Concerns raised 5 Failure of National Early Warning Score training to improve patient assessment View source Low PIC staff understanding of significant clinical signs and oxygen requirements View source Lack of clear guidance for communicating patients’ physical condition to GPs View source Lack of ongoing audit and monitoring of training impact on patient assessment View source Lack of a clear service level agreement for PIC and GP joint care View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
6 Mar 2014 Natasha Raghoo · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 13 Sporadic and insufficient physical observations View source Delays in obtaining records from community services View source Inconsistent shift handover communication View source Lack of staff training in cardiopulmonary resuscitation and defibrillator use View source Failure to provide timely electrocardiograms View source Unclear policy for involving family in care planning View source Failure to check agency staff prior work before deployment View source Haphazard communication between staff and family View source Unclear responsibility for stopping physical observations View source Failure to use an available ward defibrillator View source Unclear policy on the duration of patient observations View source Unclear policy for access to GP services View source Poor-quality staff handovers View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
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
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations