13 Dec 2013 STEPHANIE DANIELS · Prevention of Future Deaths report Manchester City
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Concerns raised 9 Failure to complete and record patient observations View source Lack of nurse review of recent records during admission or transfer handover View source Delays in admission to an appropriate mental health bed View source Failure to properly clerk in mental health patients View source Failure to implement handover policies in practice View source Lack of clinical supervision and guidance for junior medical staff View source Failure to conduct prompt, thorough and independent investigations of serious patient deaths View source Failure of junior medical staff to review clinical records and history before prescribing medication View source Lack of a reliable method for notifying the responsible Consultant of patient admission View source See 6 more concerns
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STEPHANIE DANIELS · Prevention of Future Deaths report
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Report summary
Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and record patient observations
Wider context from the report “8. Performing and recording observations on other patients
I was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during the course of the inquest and was brought to the attention of MHSC so that they could carry out their own investigations.
” 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of nurse review of recent records during admission or transfer handover
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records . MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in admission to an appropriate mental health bed
Wider context from the report “3. Bed Availability
MHSC say that following the death of the deceased, a new policy has been introduced so that there is no waiting time at all for the allocation of a bed in the case of a patient who is deemed clinically to require one. A bed will be found somewhere which will be appropriate to their needs. As I understood the evidence from the CCG in the case this should have occurred in any event. However, other NHS Trusts nationwide who do not have such a policy, may have patients whose delayed admission means that they are not having the appropriate nursing and clinical input, as well as medication review . In turn this means their condition may continue to deteriorate and when effective care does start, the patient may well be more ill than they should be. I am concerned that the importance of this is recognised not only by MHSC but nationally for all other NHS mental health trusts.
” 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to properly clerk in mental health patients
Wider context from the report “4. Clerking In
The failure to properly clerk in the patient is a matter of serious concern , especially as many such patients will have physical health problems. MHSC had clear policies requiring the clerking in of a patient, but these were simply not adhered to . It is very common for patients with mental health problems to have associated physical conditions which require appropriate monitoring and treatment. It seems that despite the existence of appropriate policies, in practice these were not being complied with . Whether or not any new or different policy or auditing of compliance is the way to achieve uniformity is a matter for MHSC. I repeat what I have said earlier. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective.
” 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to implement handover policies in practice
Wider context from the report “2. Handover
All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice . Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective .
” 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clinical supervision and guidance for junior medical staff
Wider context from the report “5. Supervision of Junior Medical Staff
I am concerned about the lack of appropriate clinical supervision and guidance for junior medical staff . Two junior doctors were asked to attend the ward and made no appropriate clinical records of the reason for their attendance, reviewing the records, seeing the patient and explaining any clinical decision to prescribe medication. It is appreciated that they are busy with a number of duties but it is a matter of concern that they did not undertake basic clinical recording duties for a patient who clearly should have been seen. They did not notice that the patient had not been clerked in. Medication was being prescribed without adequate consideration of the relevant clinical history. They did not notice the named Consultant in charge of the patient was unaware of the admission. Appropriate clinical supervision would be expected to ensure an appropriate standard of performance. I understand that supervision may be delegated by the North West Deanery to the relevant NHS Trust but there has to be some basic accepted levels of interaction, communication and supervision between the junior Doctors and their Consultants to ensure an appropriate standard and continuity of care. This may be a joint responsibility between the Deanery and the NHS trust 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct prompt, thorough and independent investigations of serious patient deaths
Wider context from the report “1. Internal NHS SUI Investigation v Independent Investigation
I am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires a prompt, thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken. This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin).
In this case there were significant errors and omissions in the SUI investigation . Important witnesses were not interviewed. The delay in finding the deceased a bed was not a central issue and no specific findings were made about it. The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as other steps in compliance with the Trust’s Rapid Tranquilisation Policy. It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented. Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that very significant failures in the investigative process have occurred. The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March.
This is not the first time that the Trust SUI investigations have been found to be flawed and I have experience of other Trusts’ investigations also being significantly flawed. In conclusion in this sort of case I am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved, flawed SUI investigation reports may continue to be produced . This is a policy decision for the NHS but I strongly urge consideration of 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of junior medical staff to review clinical records and history before prescribing medication
Wider context from the report “6. Prescribing of Medication by Junior Medical Staff
I am concerned by the circumstances in this case where medication came to be prescribed. There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here. Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. They simply prescribed the medication. They had no recollection of reviewing the deceased’s records and understood that was essential when considering prescribing any medication, and in particular PRN rapid tranquillisation. In this case, the patient was already taking a number of drugs which had sedative effects. Two further medications were introduced that have similar properties and that also could potentially affect heart function.
” 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 PHIRST Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable method for notifying the responsible Consultant of patient admission
Wider context from the report “7. Mechanism by which the Consultant in charge of the patient would learn of the patient’s admission
It is of concern that there was apparently no simple method of ensuring that the Consultant in whose name the patient was admitted became aware of the admission and could therefore ensure appropriate clinical leadership and review was undertaken. It would seem that there could be a number of simple solutions for this problem.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations