff, on 15 July 2025, with a focus on assessment and risks of low weight and associated health needs. Further training is scheduled on 18 September 2025. 26.2 Efforts are made to capture the voice of the child/young person via phone contact and offer of appointment. This is undertaken for each assessment and forms part of the information gathering when a parent or carer is the primary contact. The non-engagement guideline would be applicable in this instance. The non-engagement guidance outlines if a young person, parent or carer cancels an appointment and it is re-booked, care coordinators/Key workers will assess any patterns and the potential risks. They will re-assess the plan of care as needed and inform relevant others depending on the level of concern.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 5 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update CAMHS non-engagement guidance to address frequent cancellations, low weight or restricted intake, MDT discussion and safeguarding escalation.

Verbatim wording from the response
“24. In January 2025, the 'Was Not Brought/Did Not Engage' CAMHS guidance was updated to include frequent cancellation guidance. This encompasses non-engagements of young people and children. In this situation, cases will be discussed within the CAMHS MDT and if deemed appropriate, escalated for consideration of a safeguarding referral or Early Help assessment (Early Help is explained in more detail below, in paragraph 31). The addition, the CAMHS guidance outlines that if concerns regarding weight loss and/or restricted dietary intake are identified in the referral and child or young person was not brought or fails to engage in appointments, safeguarding advice and referral must be considered.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 5 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Embed the MEED assessment tool in outpatient consultation records and direct staff to use MEED and ARFID guidance when assessing patients aged 16 and over.

Verbatim wording from the response
“10. Nutrition and Dietetics staff working with patients from 16 years and above, have been advised by the Professional lead for Dietetics, at the monthly Adult team meeting on 25 June 2025, to consider the national MEED guidelines and ARFID (Avoidant/Restrictive Food Intake Disorder) checklist to support the assessment of patients in the out-patient setting for current and future caseloads:”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review CAMHS non-attendance and cancellation rates through caseload-management meetings, including checks of risk assessments and care plans.

Verbatim wording from the response
“26.3 'Was Not Brought' and cancellation rates will be reviewed through caseload management (CLM) meetings with clinicians. The purpose is to review caseload numbers, was not brought and cancellation rates. Checks are also made that risk assessments and care plans have been completed. Frequency of caseload management depends on the role of staff e.g. Consultant Psychiatrists have CLM every 3 months. Other members of staff may have CLM every 2 months. This provides assurance that governance processes are being followed.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 5 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Cascade safety messages on accurate height and weight measurement, assessment frequency and documentation through Trust communications and policy.

Verbatim wording from the response
“11. Internal communications and safety messages have been cascaded to Trust staff regarding the importance of obtaining accurate height and weight measurements in July 2025, including frequency of assessment and clarity on how the measurements were obtained, documented within the approved Trust-wide Nutrition and Hydration Policy.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue reviewing clinical systems and digital platforms to streamline central reporting and interoperability of height and weight measurements.

Verbatim wording from the response
“12. The Trust are continuing to review all clinical systems and digital platforms to streamline, where possible, the reporting of weight and height and the interoperability of systems to provide assurance that measures are captured and reported centrally by all services.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 3 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Offer home visits to higher-risk patients who cannot or will not attend an in-person Trust appointment.

Verbatim wording from the response
“29. The standard referral criteria to the Dietetics service for nutrition support is patients with a BMI of less than 18.5 and/or 5-10% weight loss within 3-6 months. Higher risk patients (i.e. those referred with a BMI of less than 17.5, in line with MEED definitions for immediate risk to life) can now be offered a home visit, if it is felt that the patient won't or can't attend an in-person appointment at one of the Trust sites.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 6 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.

Verbatim wording from the response
“3. Introduction of SystmOne as a clinical electronic records system for Nutrition and Dietetics outpatient consultations (Go Live of the Nutrition and Dietetics SystmOne unit was August 2024) provides:”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce a documented SOP for triaging and assessing suspected eating-disorder and disordered-eating referrals.

Verbatim wording from the response
“7. The below actions, which had been identified before the Inquest, but were not yet complete, have since been progressed and put in place:”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 2 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The service cannot guarantee that every first appointment will be face-to-face because patient choice may prevent this.

Verbatim wording from the response
“32. The Trust acknowledges (e.g. because of patient choice) that it is not always possible to guarantee all first appointments are face-to-face, but that, all first attendance appointments should be face-to-face where clinically appropriate, and this standard has been set at the Outpatient Steering Group.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 6 · response
Published 14 July 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A return to face-to-face appointments as standard requires additional resources and a commissioning review, preventing immediate universal implementation.

Verbatim wording from the response
“27. The Dietetics service aims to return to a pre-COVID out-patient position whereby face-to-face appointments are offered as standard for all appointments. However, this is likely to require additional resource and a commissioning review. In the meantime, face to face appointments will be prioritised to all younger persons with red flags for low BMI.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 5 · response
Published 14 July 2025
Open published response
18 Mar2025
Northumberland
Concerns raised5
1. Misunderstanding of peripheral vision and witnessed or unwitnessed falls
2. Insufficient scrutiny of witness accounts during investigations
3. Insufficient capacity for line-of-sight observation of patients at risk of falls
1. Failure to establish accurate circumstances of falls during investigations
2. Failure to carry out falls observations in accordance with Trust falls policy
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.
  Stated planned
2. Action
  Disseminate the revised falls policy through governance approval, staff training, communications bulletins, meetings, safety huddles, and mandatory refresher training.
  Stated planned
3. Action
  Require trained Governance Leads to participate in all internal investigations and ensure witness statements receive managerial or Deputy Director sign-off before finalisation.
  Stated planned
1. Action
  Highlight maintaining line-of-sight observation and calling for assistance when required in staff training.
  Stated planned
2. Action
  Brief Ward 9 clinical staff on accurate witnessed and unwitnessed fall terminology and its use in incident reporting and communications.
  Stated in progress
Respondent positions 1
1. Position
  Existing acuity assessment, escalation, staffing support and monitoring processes are considered sufficient to manage changing numbers of patients at risk of falls.
  Existing arrangements considered sufficient
AI-generated summary

Renate MARK · 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

Renate MARK suffered an unwitnessed inpatient fall in hospital on 24 April 2024, sustaining a cervical spinal fracture and subdural haematoma, and died there on 25 April 2024 after receiving palliative care. Concerns included that she was assessed as a level 3 falls risk but was not under direct observation, that investigations relied on the incorrect belief that the fall was witnessed, and that too many patients at risk of falls were being monitored through peripheral vision. Further concern was raised about insufficient scrutiny of witness accounts during the Trust’s investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Misunderstanding of peripheral vision and witnessed or unwitnessed falls
Wider context from the report
“(2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff's peripheral vision. The inquest heard that on 24 April 2024 8 patients were assessed as level 3 falls risk and 1 patient was assessed as level 4 falls risk. I am concerned as to the number of patients at risk of falls being observed in this way. I am further concerned that there is a misunderstanding of what is meant by peripheral vision and what constitutes a witnessed or unwitnessed fall. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Insufficient scrutiny of witness accounts during investigations
Wider context from the report
“(3) I am concerned there is not greater scrutiny of witness accounts as part of the Trust's investigation process in particular given the concerns raised by the deceased's family early in the investigation and the other witness accounts to provide earlier learning to prevent future events. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Insufficient capacity for line-of-sight observation of patients at risk of falls
Wider context from the report
“(2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff's peripheral vision. The inquest heard that on 24 April 2024 8 patients were assessed as level 3 falls risk and 1 patient was assessed as level 4 falls risk. I am concerned as to the number of patients at risk of falls being observed in this way. I am further concerned that there is a misunderstanding of what is meant by peripheral vision and what constitutes a witnessed or unwitnessed fall. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to establish accurate circumstances of falls during investigations
Wider context from the report
“(1) The deceased was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. Witness statements served in advance of the inquest stated the fall was witnessed. It was however eventually accepted in evidence that the fall was in fact unwitnessed. The precise circumstances of the fall could not be determined. All of the investigations undertaken by the Trust relied upon the incorrect understanding that the fall was witnessed and observations were in line with Trust falls policy, when they were not. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to carry out falls observations in accordance with Trust falls policy
Wider context from the report
“(1) The deceased was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. Witness statements served in advance of the inquest stated the fall was witnessed. It was however eventually accepted in evidence that the fall was in fact unwitnessed. The precise circumstances of the fall could not be determined. All of the investigations undertaken by the Trust relied upon the incorrect understanding that the fall was witnessed and observations were in line with Trust falls policy, when they were not. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.

Verbatim wording from the response
“In terms of a Trust wide response, the Trust's Strategic Falls Group provides on the strategic direction and actions that are to be taken by the Trust where there is a patient safety incident concerning a falls risk. As a direct response to the concerns raised by HM Coroner in the PFD Report, the group has been tasked with undertaking a review of the Trust's current Integrated Falls Prevention Policy and to provide further detail within this policy, including the inclusion of a glossary, citing definitions of wording contained in the policy, which is to include the definition of a 'witnessed' and 'unwitnessed' fall. The use of the term 'peripheral vision' will be removed from the policy and replaced by the wording 'in line of sight' so as to avoid any potential confusion by staff.”

Source location
Response from Northumbria NHS
Page 2 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate the revised falls policy through governance approval, staff training, communications bulletins, meetings, safety huddles, and mandatory refresher training.

Verbatim wording from the response
“The finalised policy will be agreed at governance level through the Trust's governance structure and thereafter will be included in the syllabus for future falls training sessions and events that are attended by all staff Trust wide, that are responsible for handling patients. The revised Integrated Falls Prevention Policy will then be supported by a Trust wide communication strategy to ensure staff are aware of the revised policy, and the policy updates contained therein. The Policy updates will be shared Trust wide via the Trust Communications Bulletin, Heads of Department meetings, site meetings via team meetings and ward safety huddles, led by the ward matron and also at governance meetings. In addition, the revised policy will continually be referred to in mandatory annual refresher falls training that is undertaken by all staff involved with handling patients.”

Source location
Response from Northumbria NHS
Page 2 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require trained Governance Leads to participate in all internal investigations and ensure witness statements receive managerial or Deputy Director sign-off before finalisation.

Verbatim wording from the response
“In response to this concern, the Trust Governance Leads, who are trained in investigation management, will be involved in all internal investigations in order to ensure in depth scrutiny of witness accounts following an incident. Where any deficiencies or further information / clarification is needed, this will be fed back to the investigating officer to action. The Governance Leads will also ensure that the statements collated as part of the Trust investigation, are signed off at a Managerial/Deputy Director level adding an additional layer of scrutiny before final sign off.”

Source location
Response from Northumbria NHS
Page 3 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Highlight maintaining line-of-sight observation and calling for assistance when required in staff training.

Verbatim wording from the response
“In relation to Mrs Mark’s fall, the nursing assistant was assigned to Pod 3 on Ward 9; there were 8 patients being nursed in single bedrooms each with an ensuite bathroom. Pod 3 has a circular design which would enable a member of staff to observe those 8 rooms, through windows and glass/open doors from the corridor. At the time of the incident, patients were asleep/settled, and it was only Mrs Mark that was awake requiring the toilet. As she required the toilet and was at risk of falling, in order to maintain her safety, the nursing assistant should have called for additional support from another colleague to ensure falls observations for the other patients were maintained whilst he attended to Mrs Mark's in the bathroom. This learning has been fed back to the Ward 9 Team and nursing assistant involved in the incident.”

Source location
Response from Northumbria NHS
Page 2 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Brief Ward 9 clinical staff on accurate witnessed and unwitnessed fall terminology and its use in incident reporting and communications.

Verbatim wording from the response
“The incident concerning Mrs Mark occurred on Ward 9 of the Northumbria Specialist Emergency Care Hospital (NSECH). As an immediate response, the Trust is in the process of briefing the ward team, which includes all clinical staff, on what constitutes a 'witnessed' and 'unwitnessed' fall and the importance of ensuring that this terminology is understood and used accurately, where an incident occurs. The briefing will explain the importance of using accurate terminology is understood and used when information is disclosed to family following a falls incident, in order to allow for a robust internal Trust investigation and in circumstances”

Source location
Response from Northumbria NHS
Page 1 · response
Published 26 March 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing acuity assessment, escalation, staffing support and monitoring processes are considered sufficient to manage changing numbers of patients at risk of falls.

Verbatim wording from the response
“The Trust is confident that robust processes are in place to assess acuity of care at ward level for all wards as detailed in Claire Simpson's statement dated 13 March 2025 (served with the court as part of the inquest process). The processes are led by Matrons and supported by Operational Managers and Operational Leads, who are responsive to increasing staffing in order to address any concerns raised regarding increased patient acuity. There is also a process in place supported by funding, where staff can request additional staffing i.e. Bank staff, in order to support high numbers of patients at risk of falls. Bank staff are a Trust employed workforce, who provide cover on a pre booked, as needed basis. They are trained to Trust standards for falls management.”

Source location
Response from Northumbria NHS
Page 2 · response
Published 26 March 2025
Open published response
17 Apr2024
Northumberland
Concerns raised3
1. Inaccurate recording of cannula events and siting in medical records
2. Delays in the administration of IV antibiotics
3. Failure to ensure effective administration of antibiotics
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Disseminate the safety message and videos Trustwide through multiple media, the intranet, email bulletin and digital newsletter.
  Stated planned
2. Action
  Highlight cannula documentation requirements and difficult-access escalation at ward safety huddles.
  Stated planned
3. Action
  Amend MM01 to require immediate, reasoned recording of incomplete or partial medication doses.
  Stated completed
1. Action
  Establish a clearer escalation process for staff managing difficult intravenous access.
  Stated planned
2. Action
  Audit Ward 1 cannula care-plan compliance to identify documentation gaps.
  Stated completed
3. Action
  Create a step-by-step training video showing staff how to amend incomplete or partial doses in eMeds.
  Stated completed
4. Action
  Conduct weekly reaudits of cannula care-plan documentation to drive improvement.
  Stated in progress
5. Action
  Create a Trust safety message covering difficult access, cannula documentation, partial-dose recording and eMeds amendments.
  Stated in progress
Respondent positions 1
1. Position
  The delay in administering intravenous antibiotics was not considered likely to have contributed to the patient’s death.
  Disputes the concern
AI-generated summary

Eleanor Smith Deceased · 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

Eleanor Smith suffered an unwitnessed fall, sustaining a left femoral neck fracture, and underwent surgical repair. She developed an infection postoperatively and died in hospital on 24 September 2023. The principal concerns were a significant delay in administering intravenous antibiotics, whether the antibiotics were effectively administered, and whether the medical records accurately documented cannula placement and medication administration.

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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate recording of cannula events and siting in medical records
Wider context from the report
“1. It was the concern of the family throughout the investigation that there was a delay in the administration of IV antibiotics and the antibiotics were not administered effectively. The Trust accepted that there was a significant delay in the administration of antibiotics of a period of 24 hours but that it was unlikely that the delay affected the outcome. The family gave evidence that they were present until around 21.00 hours on 23 September 2023 and described difficulties experienced by staff on 23 September 2023 in the siting of a canula. There was an attempt for the canula to be placed in one arm, then the other and was eventually sited in the foot. It was the position of Trust that from 17.56 hours on 23 September 2023 there was a working cannula and prescribed medication was administered. I accepted the evidence of the family and I am concerned that the medical records did not accurately record the events and siting of the canula. I am further concerned as to whether prescribed medication on this occasion being antibiotics were effectively administered and what checks there are to ensure the effective administration of medicines. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Delays in the administration of IV antibiotics
Wider context from the report
“1. It was the concern of the family throughout the investigation that there was a delay in the administration of IV antibiotics and the antibiotics were not administered effectively. The Trust accepted that there was a significant delay in the administration of antibiotics of a period of 24 hours but that it was unlikely that the delay affected the outcome. The family gave evidence that they were present until around 21.00 hours on 23 September 2023 and described difficulties experienced by staff on 23 September 2023 in the siting of a canula. There was an attempt for the canula to be placed in one arm, then the other and was eventually sited in the foot. It was the position of Trust that from 17.56 hours on 23 September 2023 there was a working cannula and prescribed medication was administered. I accepted the evidence of the family and I am concerned that the medical records did not accurately record the events and siting of the canula. I am further concerned as to whether prescribed medication on this occasion being antibiotics were effectively administered and what checks there are to ensure the effective administration of medicines. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure effective administration of antibiotics
Wider context from the report
“1. It was the concern of the family throughout the investigation that there was a delay in the administration of IV antibiotics and the antibiotics were not administered effectively. The Trust accepted that there was a significant delay in the administration of antibiotics of a period of 24 hours but that it was unlikely that the delay affected the outcome. The family gave evidence that they were present until around 21.00 hours on 23 September 2023 and described difficulties experienced by staff on 23 September 2023 in the siting of a canula. There was an attempt for the canula to be placed in one arm, then the other and was eventually sited in the foot. It was the position of Trust that from 17.56 hours on 23 September 2023 there was a working cannula and prescribed medication was administered. I accepted the evidence of the family and I am concerned that the medical records did not accurately record the events and siting of the canula. I am further concerned as to whether prescribed medication on this occasion being antibiotics were effectively administered and what checks there are to ensure the effective administration of medicines. ”
Open source report
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
Disseminate the safety message and videos Trustwide through multiple media, the intranet, email bulletin and digital newsletter.

Verbatim wording from the response
“The safety message and videos will be disseminated Trustwide via multiple media platforms, along with being shared on the Trust's intranet site and will also be sent to all staff by way of an email bulletin and on the communication digital newsletter. This will be sent separate to the normal safety message processes.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Highlight cannula documentation requirements and difficult-access escalation at ward safety huddles.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend MM01 to require immediate, reasoned recording of incomplete or partial medication doses.

Verbatim wording from the response
“In conjunction with this, Medicines Management Policies and Procedures (MM01) Version 9.3 has now been amended to reflect the importance of partial dose recording, including reasoning. The key changes to policy are detailed below and the amended policy is attached:”

Source location
Response from Northumbria Healthcare
Page 6 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a clearer escalation process for staff managing difficult intravenous access.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit Ward 1 cannula care-plan compliance to identify documentation gaps.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Create a step-by-step training video showing staff how to amend incomplete or partial doses in eMeds.

Verbatim wording from the response
“From the evidence presented at Mrs Smith’s inquest although this facility is being used appropriately in many cases there are instances where this has not been done. Moreover, within the recorded amendments there are a significant number that have been recorded as either other (195) or blank (15), which does not provide sufficient clinical context. To address this gap, we have created a new training video for staff that demonstrates how to effectively use this facility in a step-by-step manner (see attached eMeds Amending Administration.mp4 in Concern 1).”

Source location
Response from Northumbria Healthcare
Page 6 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct weekly reaudits of cannula care-plan documentation to drive improvement.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Create a Trust safety message covering difficult access, cannula documentation, partial-dose recording and eMeds amendments.

Verbatim wording from the response
“We are in the process of creating a safety message (see attached text and video) that will highlight:”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The delay in administering intravenous antibiotics was not considered likely to have contributed to the patient’s death.

Verbatim wording from the response
“The Trust is committed to ensuring that lessons are learnt when any patient safety incident occurs. At the time of the incident a multidisciplinary learning from deaths mortality review was undertaken by the Trust and some key learning points were identified, the most relevant of which was that there was a delay to the decision to prescribe and administer intravenous antibiotics which was inadequately recorded in the electronic record. The mortality review team was clear in its conclusion that the delay to administration of antibiotics was not likely to have contributed to Mrs Smith’s death as she was felt to be dying following the stress of surgery and the initial injury.”

Source location
Response from Northumbria Healthcare
Page 1 · response
Published 29 April 2024
Open published response
8 Jul2021
Newcastle Upon Tyne and North Tyneside
Concerns raised4
1. Failure to maintain observational charts for patients at risk of falls
2. Failure to provide observation at the level and frequency required by falls-risk assessment
3. Failure to document daily and post-change falls-risk reassessments
1. Failure to document justified falls-risk reassessments during hospital transfer
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Implement a ward observation chart specifying enhanced-observation levels and required frequencies.
  Stated completed
2. Action
  Use AFLOAT across all hospital sites to set observation levels, with nurses documenting reasons for departing from its recommendation.
  Stated completed
3. Action
  Create electronic alerts notifying staff when scheduled patient observations are due.
  Stated planned
1. Action
  Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.
  Stated in progress
Respondent positions 2
1. Position
  AFLOAT determines observation levels rather than falls risk; falls risk is assessed separately under the Trust’s Falls Risk Assessment document.
  Disputes the concern
1. Position
  Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.
  Existing arrangements considered sufficient
AI-generated summary

Benjamin Clark · 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

Benjamin Clark died in hospital on 17 January 2021 after a series of falls, including an unwitnessed fall on the ward, resulting in Acute on Chronic Subdural Haematomas. The concerns included an undocumented downgrading of his falls-risk assessment, unclear observation requirements, suboptimal record keeping, lack of observational charts, and insufficient written evidence of daily reassessment or reassessment after significant changes.

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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain observational charts for patients at risk of falls
Wider context from the report
“3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital. Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation. There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide observation at the level and frequency required by falls-risk assessment
Wider context from the report
“2. Matron ████████ told me that at the time of the fall, Mr. Clark was under observation as though he was a Level 1 falls risk, despite being assessed as Level 2. Note keeping was suboptimal and there was a lack of clarity as to whether he should have been observed every 30 minutes or every 60 minutes. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to document daily and post-change falls-risk reassessments
Wider context from the report
“3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital. Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation. There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to document justified falls-risk reassessments during hospital transfer
Wider context from the report
“1. I heard evidence from Matron ████████ who carried out a Root Cause Analysis following Mr. Clark’s fall in hospital. She told me that despite Mr. Clark having been assessed to be a Level 3 Risk of Falls in Northumbria Specialist Emergency Care Hospital (NSECH), when he was transferred to North Tyneside General Hospital his falls risk was downgraded to Level 2 without any notes being provided to justify this reassessment. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a ward observation chart specifying enhanced-observation levels and required frequencies.

Verbatim wording from the response
“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use AFLOAT across all hospital sites to set observation levels, with nurses documenting reasons for departing from its recommendation.

Verbatim wording from the response
“The evidence provided to HM Assistant Coroner was that the AFLOAT tool was used in both hospitals and the AFLOAT assessment is kept on the ward. The AFLOAT assessment is a laminated chart, kept on all wards, which staff refer to for setting a level of observation, prior to adding onto NerveCentre. The evidence heard was that the AFLOAT tool had not been included within Mr Clark’s documentation. The evidence did not suggest that only NSECH used this tool in writing.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 3 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Create electronic alerts notifying staff when scheduled patient observations are due.

Verbatim wording from the response
“5. Once the documentation is placed on NerveCentre, an electronic alert will be created for observations and will alert staff via a hand held electronic device that a particular patient observation is due, ensuring a more robust regime for observations. The level of observation set by a Registered Nurse is linked to the timed alert required for care rounding.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.

Verbatim wording from the response
“4. Discussions are ongoing between the Matrons within NTGH in order to place the AFLOAT risk assessment and observation chart onto the electronic care record NerveCentre. The Trust can confirm that this will be done before the end of August 2021. Notwithstanding this, the documents are in use in paper form.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
AFLOAT determines observation levels rather than falls risk; falls risk is assessed separately under the Trust’s Falls Risk Assessment document.

Verbatim wording from the response
“As per paragraph 4, AFLOAT is in use in paper form. The Trust can confirm that AFLOAT is used by all hospital sites within the Trust to assist with setting the level of observation. However, the final decision is at the nurse’s professional judgement. The nurse should document their rationale if they do not agree with the AFLOAT recommendation.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 3 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.

Verbatim wording from the response
“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location
2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021
Open published response
28 May2019
Newcastle upon Tyne
Concerns raised6
1. Failure to use Foetal Scalp Electrodes for critical fetal distress information
2. Suboptimal clinical documentation
3. Lack of patient-specific sequential scan data storage and sonographer alerts
1. Failure to provide advice and explanations for informed pregnancy and delivery decisions
2. Failure to circulate independent expert findings and conclusions to relevant maternity staff
3. Unavailability of clinician access to obstetric and diabetic records
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Conduct ongoing monthly documentation audits, produce quarterly Board reports, and share themes to inform multidisciplinary learning and training.
  Stated in progress
2. Action
  Complete a documentation audit whose findings inform documentation training.
  Stated completed
3. Action
  Circulate the redacted expert report to all Obstetrics and Gynaecology staff, including midwives, to inform future practice.
  Stated completed
1. Action
  Review and provide PROMPT documentation training for midwives and obstetricians, informed by documentation audit findings.
  Stated completed
AI-generated summary

Maia Hazel Ann Strachan · 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

Maia Hazel Ann Strachan was born on 6 July 2017 and died in hospital on 7 July 2017 after a complicated delivery involving shoulder dystocia, hypoxic ischaemic encephalopathy and severe macrosomia. The report identified concerns about inaccurate and suboptimal ultrasound assessment, inaccessible obstetric and diabetic records, missed opportunities for Caesarean delivery and joint decision-making, fetal scalp electrode use, documentation, and dissemination of expert findings.

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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to use Foetal Scalp Electrodes for critical fetal distress information
Wider context from the report
“(4) Foetal Scalp Electrode: The use of Foetal Scalp Electrodes (FSE) provide critical information in respect of foetal distress and the time implications thereof. The Trust should draft and implement a clear and comprehensive Local Policy/Protocol for FSE use. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Suboptimal clinical documentation
Wider context from the report
“(5) Suboptimal Documentation: The Trust should implement a robust training and audit plan to address the risks of this occurring in the future. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Lack of patient-specific sequential scan data storage and sonographer alerts
Wider context from the report
“(1) The ability to store sequential scan data specific to each patient and provide alerts to the Sonographer. This would facilitate comparison and prompt further investigation potentially altering a patient’s care plan and outcome. The Trust’s plan to procure software to facilitate the above should be urgently implemented. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide advice and explanations for informed pregnancy and delivery decisions
Wider context from the report
“(3) Joint Decision Making: - Provision of advice and explanation of the risks of pregnancy and the risks/benefits of vaginal delivery or by Caesarean Section are essential to ensure informed decision making. The Trust should draft and implement a clear and comprehensive Local Joint Decision Making Policy/Protocol. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Failure to circulate independent expert findings and conclusions to relevant maternity staff
Wider context from the report
“(6) The Findings and Conclusions of ████████ (Independent Expert Witness): A redacted copy of ████████ report and conclusions should be circulated to all obstetrics and gynaecology staff (both nursing and medical) and all midwives. ”
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 Northumbria Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of clinician access to obstetric and diabetic records
Wider context from the report
“(2) A system of joint obstetric and diabetic care operates without the facility for clinicians to access patients’ obstetric and diabetic records whether manually or electronically. Accessibility is essential to inform clinical decisions and should be urgently addressed ”
Open source report
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 monthly documentation audits, produce quarterly Board reports, and share themes to inform multidisciplinary learning and training.

Verbatim wording from the response
“This audit has until recently been completed annually however this has been superseded by a recent agreement within the Surgical Business Unit for an ongoing monthly audit of a specific number of notes in each speciality. There will be a”

Source location
Maia-Strachan-Response
Page 1 · response
Published 2 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Complete a documentation audit whose findings inform documentation training.

Verbatim wording from the response
“Current training around the required standard for documentation has been reviewed and is provided, as part of the PROMPT annual training for all team members including midwives and obstetricians. The content of the training is informed by the findings of a recently completed documentation audit.”

Source location
Maia-Strachan-Response
Page 1 · response
Published 2 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Circulate the redacted expert report to all Obstetrics and Gynaecology staff, including midwives, to inform future practice.

Verbatim wording from the response
“2. You raised concern about the midwifery care in the second stage of labour; and planned to share a redacted copy of the expert report provided by Dr Sparey for circulation to inform future practice.”

Source location
Maia-Strachan-Response
Page 2 · response
Published 2 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and provide PROMPT documentation training for midwives and obstetricians, informed by documentation audit findings.

Verbatim wording from the response
“Current training around the required standard for documentation has been reviewed and is provided, as part of the PROMPT annual training for all team members including midwives and obstetricians. The content of the training is informed by the findings of a recently completed documentation audit.”

Source location
Maia-Strachan-Response
Page 1 · response
Published 2 August 2019
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised8

Failure to conduct speech and language therapy assessment using referral information, eating observation and care records

Failure to ensure staff have current Basic Life Support and First Aid at Work training

Lack of staff training and competence in care plans, MUST, BMI calculation and nutritional risk assessment

Failure to refer residents identified as high nutritional risk to appropriate clinical services

Failure to ensure food provided conforms to residents' identified diet plans

Failure to provide pertinent referral information to speech and language therapy

Failure to ensure agency staff receive and have verified induction

Delays in care assistant intervention when a resident shows signs of choking

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Concerns raised10

Failure to escalate care or make onward referral

Lack of in-person dietetic assessment recording weight and clinical observations

Insufficient staff understanding of Medical Emergencies in Eating Disorders guidelines

Confusion and delayed cascading of Consultant-to-Consultant referral guidance

Lack of physical face-to-face monitoring of weight

Lack of scrutiny of reluctance to engage and attend appointments

Lack of one accessible system for weights, heights and BMI

Lack of clear accountable oversight of outpatient care

Failure to provide face-to-face or direct contact before CAMHS discharge

Failure to share clinically significant eating and weight information with an appropriate body

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.21

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 2

Respondent positions 2

Actions described in response 21

Respondent positions 2