Partnerships in Care Limited

Health and care · Independent healthcare provider

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First report 6 Mar 2014•Latest report 1 May 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 2
Published responses: 50%
Concerns addressed: 3
Stated actions: 13

Concerns and recipient responses

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

1 May2015
Nottinghamshire
Concerns raised5
1. Failure of National Early Warning Score training to improve patient assessment
2. Low PIC staff understanding of significant clinical signs and oxygen requirements
3. Lack of clear guidance for communicating patients’ physical condition to GPs
1. Lack of ongoing audit and monitoring of training impact on patient assessment
2. Lack of a clear service level agreement for PIC and GP joint care
Actions described in response 7
1. Action
  Maintain a Service Level Agreement with the local GP practice for joint care.
2. Action
  Include NEWS training in induction for all new qualified staff.
3. Action
  Retrain qualified staff at relevant sites in NEWS interpretation and escalation responses.
1. Action
  Refresh NEWS training annually and remind staff to complete the refresher.
2. Action
  Provide NEWS policies and guidance on the PIC intranet for staff reference.
3. Action
  Provide Intermediate Life Support training covering recognition of cyanosis, pallor, breathlessness and oxygen-treatment needs.
4. Action
  Address identification of specified clinical issues through one-to-one clinical-practice supervisions with a Senior Manager.
AI-generated summary

Jayne Jowett · 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

Jayne Jowett, who was resident in a low secure and locked rehabilitation mental health facility, became unwell with intermittent respiratory difficulties, low oxygen saturations, dizziness, breathlessness and episodes of collapse before she died of a pulmonary embolus on 23 September 2014. The report identified concerns about staff training and response to National Early Warning Scores, understanding of significant clinical signs, and the lack of clear arrangements for sharing physical-health information between the facility and the GP surgery.

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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of National Early Warning Score training to improve patient assessment
Wider context from the report
“1. PIC Staff Training in National Early Warning Scores: Training in both interpretation of scores, and response to escalation in scores has not to date demonstrated improvement in assessment of a patients clinical condition. The impact of training on patient assessment requires ongoing audit and monitoring. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Low PIC staff understanding of significant clinical signs and oxygen requirements
Wider context from the report
“2. PIC staff at Annesley House have low levels of understanding of the significance of clinical signs such as cyanosis, pallor, breathlessness, and the significance of a patient needing oxygen treatment. There are no plans currently in place to address this ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear guidance for communicating patients’ physical condition to GPs
Wider context from the report
“3. There remains no clear current service level agreement regarding how best for PIC to work with the local GP surgery to provide high quality joint care. There is no clear guidance that ensures all information regarding a patient’s physical condition is communicated to a GP when seeing a patient. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of ongoing audit and monitoring of training impact on patient assessment
Wider context from the report
“1. PIC Staff Training in National Early Warning Scores: Training in both interpretation of scores, and response to escalation in scores has not to date demonstrated improvement in assessment of a patients clinical condition. The impact of training on patient assessment requires ongoing audit and monitoring. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear service level agreement for PIC and GP joint care
Wider context from the report
“3. There remains no clear current service level agreement regarding how best for PIC to work with the local GP surgery to provide high quality joint care. There is no clear guidance that ensures all information regarding a patient’s physical condition is communicated to a GP when seeing a patient. ”
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
Maintain a Service Level Agreement with the local GP practice for joint care.

Verbatim wording from the response
“Annesley House works closely with the local GP practice at Ashfield House Surgery. I am pleased to say that we have a Service Level Agreement in place and a copy of this is attached.”

Source location
2015-0175-Response-by-Partnership-in-Care
Page 2 · response
Published 1 May 2015
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
Include NEWS training in induction for all new qualified staff.

Verbatim wording from the response
“All nursing staff at relevant sites were trained on the NEWS when this was rolled out originally in 2013, and all qualified staff at those sites have been retrained on this following this inquiry. We have now also arranged for this to form part of the induction training so that all new qualified staff will be trained on this as part of their induction to PIC. Additionally, the training is to be refreshed annually. Staff receive an email reminder of the need to do this annual refresher training. Part of the PIC internal audit system includes checking that staff complete their necessary training.”

Source location
2015-0175-Response-by-Partnership-in-Care
Page 1 · response
Published 1 May 2015
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
Retrain qualified staff at relevant sites in NEWS interpretation and escalation responses.

Verbatim wording from the response
“All nursing staff at relevant sites were trained on the NEWS when this was rolled out originally in 2013, and all qualified staff at those sites have been retrained on this following this inquiry. We have now also arranged for this to form part of the induction training so that all new qualified staff will be trained on this as part of their induction to PIC. Additionally, the training is to be refreshed annually. Staff receive an email reminder of the need to do this annual refresher training. Part of the PIC internal audit system includes checking that staff complete their necessary training.”

Source location
2015-0175-Response-by-Partnership-in-Care
Page 1 · response
Published 1 May 2015
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
Refresh NEWS training annually and remind staff to complete the refresher.

Verbatim wording from the response
“All nursing staff at relevant sites were trained on the NEWS when this was rolled out originally in 2013, and all qualified staff at those sites have been retrained on this following this inquiry. We have now also arranged for this to form part of the induction training so that all new qualified staff will be trained on this as part of their induction to PIC. Additionally, the training is to be refreshed annually. Staff receive an email reminder of the need to do this annual refresher training. Part of the PIC internal audit system includes checking that staff complete their necessary training.”

Source location
2015-0175-Response-by-Partnership-in-Care
Page 1 · response
Published 1 May 2015
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
Provide NEWS policies and guidance on the PIC intranet for staff reference.

Verbatim wording from the response
“Further, the policy and details relating to NEWS are available for staff to access on the PIC intranet so that they can refresh themselves at any time where necessary.”

Source location
2015-0175-Response-by-Partnership-in-Care
Page 1 · response
Published 1 May 2015
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
Provide Intermediate Life Support training covering recognition of cyanosis, pallor, breathlessness and oxygen-treatment needs.

Verbatim wording from the response
“The training provided by PIC is extensive. This includes training in Intermediate Life Support (“ILS”) for all doctors, registered nurses, and tutors responsible for training staff in relation to the management of violence and aggression. The ILS training that we provide includes recognition of these issues. The training providers who deliver this training are all externally accredited to provide training on these matters, and the content of the courses is periodically reviewed by PIC as part of its governance processes. We will also be ensuring that staff are aware of the specific identification of clinical issues that you have raised here through the one to one supervisions in which staff have their clinical practice discussed by a Senior Manager.”

Source location
2015-0175-Response-by-Partnership-in-Care
Page 2 · response
Published 1 May 2015
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
Address identification of specified clinical issues through one-to-one clinical-practice supervisions with a Senior Manager.

Verbatim wording from the response
“The training provided by PIC is extensive. This includes training in Intermediate Life Support (“ILS”) for all doctors, registered nurses, and tutors responsible for training staff in relation to the management of violence and aggression. The ILS training that we provide includes recognition of these issues. The training providers who deliver this training are all externally accredited to provide training on these matters, and the content of the courses is periodically reviewed by PIC as part of its governance processes. We will also be ensuring that staff are aware of the specific identification of clinical issues that you have raised here through the one to one supervisions in which staff have their clinical practice discussed by a Senior Manager.”

Source location
2015-0175-Response-by-Partnership-in-Care
Page 2 · response
Published 1 May 2015
Open published response
6 Mar2014
West Sussex
Concerns raised13
1. Sporadic and insufficient physical observations
2. Delays in obtaining records from community services
3. Inconsistent shift handover communication
1. Lack of staff training in cardiopulmonary resuscitation and defibrillator use
2. Failure to provide timely electrocardiograms
3. Unclear policy for involving family in care planning
4. Failure to check agency staff prior work before deployment
5. Haphazard communication between staff and family
6. Unclear responsibility for stopping physical observations
7. Failure to use an available ward defibrillator
8. Unclear policy on the duration of patient observations
9. Unclear policy for access to GP services
10. Poor-quality staff handovers
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Natasha Raghoo · 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

Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Sporadic and insufficient physical observations
Wider context from the report
“2. Physical observations of blood pressure, pulse and temperature were sporadic and few in number. This was cause for concern as Natasha had a raised blood pressure and had been commenced on treatment, Observations stopped two days prior to death and no member of staff was able to explain who was responsible for this action. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Delays in obtaining records from community services
Wider context from the report
“8. Obtaining records particularly from community services involved with the care of the patient was difficult and slow. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent shift handover communication
Wider context from the report
“4. Staff handovers occur twice daily in the morning and evening. Those finishing a shift hand over information about the patients to the incoming shift. It was apparent that communication was inconsistent, particularly when bank or agency staff were involved. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff training in cardiopulmonary resuscitation and defibrillator use
Wider context from the report
“1. During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator. The latter was reported not to have been used by hospital staff although available on the ward. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide timely electrocardiograms
Wider context from the report
“3. Whilst under the care of the Dene,and on antipsychotic drugs and with a raised blood pressure an electrocardiogram was not carried out because all routine ECGs are performed by a visiting nurse from a General Practitioners surgery on a set day of the week. An ECG machine is available within the hospital but is not routinely used. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Unclear policy for involving family in care planning
Wider context from the report
“5. Communications between staff and family were haphazard the policy of involving family in care planning was not clear. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to check agency staff prior work before deployment
Wider context from the report
“7. Unclear as to whether checking to ensure that when using agency staff they have not already worked a shift elsewhere that day. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Haphazard communication between staff and family
Wider context from the report
“5. Communications between staff and family were haphazard the policy of involving family in care planning was not clear. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Unclear responsibility for stopping physical observations
Wider context from the report
“2. Physical observations of blood pressure, pulse and temperature were sporadic and few in number. This was cause for concern as Natasha had a raised blood pressure and had been commenced on treatment, Observations stopped two days prior to death and no member of staff was able to explain who was responsible for this action. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to use an available ward defibrillator
Wider context from the report
“1. During the course of the evidence, concern was expressed concerning the training that staff had received in the techniques of cardio pulmonary resuscitation and the use of the defibrillator. The latter was reported not to have been used by hospital staff although available on the ward. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Unclear policy on the duration of patient observations
Wider context from the report
“9. The policy on length of time staff are expected to conduct observations, and the quality of handover from one member of staff to another. ”
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 Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Unclear policy for access to GP services
Wider context from the report
“6. The policy of access to GP services was not clear leading to misunderstanding by the Princess Royal as to where to send a report. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Partnerships in Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Poor-quality staff handovers
Wider context from the report
“9. The policy on length of time staff are expected to conduct observations, and the quality of handover from one member of staff to another. ”
Open source report

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 raised5

Failure of National Early Warning Score training to improve patient assessment

Low PIC staff understanding of significant clinical signs and oxygen requirements

Lack of clear guidance for communicating patients’ physical condition to GPs

Lack of ongoing audit and monitoring of training impact on patient assessment

Lack of a clear service level agreement for PIC and GP joint care

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.7

Concerns raised13

Sporadic and insufficient physical observations

Delays in obtaining records from community services

Inconsistent shift handover communication

Lack of staff training in cardiopulmonary resuscitation and defibrillator use

Failure to provide timely electrocardiograms

Unclear policy for involving family in care planning

Failure to check agency staff prior work before deployment

Haphazard communication between staff and family

Unclear responsibility for stopping physical observations

Failure to use an available ward defibrillator

Unclear policy on the duration of patient observations

Unclear policy for access to GP services

Poor-quality staff handovers

Actions described in response 7