Concerns raised 4 Delays in outpatient follow-up for ear infections View source Failure to prescribe oral antibiotics at discharge despite microbiology advice View source Failure to establish clear responsibility for patient care View source Failure of separate hospital trusts to provide clinicians with access to each other’s medical records View source See 1 more concern
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
Andrew James Tizard-Varcoe · 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
Andrew James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.
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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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in outpatient follow-up for ear infections
Wider context from the report “(2) In addition, the evidence revealed that there were three occasions when Mr Tizard-Varcoe was not followed up as an outpatient in a timely manner (August 2021, November 2021 and February 2022). On one occasion Mr Tizard-Varcoe possibly ran out of antibiotic medication and on another Mr Tizard-Varcoe was discharged without antibiotic medication. The lack of timely follow up appointments resulted in reduced monitoring and assessment and a poor understanding of the effectiveness of treatment and the progression of his ear infection.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe oral antibiotics at discharge despite microbiology advice
Wider context from the report “(3) In addition, on 1 November 2021, Mr Tizard-Varcoe was discharged from the Royal and Devon Hospital without a prescription for oral antibiotics despite advice from microbiologists to do so ; the evidence showed that this was a clinical decision made by a junior ear nose and throat doctor against an improving clinical picture . The discharge was overseen by a consultant from a different specialism due to Mr Tizard-Varcoe’s health needs at the time.
Evidence at the inquest from the responsible ear nose and throat consultant, indicated that he would probably have prescribed antibiotics on advice of microbiologists. Due to the progression of the infection from the ear canal into the bone at the base of the skull there is a real possibility that the clinical presentation did not reflect the true situation and this was a missed opportunity to provide continuity of treatment.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear responsibility for patient care
Wider context from the report “(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care . It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of separate hospital trusts to provide clinicians with access to each other’s medical records
Wider context from the report “(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records . The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care. It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe.
” 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 Introduce virtual ticket scheduling through MyCare, with appointment notifications, patient self-booking and letters for patients without the application.
Verbatim wording from the response “Ticket scheduling is another change due to be brought in which will be a virtual booking system on our MyCare app. This feature will send out notifications to the patients inviting them to book an appointment, the app will present all available slots to the patient for booking. All bookings are completed and confirmed via the app. Any patients without the app will be sent standard letters inviting them to clinic. This will avoid patients having to call into the office for an appointment which will be much faster.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Use the EPR fast-pass system to offer suitable vacant outpatient slots to patients through the MyCare application.
Verbatim wording from the response “Another one of the changes that has been implemented is that the use of the EPR system has been further developed to include a “fast pass” and “ticket scheduling system” that sends out any vacant slots to the patients suitable for booking up to 6 times daily via the MyCare (EPR app) until the slots are filled. Patients can bring pre-booked appointments forward to a closer date.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Appoint two permanent ENT consultants and provide daily named-consultant ward rounds with senior review of discharges and ongoing treatment plans.
Verbatim wording from the response “At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant that not every discharge could be reviewed by a named Consultant. Since 2022, a further two permanent ENT Consultants have been appointed. This has allowed the team to have a named consultant ward round on a daily basis and this means there is now senior supervision of decision making on every ward round. This includes reviewing all patients due to be discharged as well as their management plan on discharge. With this now in place, I am assured that there would be senior oversight of ongoing treatment and patients such as Mr Tizard-Varcoe would be discharged with appropriate treatment plans in place.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Implement a single electronic patient record across the merged Trust sites to improve coordination and continuity of care.
Verbatim wording from the response “In April 2022, the two Trusts formally merged creating Royal Devon University Healthcare NHS Foundation Trust and by July 2022, both sites and all staff were using the same electronic records system (EPIC). This use of the one combined patient record has significantly improved care for patients receiving care across both sites and this has been a significant and important change since Mr Tizard-Varcoe’s death.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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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 Strengthen ENT outpatient follow-up monitoring through booking validation, waiting-list dashboards, overdue-date tracking, additional booking-office staffing and routine capacity reviews.
Verbatim wording from the response “At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings were made. I can reassure you that over the past few years, a significant amount of work has gone into improving booking processes and waiting list (workqueue) monitoring. There is now much more robust ongoing validation/ assurance of booking processes and waiting lists.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
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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 Named consultant ward rounds and discharge-plan reviews are considered sufficient to provide senior oversight of ongoing treatment at discharge.
Verbatim wording from the response “At the time of Mr Tizard-Varcoe’s discharge, there was a shortage of ENT Consultants which meant that not every discharge could be reviewed by a named Consultant. Since 2022, a further two permanent ENT Consultants have been appointed. This has allowed the team to have a named consultant ward round on a daily basis and this means there is now senior supervision of decision making on every ward round. This includes reviewing all patients due to be discharged as well as their management plan on discharge. With this now in place, I am assured that there would be senior oversight of ongoing treatment and patients such as Mr Tizard-Varcoe would be discharged with appropriate treatment plans in place.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
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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 Merged services, a shared electronic record and planned Devon-wide integration are considered sufficient to improve coordination across sites.
Verbatim wording from the response “I am assured that since the merger of the two Trusts and the implementation of Epic in across both sites and, continuity of care and patient safety has been improved.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
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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 Enhanced booking validation, waiting-list monitoring, staffing and electronic scheduling are considered sufficient to monitor ENT outpatient follow-ups efficiently.
Verbatim wording from the response “At the time that Mr Tizard-Varcoe was under the care of the ENT Team at the RD&E, there was a relatively new Electronic Patient Record (“EPR”) system in place, through which outpatient bookings were made. I can reassure you that over the past few years, a significant amount of work has gone into improving booking processes and waiting list (workqueue) monitoring. There is now much more robust ongoing validation/ assurance of booking processes and waiting lists.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
Concerns raised 7 Delays in moving patients to prevent pressure sore deterioration View source Failure to complete malnutrition universal screening tool assessments View source Failure to complete and repeat pressure ulcer risk assessments View source Failure to photograph wounds to monitor progression or deterioration View source Failure to plan follow-up after Tissue Viability Team assessment View source Failure to routinely document skin checks View source Failure to complete an initial skin check within 6 hours of admission View source See 4 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
Raymond Albert Alfred Reid · 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
Raymond Albert Alfred Reid was admitted to hospital with a catheter-related urinary tract infection, developed pressure sores and pneumonia during a prolonged stay, and died on 1 March 2023. The report identified concerns about gaps in pressure sore prevention, monitoring, documentation, nutritional screening, repositioning, wound follow-up and photography.
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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in moving patients to prevent pressure sore deterioration
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete malnutrition universal screening tool assessments
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and repeat pressure ulcer risk assessments
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to photograph wounds to monitor progression or deterioration
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to plan follow-up after Tissue Viability Team assessment
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document skin checks
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete an initial skin check within 6 hours of admission
Wider context from the report “(2) The pressure sores developed in hospital and the deterioration of the pressure sores was possibly caused by gaps in care and knowledge. More particularly the evidence at the inquest (and the findings of an internal concise investigation) revealed that:
a. A first skin check was not completed within 6 hours of admission in accordance with Trust policy.
b. The pressure ulcer risk assessment was not completed within 6 hours of admission and was not repeated daily in accordance with Trust policy.
c. Skin checks were not routinely documented – there were 21 intermittent days when a skin check was not recorded.
d. A malnutrition universal screening tool assessment was not completed in accordance with Trust policy.
e. There were long periods when Mr Reid was not moved – there were episodes during 15/2/23 to 21/2/23 when Mr Reid was not documented to have been moved for 5-10 hours. This is not best practice.
f. Following a Tissue Viability Team assessment there was no follow up planned – this should have been planned to monitor wound progression.
g. No photographs were taken between 8/2/23 and 21/2/23. The taking of photographs represents best practice to enable the progress and/or deterioration of a wound to be fully understood.
” 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 Establish a Northern-site leadership workstream to strengthen front-line nursing practice in pressure-ulcer prevention and management, with senior oversight of delivery.
Verbatim wording from the response “In order to ensure that this is actually being delivered on the front line, the Chief Nursing Officer has commissioned a significant leadership piece of work from the Director of Nursing on the Northern site. She has been asked to ensure we have right systems and processes for care in Northern services and specifically looking to “foster leadership in best practice in front line nursing staff who have ward based responsibilities regarding the day to day prevention and management of pressure ulcers”. This Group is being set up and delivery against the agreed actions will be report to the Tissue Viability Group and the Patient Safety Committee so again there will be high level and senior oversight of this piece of work.” Source location Response from Royal Devon Healthcare NHS
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 Review reported tissue-damage incidents, take immediate local learning actions, and assess implications for the Trust-wide improvement plan.
Verbatim wording from the response “From this, you can see that there is a huge amount of work covered by the Group. All Care Groups attend the quarterly meeting and it is jointly led by the two Trust Tissue Viability Leads. All reported incidents of tissue damage are reviewed by the TV team in collaboration with the Care Group Senior Nurses. Immediate local learning/actions will be taken following this initial review. All incidents will also be reviewed to determine any implications for the Trust wide TV improvement plan. Trends and discrepancies in care can be identified centrally and early work can then be done to improve patient care.” Source location Response from Royal Devon Healthcare NHS
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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 Trust-wide pressure damage prevention arrangements provide sufficient assurance that further work and dissemination are not required.
Verbatim wording from the response “I am pleased to be able to write and provide you with real assurance that the Trust is doing significant work to reduce pressure damage in patients and I hope you will be reassured that this has been a priority of the Trust for some time now and substantial work is being done to ensure improvements.” Source location Response from Royal Devon Healthcare NHS
Open published response
15 Sep 2023 Geoffrey Robin Brooks · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 1 Failure of discharge summaries to clearly communicate target fluid intake View source
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
Geoffrey Robin Brooks · 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
Geoffrey Robin Brooks, who had nephrogenic diabetes insipidus, was admitted to hospital in October 2020 after his health deteriorated and died on 12 November 2020 despite treatment. The discharge summary did not clearly state that his required fluid intake of 2.5 to 3 litres per day was a target, and the target was not met while he was in the nursing home; the inquest concluded that he died from complications of nephrogenic diabetes insipidus on a background of poor fluid intake.
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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of discharge summaries to clearly communicate target fluid intake
Wider context from the report “During his evidence the consultant physician with the responsibility for the care and treatment of Mr Brooks acknowledged that the discharge summary was ambiguous and did not make it clear that the 2.5 – 3L was a target fluid intake ; he agreed that it could be interpreted that Mr Brooks should be restricted to no more than 2.5 to 3L of fluid a day . As a consequence, the nursing home staff were unaware of the needs of Mr Brooks . The target fluid intake was not met in the period that Mr Brooks was in the nursing home, which contributed to his death.
” 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 Review use of the After Visit Summary across inpatient and outpatient services through an established working group.
Verbatim wording from the response “3. After Visit Summary
Epic has introduced the ability to generate a patient focused document for inpatient and outpatient attendances - the After Visit Summary (AVS) which can be given to patients at the point of hospital discharge. To date, the AVS has not been widely rolled out, particularly after inpatient stays.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Use bespoke discharge-summary templates for complex patient groups to clarify pertinent information and follow-up instructions.
Verbatim wording from the response “2. Bespoke templated discharge summaries
Some areas (e.g. Stroke, Acute Care of the Elderly) have specific templates for completing discharge letters which ensures pertinent information and ongoing instructions are as clear as possible. This is important for more complex patient groups who need to have specific assessments and follow-up.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Review community-hospital staffing to develop a more robust, consistent medical team with specialty-doctor and Advanced Clinical Practitioner oversight.
Verbatim wording from the response “We are currently reviewing the staffing model of our community hospitals which we hope will lead to a more robust, consistent medical team with specialty doctor and Advanced Clinical Practitioner oversight. This will provide an additional safety-net around discharge and again letters will be more likely to be written and checked by individuals who have reliably been involved in a patient’s care.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Maintain a four-day junior-doctor rota in Medicine to reduce cross-cover and improve staffing consistency for discharge documentation.
Verbatim wording from the response “5. Enhanced ward staffing consistency
Within Medicine, our staffing model was changed recently so that junior doctors in training have switched to a 4-day working week. Previously, compensatory rest meant that juniors were often moved from their base wards to cover rota gaps; this led to a loss of consistency in medical staffing which is a risk to discharge letters writing as discussed above. The new rota pattern means the need for cross cover is greatly reduced.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Relaunch the Trust-wide discharge-summary working group with primary-care representation to refine discharge processes and communication.
Verbatim wording from the response “The Trust wide discharge summary working group will be shortly relaunched with a plan to have primary care representation to try and further refine discharge processes and communication with primary care. There is potential to develop more discharge summary templates for specific specialties or conditions. We are continually working on improving the completion rates of discharge summaries and ensuring they are sent in accordance with the NHS Standard Contract agreement of within 24 hours following inpatient, day case or ED attendance.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Use Epic’s Hospital Course function to build discharge summaries from clinicians’ real-time inpatient documentation.
Verbatim wording from the response “The RDUH switched to an electronic patient record (Epic) across its Eastern services in October 2020, which was after the date of this incident. This has led to significant improvements in documentation across inpatient and outpatient encounters. Epic has several features that help improve documentation specifically around discharge:” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
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 Produce guidance and standard operating procedures for ward teams following the After Visit Summary review.
Verbatim wording from the response “A working group has been established and will shortly begin meeting to review the use of the AVS across inpatient and outpatient areas across the Trust. Once completed, the group will produce new guidance and Standard Operating Procedures (SOPs) for ward teams, meaning the AVS would be given to the patient and the discharge summary sent electronically to the GP as a matter of routine. It clearly lays out medication changes, follow-up arrangements and can be used to provide patient’s with specific instructions. In this case, clear documentation of fluid intake requirements could have been flagged in this document.” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
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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 Trust considers reviewing every discharge letter by a consultant infeasible because of resource demands, unclear responsibility, delays and risks of error.
Verbatim wording from the response “Other considerations
The Trust has considered whether every discharge letter should be reviewed by a consultant. On balance, this would not seem feasible due to:” Source location Response from Royal Devon University Healthcare NHS Foundation Trust
Open published response
3 Apr 2019 Stuart Michael CLARK · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 3 Failure to assess disclosed risk of self-harm or suicide View source Failure to directly inform senior clinical staff of disclosed suicide risk View source Delays in recording clinically significant disclosures in medical notes View source
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
Stuart Michael 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
Stuart Michael CLARK died shortly after being recovered from a canal on 3 October 2017, after entering the water wearing a rucksack filled with weights. During a hospital admission before his death, he disclosed that he was a vulnerable adult and a suicide risk, but this was not escalated or followed by an assessment of his risk of self-harm or suicide. The report identified that senior clinical staff were not directly informed and that the relevant medical record entry was not available to other staff at the time.
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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assess disclosed risk of self-harm or suicide
Wider context from the report “(1) The evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Canpere) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk. This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent, plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services.
Senior clinical staff were not directly informed of the disclosure. The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide, and if appropriate she would have referred him to the mental health services.
The nurse made an entry in the medical records; however, the medical notes were not made up until the end of the day and therefore the information was not available to the other staff at the relevant time.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to directly inform senior clinical staff of disclosed suicide risk
Wider context from the report “(1) The evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Canpere) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk. This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent, plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services.
Senior clinical staff were not directly informed of the disclosure. The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide, and if appropriate she would have referred him to the mental health services.
The nurse made an entry in the medical records; however, the medical notes were not made up until the end of the day and therefore the information was not available to the other staff at the relevant time.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in recording clinically significant disclosures in medical notes
Wider context from the report “(1) The evidence revealed that Mr CLARK disclosed to a member of nursing staff on Lowman (Canpere) Ward at the Royal Devon and Exeter Hospital that he was a vulnerable adult and a suicide risk. This disclosure was not followed up with an assessment to determine if Mr CLARK had any intent, plan or history of self-harm or suicide. An assessment would have helped determine his risk and inform the decision on a referral to mental health services.
Senior clinical staff were not directly informed of the disclosure. The SHO Dr responsible for Mr CLARK stated in her evidence that had she known about the disclosure she would have assessed his risk of self-harm and suicide, and if appropriate she would have referred him to the mental health services.
The nurse made an entry in the medical records; however, the medical notes were not made up until the end of the day and therefore the information was not available to the other staff at the relevant time .
” 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 Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
Verbatim wording from the response “However, the Trust is always seeking to improve safety for its patients. We will be reinforcing individual responsibility and accountability for patient safety and suicide prevention to all staff. In June 2019, the Trust is running a two day ‘Care Matters’ professional leadership forum for Nurses, Allied Health Professionals and midwives. These sessions will be run and delivered in person by ████████
████████ Deputy Chief Executive/Chief Nurse, and will reach over 100 leads who will then cascade to their respective teams. The focus of this forum is Professional Safety and this case will be used during this forum as an example to reiterate the importance of escalating concerns about vulnerable patients to ensure the appropriate assessments and support can be provided to them.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 current training and support for recognising risk, escalating concerns and safeguarding adults.
Verbatim wording from the response ““review procedures and training related to the actions to be taken when a disclosure is made to ward staff giving rise to the suspicion of the risk of self-harm or suicide”.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Verbatim wording from the response “The Trust is satisfied that this was an isolated incident and staff are aware of their safeguarding obligations. However, the Safeguarding Team is going to issue a reminder to all staff in an upcoming newsletter (which reaches all clinical staff) about safeguarding procedures when there is a disclosure about possible suicidal intent. This briefing will include information about the ‘It’s safe to talk about suicide’ leaflet, a copy of which is attached. This is available on the Trust’s safeguarding intranet page but we want to raise awareness further of this issue. The leaflet was produced by Exeter Medical School in conjunction with Suicide Charities and Devon County Council for staff to use to support people when suicidal intention is disclosed.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
Verbatim wording from the response “The Trust is satisfied that this was an isolated incident and staff are aware of their safeguarding obligations. However, the Safeguarding Team is going to issue a reminder to all staff in an upcoming newsletter (which reaches all clinical staff) about safeguarding procedures when there is a disclosure about possible suicidal intent. This briefing will include information about the ‘It’s safe to talk about suicide’ leaflet, a copy of which is attached. This is available on the Trust’s safeguarding intranet page but we want to raise awareness further of this issue. The leaflet was produced by Exeter Medical School in conjunction with Suicide Charities and Devon County Council for staff to use to support people when suicidal intention is disclosed.” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 training, policies, safeguarding support and mental health provision are considered sufficient to ensure staff recognise and escalate suicide risks.
Verbatim wording from the response “There is a mandatory training programme that is completed by all staff on induction with the Trust, whatever their role. Regular updates are required at a maximum interval of every three years. The training programme has the following objectives:” Source location 2019-0125-Response-by-Royal-Devon-and-Exeter-NHS-Trust
Open published response
14 Feb 2017 Wendy Louise Telfer · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 4 Lack of available psychiatric inpatient beds View source Failure to correctly apply the Mental Health Act in physical care environments View source Delays in discharge caused by inadequate social and community care resources View source Lack of adequate mental health training for physical healthcare staff View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Wendy Louise Telfer · 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
Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.
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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of available psychiatric inpatient beds
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds . The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one , but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients, and it is acknowledged that this is a wider issue of social and community care and resources. This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly apply the Mental Health Act in physical care environments
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve", although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment , which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in discharge caused by inadequate social and community care resources
Wider context from the report “(2) Wendy was to be admitted to a psychiatric bed at one stage of this final hospital stay, but she could not be transferred immediately due to the lack of beds. The Devon Partnership Trust was candid and open regarding their considerable difficulties in this regard, that have been worsening over a number of years. Currently the Court was advised that a block booking of beds has been secured in the North Somerset region, but this short term solution is financially unsustainable, and not a good solution in term of patient need and geographical location. It is accepted that the problem of psychiatric in-patient beds is a national one, but on this occasion, had a bed been available when needed for Wendy, her death is likely to have been avoided.
The Court was advised that much of the difficulty is delayed discharge of patients , and it is acknowledged that this is a wider issue of social and community care and resources . This report is therefore being copied to the commissioners as well for their further consideration of the current untenable situation.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate mental health training for physical healthcare staff
Wider context from the report “(1) It was recognised at inquest that there is a frequent need for patients with significant mental health needs to increasingly be cared for in a physical care environment, due to concurrent physical and mental health needs, and due to an increasing difficulty in sourcing psychiatric beds, which often requires a wait on a general ward. It was also acknowledged that the training of the physical healthcare staff "needs to improve" , although it must be said that efforts have been made and are continuing to address this issue.
From the evidence there was clear confusion regarding the application of the Mental Health Act in the physical care environment, which led in this case to Wendy being allowed to leave the ward unaccompanied and without transport, which could have been avoided with better understanding of the available restrictive legislation.
” 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 Deliver regular Mental Health Act training to Emergency Department, Site Management, medical and foundation doctor staff.
Verbatim wording from the response “Part of the role of the DPT Liaison Psychiatry team is to offer training to colleagues in the acute hospital. This is done both formally and informally. In 2016, the Liaison Psychiatry Team has formally trained at least 496 staff, having taught 175 teaching sessions.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 Train volunteer clinicians as Mental Health Champions through a five-day programme.
Verbatim wording from the response “• Mental Health Champion Training (x5 full days) to RD&E clinicians who have volunteered themselves as Mental Health Champions for the RD&E. This helps support staff with patients in practice.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 a training needs analysis to determine further training requirements, target areas and appropriate staff levels.
Verbatim wording from the response “With regards to future development, there is a general consensus that a greater awareness and understanding of the MHA would be beneficial to all staff. Ensuring that this training is of a suitable level, proportionate and appropriate to staff grading is essential. We are looking at the best ways to target resources most effectively and efficiently.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 Consider distributing Mental Health Act information leaflets with staff payslips.
Verbatim wording from the response “Consideration is also being given to the viability a ‘leaflet drop’ with payslips. This has recently been done by the Child Protection/Safeguarding Team to good effect. This would ensure that all staff in all grades and positions have some basic training and an information resource on the MHA. Further ‘catch all’ training may also include information being added the RD&E intranet as a must-read document. It is hoped that the new ‘Mental Health Champions’ being trained could assist with any new training.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 Train a specialist nursing staff pool for dedicated mental health input, reducing reliance on agency staff.
Verbatim wording from the response “Further, the RD&E is training a specialist pool of nursing staff for specific mental health input. This will lessen the need to use agency staff. This will allow the Trust to have better control over the training and expertise of the specialist mental health staff. It will also improve communication between the physical and mental health care professionals.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 a package on managing challenging behaviour and using rapid tranquillisation as a last resort to medical ward staff.
Verbatim wording from the response “• A whole day’s package has just been built and is due to start being delivered later this month called “Management of Challenging Behaviour – Using Rapid Tranquilliser as a last resort” – this refers to use of the MHA in its content. This is being delivered to the medical wards and targeted at registered and non-registered staff where patients with mental health needs alongside physical needs are being nursed.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 escalation arrangements require staff to seek specialist psychiatric advice and remain the Trust’s first-line approach for future Mental Health Act concerns.
Verbatim wording from the response “All of the current MHA training requests that if staff have any concerns about a patient’s mental health, then they should contact the specialist Psychiatric Liaison Team for advice on how to manage that patient in normal working hours and the psychiatric on call Crisis Team out of hours. The escalation process also includes contacting the Devon Partnership Trust on call team both in and out of hours if an issue is unresolved. The next stage of the process includes contacting the Devon Partnership Trust on-call Director if required. This is what is practiced throughout the RD&E at the moment. This would also be our first line of advice in any future training.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
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 Specialist assessments and advice did not support detaining the patient under the Mental Health Act when she attempted to leave.
Verbatim wording from the response “With respect to Wendy Telfer’s case, she had been formally assessed on two occasions by specialist practitioners from the DPT and they did not consider she should have been under a formal MHA section. On the day of her discharge, there was some uncertainty about her MHA status and her current presenting symptoms. Therefore, RD&E staff sought specialist advice from the Psychiatry Liaison Team on two separate occasions. They were not advised to use the MHA to detain the patient if she tried to leave. It was on the basis of this specialist advice that she was allowed to leave.” Source location 2017-0046-Response-by-Royal-Devon-and-Exeter-NHS-Trust
Open published response
26 Jun 2015 Alec James MATHIAS · Prevention of Future Deaths report Exeter and Greater Devon
View report summary
Concerns raised 2 Failure to send discharge letters to GPs documenting dangerous treatment side effects View source Failure to highlight hospital records with vital drug-sensitivity information View source
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.
×
AI-generated summary
Alec James MATHIAS · 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
Alec James Mathias developed drug-induced jaundice after receiving Flucloxacillin in 2008, but this reaction was not communicated to his GP or highlighted in the hospital records. He was prescribed Flucloxacillin again in 2014 for an infected finger and died after developing Flucloxacillin-induced cholestatic liver injury and liver failure. The principal concerns were failures to send discharge information to the GP and to record the drug sensitivity in the hospital notes.
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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to send discharge letters to GPs documenting dangerous treatment side effects
Wider context from the report “(1) Discharge letters have not been sent to the patients GP in a case where a dangerous side effect to treatment has been noted
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to highlight hospital records with vital drug-sensitivity information
Wider context from the report “(2) That the hospital has not highlighted its own records with vital information on drug sensitivity discovered and diagnosed on an in-patient .
” Open source report
Concerns raised 3 Failure to communicate the patient's total number of falls to all visiting staff View source Failure to record neurological observations correctly and at the minimum recommended frequency View source Use of an out-of-date post-falls checklist lacking required neurological observation details View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Robert Alan JONES · 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
Robert Alan JONES suffered multiple falls following a stroke and later deteriorated, dying at South Molton Community Hospital on 1 April 2014. The inquest recorded accidental death, with acute on chronic subdural haematoma and multiple falls due to cerebrovascular accidents. Concerns included inadequate communication about the total number of falls, use of an out-of-date post-falls checklist, and incomplete or incorrectly recorded neurological observations.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate the patient's total number of falls to all visiting staff
Wider context from the report “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained.
An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended.
They were not always recorded correctly on the observation charts.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record neurological observations correctly and at the minimum recommended frequency
Wider context from the report “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained.
An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended.
They were not always recorded correctly on the observation charts.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Use of an out-of-date post-falls checklist lacking required neurological observation details
Wider context from the report “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained.
An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended.
They were not always recorded correctly on the observation charts.
” 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 Deliver neurological-observation training to registered nurses and reduced-consciousness assessment training to non-registered support staff.
Verbatim wording from the response “(3) Ensure delivery of targeted training on performing neurological observations for nursing staff at South Molton Community Hospital and as a general communication across the trust.” Source location 2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
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 Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.
Verbatim wording from the response “(1) Revise the Trust’s falls policy to include the recommended frequency and duration of neurological observations based on NICE guidance for patients where head injury has occurred or cannot be ruled out, and inclusion of relevant history of falls in handovers of care.” Source location 2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
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 falls risk and falls information in bedside handovers and safety briefings, with observational audits, feedback, and re-audit of information-sharing gaps.
Verbatim wording from the response “The Trust’s falls policy (enclosed) has been revised to include information relating to the frequency and duration of neurological observations (in line with the relevant NICE guidelines) and published on the Trust’s policy website. The Trust’s policy includes a post falls checklist (enclosed) which details how often and for how long neurological observations should be recorded. The Trust’s bedside handover and safety briefing standard operating procedure clearly identifies information relating to patient falls (including their risk of falls) is a key component in shift to shift communication, and must be included in handover. Bedside handovers are audited via observation and reports and actions provided to wards and teams where there are gaps in information being shared. Improvement is measured by re-audit.” Source location 2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
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 Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.
Verbatim wording from the response “To support the actions detailed above, the Trust will issue a Patient Safety Alert, which will communicate the need for neurological observations when a head injury has occurred or cannot be ruled out, completion of the post falls checklist, to include the frequency and duration of observations, to ensure the post falls checklist is filed with the patient’s observation chart for ease of access for all Multi-Disciplinary Team members, and to ensure that information relating to falls risk or actual falls is included in safety briefings and bedside handover. Patient Safety Alerts are disseminated across the whole Trust to clinical and managerial leads.” Source location 2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
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 filing of post-falls checklists with physiological and neurological observation charts for daily multidisciplinary team review of patients’ multiple falls.
Verbatim wording from the response “As per (1), this information is included in safety briefings, which are multi-disciplinary events. Additionally, the Trust’s post falls checklist allows staff to record multiple falls on the same document, ensuring that information relating to falls is held in a central place. The trust is implementing a system that requires the post falls checklist to be filed with the patient’s physiological observations / neurological observations chart, which is reviewed by the Multi Disciplinary Team on a daily basis.” Source location 2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Open published response
7 Apr 2014 Roger Clive DUGGAN · Prevention of Future Deaths report Exeter & Greater Devon
View report summary
Concerns raised 3 Failure to respond sufficiently seriously and promptly to mental health crisis calls View source Failure to ensure staff responsibility for observing an agitated patient in the emergency department View source Lack of staff training to deal with mental health crisis View source
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.
×
AI-generated summary
Roger Clive DUGGAN · 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
Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.
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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond sufficiently seriously and promptly to mental health crisis calls
Wider context from the report “(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend .
It appears that staff lacked the necessary training to deal with Mental Health Crisis. After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff responsibility for observing an agitated patient in the emergency department
Wider context from the report “(2) Mr Duggan was brought to the Emergency Department of the Royal Devon & Exeter Hospital (Wonford) late on the evening of the 10th February 2013 in a state of heightened anxiety and agitation.
Night Senior Nurse Mental Health Practitioner, ████████ was called to assess. I received Evidence that ████████ left the Deceased in cubicle 8 in Minors area (which was supervised) asking the staff nurse to sit with Mr Duggan while he spoke with the family. He was told that they would keep an eye on Mr Duggan.
No one saw Mr Duggan leave the cubicle until the CCTV picked up his exit from the unit at 00.47 hours on 11th February 2013.
It appears from Evidence that neither the Senior Nurse Mental Health Practitioner not night staff on the unit took responsibility for watching Mr Duggan.
Mr Duggan was found Deceased in the River Exe at 14.30 hours 12th February 2013.
” 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 Royal Devon University Healthcare NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training to deal with mental health crisis
Wider context from the report “(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend.
It appears that staff lacked the necessary training to deal with Mental Health Crisis . After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013.
” Open source report
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Request correction
Addressed to Northern Devon Healthcare NHS Trust, now represented here by Royal Devon University Healthcare NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations