10 Mar 2026 Jennine Sasha Romeo · Prevention of Future Deaths report City of London
View report summary
Concerns raised 2 Lack of a system ensuring timely review and consideration of echocardiography results View source Lack of a pathway for echocardiography teams to flag results to clinical teams 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.
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AI-generated summary
Jennine Sasha Romeo · 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
Jennine Sasha Romeo died on 29 May 2025 after developing multiorgan failure following complications of mitral valve surgery and subsequent re-do surgery. The January 2025 echocardiogram showing serious cardiac abnormalities was not clinically reviewed until May, after hospital outpatient appointments had been cancelled. The report identified concerns about the absence of systems to ensure timely review of results and a pathway for the echocardiography team to flag significant findings.
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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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a system ensuring timely review and consideration of echocardiography results
Wider context from the report “As stated above, the evidence suggested that the outcome of a transthoracic echocardiogram performed in January 2025 at the North Middlesex University Hospital was not reviewed by any clinician until May 2025. It seems that the intention was for it to be reviewed at a valve clinic out-patient appointment, but appointments in February and March 2025 were cancelled by the hospital, and there is no evidence to suggest that the result was considered at a paper review by the Consultant on the 4th April 2025, not by any other clinical team at the hospital.
There appears to be no system in place to ensure that a result such as this is viewed and considered by a member of a relevant clinical team in a timely manner, whether or not the planned out-patient appointment takes place as planned.
Additionally, it seems that there is no relevant pathway for the echocardiography team to flag a result such as this to the clinical team.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a pathway for echocardiography teams to flag results to clinical teams
Wider context from the report “As stated above, the evidence suggested that the outcome of a transthoracic echocardiogram performed in January 2025 at the North Middlesex University Hospital was not reviewed by any clinician until May 2025. It seems that the intention was for it to be reviewed at a valve clinic out-patient appointment, but appointments in February and March 2025 were cancelled by the hospital, and there is no evidence to suggest that the result was considered at a paper review by the Consultant on the 4th April 2025, not by any other clinical team at the hospital.
There appears to be no system in place to ensure that a result such as this is viewed and considered by a member of a relevant clinical team in a timely manner, whether or not the planned out-patient appointment takes place as planned.
Additionally, it seems that there is no relevant pathway for the echocardiography team to flag a result such as this to the clinical team.
” Open source report
17 Feb 2025 Carl Edmond EASTMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Wider staff skills and knowledge deficit affecting post-fall care View source Delays in CT scans where traumatic injury is suspected View source Failure to communicate accurate clinical information between ward and medical staff View source Lack of professional curiosity among nursing and medical staff View source Deficiencies in basic clinical record keeping View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Provide falls-protocol and post-fall-management education through junior-doctor induction and ongoing nursing and medical team education.
Stated plannedThe respondent said that this action was planned when they made their response on 20 February 2025. View source
Action
Send a Trust-wide safety bulletin reminding staff to document falls assessments, interventions and post-fall management.
Stated plannedThe respondent said that this action was planned when they made their response on 20 February 2025. View source
Action
Review NICE guidance for emergency-department patients after falls to identify improvements to inpatient-fall imaging timeliness and reporting.
Stated plannedThe respondent said that this action was planned when they made their response on 20 February 2025. View source
Action
Require overnight reporting of inpatient falls to the bed and site management team, with escalation when medical review is not completed within one hour.
Stated completedThe respondent said that this action was complete when they made their response on 20 February 2025. View source
Action
Implement and embed SBAR communication education in ward inductions, junior-doctor induction, safety huddles, board rounds and medical discussions.
Stated plannedThe respondent said that this action was planned when they made their response on 20 February 2025. View source
Action
Introduce and operate an additional mid-shift safety huddle reviewing high-fall-risk patients and changes in condition.
Stated completedThe respondent said that this action was complete when they made their response on 20 February 2025. View source
Action
Update electronic patient records to capture falls assessments, interventions, care planning and post-fall management at admission, after falls and when condition changes.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025. View source
Action
Deliver regular falls-prevention simulation training, including protocol, post-fall management, documentation, escalation and prevention, to nursing and medical staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025. View source
Action
Monitor compliance with falls documentation through audits, the Falls Steering Group and clinical safety governance committees.
Stated completedThe respondent said that this action was complete when they made their response on 20 February 2025. View source
Action
Reinforce accurate falls documentation requirements with ward staff through divisional governance education.
Stated plannedThe respondent said that this action was planned when they made their response on 20 February 2025. View source See 7 more actions
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AI-generated summary
Carl Edmond EASTMAN · 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
Carl Eastman was admitted to hospital after a fall at home and later suffered an unwitnessed fall on 28 July 2024 while in hospital. He sustained an irreversible brain bleed and died in hospital that evening as a direct result of the injury. Concerns included delays in CT scans after falls, widespread communication and record-keeping issues, failure to follow post-fall procedures, and possible wider skills or knowledge deficits among staff.
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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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Wider staff skills and knowledge deficit affecting post-fall care
Wider context from the report “3. As set out above, there was clear evidence that the Trust has put extensive measures in place to address the issue of staff having not followed the Trust’s own post-fall procedures and protocols. However, I am concerned that the issue may not be limited to just those particular protocols and may be indicative of a wider skills/knowledge deficit .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in CT scans where traumatic injury is suspected
Wider context from the report “1. The consultant geriatrician’s evidence was that CT scan was requested to take place ‘as soon as possible’ following the first unwitnessed fall on 25 July 2024; however, they accepted that this was not conducted in a timely manner .
Further, following the second unwitnessed fall on 28 July 2024, there was a further delay in a CT scan taking place . I was told that this scan should have been conducted within 1-2 hours of the request being made, yet it took place over three hours after the patient was reviewed by the doctor and the request for the scan was made .
In Mr Eastman’s case, the delays in receiving the scans transpired to be immaterial in the particular circumstances. However, I am concerned that if delays in such scans, where traumatic injury is suspected, are repeated in the future, there is a risk that deaths could occur .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate accurate clinical information between ward and medical staff
Wider context from the report “2. There was evidence of what I considered to be ‘widespread communication issues’ in the care provided to Mr Eastman. These included:
• When the on-call doctor attended to review Mr Eastman at approximately 02:45 on 28 July 2024, ward staff (incorrectly) told the doctor that nobody had fallen on the ward , which lead to the doctor leaving the ward without Mr Eastman having been reviewed. As the consultant geriatrician said in his evidence, communication between the ward staff and medical staff was not good .
• The evidence revealed that there were deficiencies in basic record keeping.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of professional curiosity among nursing and medical staff
Wider context from the report “4. Following on from the matter set out in paragraph 3 above, the evidence revealed a lack of professional curiosity on the part of some staff members (nursing and medical) . In my view, this could also be indicative of an underlying skills/knowledge deficit.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in basic clinical record keeping
Wider context from the report “2. There was evidence of what I considered to be ‘widespread communication issues’ in the care provided to Mr Eastman. These included:
• When the on-call doctor attended to review Mr Eastman at approximately 02:45 on 28 July 2024, ward staff (incorrectly) told the doctor that nobody had fallen on the ward, which lead to the doctor leaving the ward without Mr Eastman having been reviewed. As the consultant geriatrician said in his evidence, communication between the ward staff and medical staff was not good.
• The evidence revealed that there were deficiencies in basic record keeping .
” 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 Provide falls-protocol and post-fall-management education through junior-doctor induction and ongoing nursing and medical team education.
Verbatim wording from the response “As part of ongoing education for medical and ward nursing teams, emphasis will be placed on the importance of the Trust’s falls protocol at night, which will be included and provided to nursing and medical teams, in conjunction with the hospital at night Standard Operating Procedure (SOP).” Source location Response from Royal Free London NHS Foundation 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 Send a Trust-wide safety bulletin reminding staff to document falls assessments, interventions and post-fall management.
Verbatim wording from the response “d. A Safety Bulletin will be sent to all staff Trust-wide, reminding them of the importance of documentation in relation to falls.
Owner: Head of Patient Safety and Risk
Action deadline: 25 April 2025
Evidence if necessary: Copy of the Safety Bulletin uploaded to Freenet” Source location Response from Royal Free London NHS Foundation 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 NICE guidance for emergency-department patients after falls to identify improvements to inpatient-fall imaging timeliness and reporting.
Verbatim wording from the response “The Trust acknowledges that the scan being performed approximately 12 hours after being ordered on 25 July 2024, was not timely. In response, a review of the National Institute for Health and Care Excellence (NICE) treatment guidelines for patients presenting to the Emergency Department (ED) following a fall will be undertaken. This review will ascertain necessary improvements to the timeliness of image reporting for inpatient falls to support the earlier identification of any suspected injuries for treatment, and ongoing management to prevent any further deterioration to patients.” Source location Response from Royal Free London NHS Foundation 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 overnight reporting of inpatient falls to the bed and site management team, with escalation when medical review is not completed within one hour.
Verbatim wording from the response “In addition to these immediate measures, and to ensure all inpatient falls are reviewed and escalated in a timely manner, wards are required to report all inpatient falls through the hospitals bed and site management team between the hours of 19:30 and 07:30. The bed and site management team will have knowledge and oversight of all inpatient falls, and patients who are not reviewed by a doctor within 1 hour will be escalated through this team.” Source location Response from Royal Free London NHS Foundation 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 and embed SBAR communication education in ward inductions, junior-doctor induction, safety huddles, board rounds and medical discussions.
Verbatim wording from the response “It is acknowledged that discussions concerning the patient’s condition could have been more thorough and this failure to communicate effectively has been taken extremely seriously by the teams involved. Communication amongst the nursing and medical teams is of the highest priority to the Trust, and immediate actions have been taken following this safety event to improve key elements of the ward-based and wider hospital communication. It has been identified that the implementation and education of the Situation, Background, Assessment and Recommendation (SBAR) method of communication, will enable the multi-disciplinary teams to ensure effective and precise information sharing in critical safety events such as Mr. Eastman’s.” Source location Response from Royal Free London NHS Foundation 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 Introduce and operate an additional mid-shift safety huddle reviewing high-fall-risk patients and changes in condition.
Verbatim wording from the response “• Introduction of an additional mid-shift ward safety huddle on the ward to include a review of patients at high risk of falling, and any changes in a patient’s condition at all” Source location Response from Royal Free London NHS Foundation 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 Update electronic patient records to capture falls assessments, interventions, care planning and post-fall management at admission, after falls and when condition changes.
Verbatim wording from the response “A review of the medical and nursing notes identified gaps in documentation. The Trust is committed to improving this and is in the final stages of approving changes to how falls assessments, interventions, care planning, and post-fall care are recorded in all patients’ medical records within Electronic Patient Record (EPR). Accordingly, the updated falls assessment will be completed in EPR when a patient is admitted to the ward, after any inpatient fall, or if there are changes in their medical condition.” Source location Response from Royal Free London NHS Foundation 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 regular falls-prevention simulation training, including protocol, post-fall management, documentation, escalation and prevention, to nursing and medical staff.
Verbatim wording from the response “There is agreement that a robust and sustainable education plan for falls must be implemented. Following the death of Mr. Eastman, a post falls simulation programme was developed and is in the process of being delivered to all nursing staff. All Clinical Practice Educators have been trained as champions to deliver the falls simulation training to ward staff. Progress of the establishment of this body of work is currently being monitored through the Senior Nurse Matrons’ meeting which takes place weekly, and all areas involved are required to report progress of this implementation by early May 2025.” Source location Response from Royal Free London 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 Monitor compliance with falls documentation through audits, the Falls Steering Group and clinical safety governance committees.
Verbatim wording from the response “Compliance on the completion of these audits will be monitored through an action plan and quarterly audits, with results reported to the Trust Falls Steering Group. Oversight of this data will be provided in the Clinical Performance and Patient Safety Committee (CPPS), chaired by the hospital’s Medical Director and attended by senior divisional leaders.” Source location Response from Royal Free London NHS Foundation 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 Reinforce accurate falls documentation requirements with ward staff through divisional governance education.
Verbatim wording from the response “b. The importance of documenting falls assessments, interventions and post fall management will be reiterated to all ward staff.
Owner: Head of Nursing AMEDEC in collaboration other divisional directors of nursing
Action deadline: 01 May 2025
Evidence if necessary: Agenda from monthly divisional governance meeting, and minutes from senior nurse/matrons meeting” Source location Response from Royal Free London NHS Foundation Trust
Open published response
3 Dec 2024 Mnayea ZMF Al Basman · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to consider further CT scanning in light of drain issues View source Failure to escalate observed clinical deterioration to the healthcare team View source Failure to establish a plan for close overnight observation View source Failure of clinical records to provide sufficiently detailed and accurate information View source Failure to inform and consult the consultant about the clinical presentation View source Insufficient professional curiosity among clinicians View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mnayea ZMF Al Basman · 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
Mnayea ZMF Al Basman, who had significant co-morbidities, underwent a right hemicolectomy for caecal adenocarcinoma and died in hospital on 25 March 2024 after developing sepsis and peritonitis caused by an anastomotic leak. Concerns included failure to escalate aspects of his deterioration to the consultant surgeon, insufficient professional curiosity, inadequate overnight observation planning, and a lack of detail in some records. The report also noted that the events preceding his death had not been subject to an internal investigation, providing little reassurance that these matters had been addressed.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider further CT scanning in light of drain issues
Wider context from the report “1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend:
• a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain , albeit there was nothing to indicate that any scan was needed on an urgent basis;
• some entries in the clinical notes may have been ‘falsely reassuring’;
• the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team;
• there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and
• there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024.
2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not.
3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail.
Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate observed clinical deterioration to the healthcare team
Wider context from the report “1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend:
• a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis;
• some entries in the clinical notes may have been ‘falsely reassuring’;
• the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team ;
• there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and
• there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024.
2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not.
3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail.
Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a plan for close overnight observation
Wider context from the report “1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend:
• a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis;
• some entries in the clinical notes may have been ‘falsely reassuring’;
• the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team;
• there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and
• there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024 .
2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not.
3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail.
Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical records to provide sufficiently detailed and accurate information
Wider context from the report “1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend:
• a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis;
• some entries in the clinical notes may have been ‘falsely reassuring’ ;
• the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team;
• there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and
• there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024.
2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not.
3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail.
Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to inform and consult the consultant about the clinical presentation
Wider context from the report “1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend:
• a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis;
• some entries in the clinical notes may have been ‘falsely reassuring’;
• the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team;
• there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman; and
• there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024.
2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not .
3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail.
Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient professional curiosity among clinicians
Wider context from the report “1) The consultant colorectal surgeon was not in the hospital over the weekend of 23/24 March 2024; however, he was able to be contacted if the need arose. The consultant surgeon noted the following matters in relation to the care provided to Mr Al Basman over that weekend:
• a further CT scan could have been indicated, particularly given issues with Mr Al Basman’s drain, albeit there was nothing to indicate that any scan was needed on an urgent basis;
• some entries in the clinical notes may have been ‘falsely reassuring’;
• the physiotherapist who saw Mr Al Basman on the morning of 24 March 2024, noted that he appeared to be ‘declining’ but there was no evidence that this was escalated this to someone within the healthcare team;
• there was a degree of insufficient professional curiosity on the part of some clinicians who saw Mr Al Basman ; and
• there should have been a plan in place to closely observe Mr Al Basman overnight on 24/25 March 2024.
2) Based on the above, the consultant surgeon formed the view that Mr Al Basman’s clinical presentation should have led to the consultant being informed and consulted, but it did not.
3) A number of the notes/records in relation to the care provided to Mr Al Basman, particularly over the weekend of 23/24 March 2024, lacked detail.
Given that the events preceding Mr Al Basman’s death have not been the subject of an internal investigation, I received little, if any, reassurance that these matters have been addressed.
” Open source report
Concerns raised 2 Lack of an effective system to document elderly patients' risk of falling in hospital View source Lack of an effective system to address elderly patients' risk of falling in hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 6
Action
Revise and apply enhanced-care guidelines requiring clinical assessment, prescribed care plans, daily reassessment and staffing aligned with patient needs.
Stated completedThe respondent said that this action was complete when they made their response on 15 August 2024. View source
Action
Maintain scenario-based clinical judgement training for all new staff.
Stated plannedThe respondent said that this action was planned when they made their response on 15 August 2024. View source
Action
Implement a dynamic ward risk assessment documenting staffing, acuity, enhanced-care allocations and changing risks, with local audit and accreditation monitoring.
Stated completedThe respondent said that this action was complete when they made their response on 15 August 2024. View source
Action
Cascade the revised falls and enhanced-care arrangements to ward managers, matrons and associate directors of nursing.
Stated completedThe respondent said that this action was complete when they made their response on 15 August 2024. View source
Action
Roll out scenario-based tabletop training on clinical judgement, acuity, dependency and staff allocation for changing ward risks.
Stated completedThe respondent said that this action was complete when they made their response on 15 August 2024. View source
Action
Implement a Careflow ward dashboard to identify outstanding falls risk assessments and support real-time monitoring, monthly summaries and governance oversight.
Stated completedThe respondent said that this action was complete when they made their response on 15 August 2024. View source See 3 more actions
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AI-generated summary
Maria Francisca Teixeira de Ceita · 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
Maria Francisca Teixeira de Ceita died in hospital on 4 July 2023 after an unwitnessed fall by her hospital bed that caused a fatal brain injury. The concerns included failure to record and implement planned one-to-one supervision for a patient known to be at risk of falling, and ineffective communication between ward staff.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system to document elderly patients' risk of falling in hospital
Wider context from the report “In view of Ms de Ceita's known risk of falling, staff at the Hospital decided to put in place one-to-one supervision. An omission in recording that plan in Ms de Ceita's medical records by the hospital staff led to that plan being effected, which in turn contributed to Ms de Ceita subsequently falling by her hospital bed and sustaining a fatal brain injury.
The matter of concern is therefore the lack of an effective system to document and address the risk of elderly patients falling while in the hospital.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective system to address elderly patients' risk of falling in hospital
Wider context from the report “In view of Ms de Ceita's known risk of falling, staff at the Hospital decided to put in place one-to-one supervision. An omission in recording that plan in Ms de Ceita's medical records by the hospital staff led to that plan being effected, which in turn contributed to Ms de Ceita subsequently falling by her hospital bed and sustaining a fatal brain injury.
The matter of concern is therefore the lack of an effective system to document and address the risk of elderly patients falling while in the hospital .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise and apply enhanced-care guidelines requiring clinical assessment, prescribed care plans, daily reassessment and staffing aligned with patient needs.
Verbatim wording from the response “Enhanced care register and review of guidelines” Source location Response from North Middlesex University Hospital
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 scenario-based clinical judgement training for all new staff.
Verbatim wording from the response “A programme of tabletop training has also been rolled out via the education team and the Trust falls lead. This training focusses on scenario-based opportunities to exercise clinical judgement and reasoning regarding acuity, dependency, and effective staff allocation during a shift. Scenarios represent varying acuity levels and changes to the dynamics of the ward during a shift, to reflect real-life challenges and to develop a consistent approach in responding to such risks as they arise. This training has proved to be a powerful and successful in supporting staff to make decisions based on real-life scenarios in the classroom, which are directly transferrable to the ward environment. Past and future training attendance is monitored via the Trust Phoenix training platform and we intend to maintain this training for all new staff.” Source location Response from North Middlesex University Hospital
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 a dynamic ward risk assessment documenting staffing, acuity, enhanced-care allocations and changing risks, with local audit and accreditation monitoring.
Verbatim wording from the response “2. Communicating changes on wards which impact risk” Source location Response from North Middlesex University Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cascade the revised falls and enhanced-care arrangements to ward managers, matrons and associate directors of nursing.
Verbatim wording from the response “These changes have been cascaded across the organisation through the Divisional Directors of Nursing to all Ward Managers, Matrons and Associate Directors of Nursing and forms part of the daily management of patients in the effective clinical assessment of complex needs, the planning and implementation of those needs and the recording and communication of the clinical plan across all staff to ensure there is an effective system to address the risk to patients at risk of falls and other complex care needs.” Source location Response from North Middlesex University Hospital
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 Roll out scenario-based tabletop training on clinical judgement, acuity, dependency and staff allocation for changing ward risks.
Verbatim wording from the response “Clinical judgement training” Source location Response from North Middlesex University Hospital
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 a Careflow ward dashboard to identify outstanding falls risk assessments and support real-time monitoring, monthly summaries and governance oversight.
Verbatim wording from the response “a. A baseline audit in June and again in August, documented that the majority of patients received an inpatient falls risk assessment on admission. To ensure full compliance with completing and updating the falls risk assessments, and for better oversight of any gaps, the initiatives described below have been developed and rolled out across the Trust.” Source location Response from North Middlesex University Hospital
Open published response
13 Aug 2018 Flora Marion BABER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 10 Failure to provide appropriately pureed food and eating assistance View source Failure to provide requested toileting assistance View source Delays in treating oral thrush View source Failure of allocated ward staff to remain awake and attentive View source Delays in referral to the speech and language team View source Inaccurate recording of patients’ continence status View source Failure to recognise opioid sensitivity when prescribing or administering opioids View source Failure to record opioid sensitivity as an alert across care records View source Failure to identify and act on swallowing problems without family prompting View source Failure to keep drinking fluids within reach View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Flora Marion BABER · 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
Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriately pureed food and eating assistance
Wider context from the report “1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed.
Also, she did not always receive appropriately pureed food or the assistance that she needed to eat .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide requested toileting assistance
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy , she was wearing an incontinence pad, and she should use that instead .
I was shocked to hear 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 Royal Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in treating oral thrush
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush .
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with 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 Royal Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of allocated ward staff to remain awake and attentive
Wider context from the report “3. Family members told me that at one point, they found the member of staff allocated to Dr Baber’s bay sitting in a chair apparently asleep .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to the speech and language team
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush.
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with 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 Royal Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients’ continence status
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy, she was wearing an incontinence pad, and she should use that instead.
I was shocked to hear 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 Royal Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise opioid sensitivity when prescribing or administering opioids
Wider context from the report “5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication.
This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home.
However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes.
At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised .
This caused her discomfort and distress, and in another case could have fatal consequences.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to record opioid sensitivity as an alert across care records
Wider context from the report “5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication.
This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home.
However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes .
At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised.
This caused her discomfort and distress, and in another case could have fatal consequences.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and act on swallowing problems without family prompting
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush.
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with 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 Royal Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep drinking fluids within reach
Wider context from the report “1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed .
Also, she did not always receive appropriately pureed food or the assistance that she needed to eat.
” Open source report
24 Aug 2017 Jonathan Anthony MEANEY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to reconcile and challenge contradictory suicide-risk information View source Failure to recognise impaired insight in the context of recurrent unexplained physical symptoms View source Failure to tailor discharge support to the patient’s reported lack of benefit from crisis-team care View source Failure to provide timely and appropriately urgent access to a mental health bed View source Failure to complete and communicate general-practitioner referrals View source Failure to obtain team consultation before mental health discharge clearance View source See 3 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
Jonathan Anthony MEANEY · 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
Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile and challenge contradictory suicide-risk information
Wider context from the report “2. When the mental nurse assessed Mr Meaney before discharge on Wednesday, 15 March, he did not question Mr Meaney’s assertion that he had not intended to take an overdose two days before . This was despite the fact that Mr Meaney had told the assessing doctor that he had been trying to kill himself and he had written notes of intent .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise impaired insight in the context of recurrent unexplained physical symptoms
Wider context from the report “3. The mental health nurse assessed Mr Meaney as rational and having good insight , despite the fact that Mr Meaney once again (as he had done repeatedly for many months) raised a physical problem for which no organic cause had been found . In court, the mental health nurse told me that he knew that Mr Meaney’s illness was mental rather than physical.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to tailor discharge support to the patient’s reported lack of benefit from crisis-team care
Wider context from the report “5. The mental health nurse who saw Mr Meaney decided to refer Mr Meaney to his general practitioner for counselling, though Mr Meaney had already said that he had not found the crisis team helpful . Then having made that decision, I heard that there was no evidence that the mental health nurse did go on to make the referral. He told me that all he would do in such a situation would be to send the GP a discharge summary, never with a short accompanying note of request.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and appropriately urgent access to a mental health bed
Wider context from the report “1. Mr Meaney waited in the emergency unit for 40 hours and so it was unsurprising that he was then keen to go home.
A mental health nurse from the C&I psychiatry liaison team called the bed manager on the morning of Tuesday, 14 March, and then saw Mr Meaney briefly to explain that no bed was available . The same nurse called the bed manager again the following morning, Wednesday, 15 March, and then saw Mr Meaney once again with no news about admission. It was at that point that Mr Meaney expressed a wish to leave.
There seemed no urgency about the need for a bed for such a seriously ill man.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and communicate general-practitioner referrals
Wider context from the report “5. The mental health nurse who saw Mr Meaney decided to refer Mr Meaney to his general practitioner for counselling, though Mr Meaney had already said that he had not found the crisis team helpful. Then having made that decision, I heard that there was no evidence that the mental health nurse did go on to make the referral . He told me that all he would do in such a situation would be to send the GP a discharge summary, never with a short accompanying note of request .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain team consultation before mental health discharge clearance
Wider context from the report “4. The mental health nurse did not consult any other member of the team before clearing Mr Meaney as fit for discharge from a mental health point of view . (The assessing doctor gave evidence that, if Mr Meaney had not agreed to admission to hospital when she saw him, she would have sought an assessment under the Mental Health Act with a view to detaining Mr Meaney for treatment.)
” 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 Work closely with CANDI to assist its investigation, action-plan development and implementation to prevent similar incidents.
Verbatim wording from the response “It follows that the Matters of Concern will need to be addressed substantively by CANDI, which we note has received your Prevention of Future Deaths Report. We understand that CANDI are undertaking a Serious Incident investigation and we are committed to working closely with CANDI, as necessary, to assist them in completing this investigation, developing and implementing an action plan to prevent similar incidents in future and to otherwise assist them in preparing their response to your Prevention of Future Deaths Report. Additionally, we have asked to be provided with copies of CANDI’s final Serious Incident investigation report and response to your Prevention of Future Deaths Report, to ensure that any opportunities for learning within this Trust are captured and shared appropriately.” Source location 2017-0244-Response
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 CANDI, which employs and manages the Mental Health Liaison service, must substantively address the concerns.
Verbatim wording from the response “We have carefully considered the Matters of Concern, all of which relate to care that was delivered by the Camden & Islington NHS Foundation Trust’s Mental Health Liaison service, based within the Royal Free Hospital Emergency Department. The staff working within the Mental Health Liaison service are employed by the Camden & Islington NHS Foundation Trust (“CANDI”), not this Trust (the Royal Free London NHS Foundation Trust), and CANDI manage the Mental Health Liaison service. If a patient attending the Trust’s Emergency Department is considered to have a mental health problem (pertinent to the attendance) or requires a mental health assessment, they are referred to the Mental Health Liaison service, which will then assess the patient and take responsibility for referring onwards to either CANDI’s inpatient facilities or another mental health trust, as appropriate.” Source location 2017-0244-Response
Open published response
Concerns raised 5 Lack of staff awareness of nurses' holding power under Section 5.4 of the Mental Health Act View source Failure to keep patients presenting with current self-harm attempts and suspected drug use within eyesight at all times View source Failure to identify and investigate matters meeting Serious Incident criteria View source Failure to admit patients whose presentation requires hospital admission following psychiatric referral View source Patients leaving the emergency department before psychiatric assessment View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Joshua Knox-Hooke · 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
Joshua Knox-Hooke, a 22-year-old man with psychosis and recent drug use, attended North Middlesex Hospital on 1 December 2014 after cutting his neck and wrist and saying he wanted to kill himself. He left before psychiatric assessment and was later found deceased, partly immersed in Danbury reservoir; the inquest concluded that he died from drowning. Concerns included failure to keep him within eyesight in accordance with hospital policy and wider issues around patients leaving before psychiatric assessment and the handling of the incident.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of nurses' holding power under Section 5.4 of the Mental Health Act
Wider context from the report “3. The triage nurse who gave evidence during the course of the Inquest did not consider that it would be possible to make a patient to remain within the hospital for their own safety . She was unaware of the nurses holding power under Section 5.4 of the Mental Health Act.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep patients presenting with current self-harm attempts and suspected drug use within eyesight at all times
Wider context from the report “1. I was informed that the Trust policy in place in December 2014 required a patient presenting with a current attempt at self-harm and suspected drug use to be nursed in an observable area AND to be kept within eyesight at all times. The evidence revealed that Joshua was not kept within eyesight at all times.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and investigate matters meeting Serious Incident criteria
Wider context from the report “4. The North Middlesex University Hospital NHS Trust did not consider this matter to fall within their criteria for a Serious Incident . No Serious Incident Investigation was carried out.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to admit patients whose presentation requires hospital admission following psychiatric referral
Wider context from the report “5. The consultant psychiatrist who gave evidence at the Inquest Hearing confirmed that Joshua had been referred to him on the morning of the 1st December 2014 , the presentation at that time would have resulted in him being admitted to hospital (with or without his consent) .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Patients leaving the emergency department before psychiatric assessment
Wider context from the report “2. The evidence revealed that it is common for patients to leave the North Middlesex A & E prior to psychiatric assessment . This was confirmed by the triage nurse in her oral evidence and also stated within the Root Cause Analysis Investigation Report of Barnet, Enfield and Haringey Mental Health NHS Trust.
” 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 Explore whether a registered mental health nurse can be provided at short notice when high-risk patients cannot be assessed within the specified time.
Verbatim wording from the response “The Trust is confident that the actions outlined above, specifically the introduction of the MHTF, will ensure high risk mental health patients are appropriately identified and assessed in a timely manner so as to reduce the risk of such patients absconding prior to assessment in future. However, the Trust has also explored whether Barnet, Enfield & Haringey Mental Health Trust are able to provide a registered mental health nurse, capable of exercising the holding powers afforded by section 5.4 of the mental health act, at short notice at times when it is not possible for a patient identified as being high risk of being appropriately assessed within the specified time. In instances where BEH MHT cannot provide sufficient RMN support to the ED, the ED attempts to book agency RMN staff at short notice.” Source location Knox-Hooke-Response
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 Agree a new incident management pathway with the mental health trust clinical lead.
Verbatim wording from the response “A new incident management pathway has subsequently been agreed with the BEH MHT clinical lead for North Middlesex Hospital. The Trust has subsequently undertaken its own Serious Incident investigation into Mr Knox-Hooke’s death by reviewing the original Serious Incident investigation undertaken by Barnet, Enfield & Haringey Mental Health Trust and ensuring it captures learning for North Middlesex Hospital.” Source location Knox-Hooke-Response
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide frontline clinical staff with training and support on using the Mental Health Triage Form, including a case study of the death.
Verbatim wording from the response “The training and support for front line clinical staff in the use of the MHTF has been led by the ED Matron. She is using Mr Knox-Hooke’s death in the training programme as a case study to reinforce the importance of the MHTF and timely assessment of high risk patients to illustrate the risks and potential consequences of failing to identify high risk patients who are subsequently able to leave the ED without having been properly assessed.” Source location Knox-Hooke-Response
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 Undertake a Serious Incident investigation into the death by reviewing the mental health trust’s investigation and capturing learning for the hospital.
Verbatim wording from the response “A new incident management pathway has subsequently been agreed with the BEH MHT clinical lead for North Middlesex Hospital. The Trust has subsequently undertaken its own Serious Incident investigation into Mr Knox-Hooke’s death by reviewing the original Serious Incident investigation undertaken by Barnet, Enfield & Haringey Mental Health Trust and ensuring it captures learning for North Middlesex Hospital.” Source location Knox-Hooke-Response
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 Reduce waiting times for high-risk mental health patients to receive psychiatric assessment.
Verbatim wording from the response “In summary, Mr Knox-Hooke was able to leave the Emergency Department whilst he awaited psychiatric assessment at a time when he was not being observed. The Trust does not provide mental health services and these services are provided on site, in the Emergency Department, by Barnet, Enfield & Haringey Mental Health Trust. In order to reduce the risk of high risk mental health patients leaving the department before they are assessed, the Trust has implemented action to reduce the waiting time for assessment for these patients. The Trust has also implemented a Mental Health Triage Form (MHTF) and prioritisation tool, a copy of which is enclosed. This tool has improved the identification of mental health risk factors at triage and enables high risk patient to be systematically identified so that their mental health assessment is prioritised.” Source location Knox-Hooke-Response
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 a Mental Health Triage Form and prioritisation tool to identify mental health risk factors and prioritise high-risk patients for assessment.
Verbatim wording from the response “In summary, Mr Knox-Hooke was able to leave the Emergency Department whilst he awaited psychiatric assessment at a time when he was not being observed. The Trust does not provide mental health services and these services are provided on site, in the Emergency Department, by Barnet, Enfield & Haringey Mental Health Trust. In order to reduce the risk of high risk mental health patients leaving the department before they are assessed, the Trust has implemented action to reduce the waiting time for assessment for these patients. The Trust has also implemented a Mental Health Triage Form (MHTF) and prioritisation tool, a copy of which is enclosed. This tool has improved the identification of mental health risk factors at triage and enables high risk patient to be systematically identified so that their mental health assessment is prioritised.” Source location Knox-Hooke-Response
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 Develop a standard operating procedure for escalating patients who cannot be deterred from leaving before assessment and immediately informing police.
Verbatim wording from the response “Patients who are deemed to be high risk are admitted to the mental health room and are allocated a 1:1 nurse and security officer to observe the patient awaiting assessment. A video feed of the mental health room is also transmitted to the nurses’ station area (Majors) in the ED. The ED Matron is currently developing a standard operating procedure so that when patients want to leave the department, prior to assessment, and cannot be deterred from leaving, this is escalated to the nurse in charge and the Police immediately informed.” Source location Knox-Hooke-Response
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 Establish joint serious incident investigations with the mental health trust for future incidents involving hospital-provided care.
Verbatim wording from the response “Finally the Trust notes your criticism that the Trust did not consider the patient’s death to be a Serious Incident and did not undertake a Serious Incident Investigation. The Trust was disappointed with this criticism as North Middlesex Hospital was not informed by Barnet, Enfield & Haringey Mental Health Trust that this patient had been found dead, nor was North Middlesex Hospital NHS Trust invited to participate in the BEH MHT serious incident investigation as it would expect to be given the circumstances. As a result, our Medical Director has discussed this with the Medical Director at BEH MHT so that future serious incident investigations undertaken by BEH MHT that involve aspects of care provided by North Middlesex Hospital undergo a joint investigation with the expectations set out in NHS England’s Serious Incidents Requiring Investigation Framework.” Source location Knox-Hooke-Response
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 hospital cannot exercise Mental Health Act holding powers because it does not provide mental health services or employ authorised registered mental health nurses.
Verbatim wording from the response “The Trust notes that you explicitly identified the fact that the triage nurse caring for Mr Knox-Hooke in ED was unaware of the nurses holding power under section 5.4 of the Mental Health Act, as a matter of concern. The Trust also notes, however, that the holding power afforded by the Mental Health Act is only to be exercised by a registered mental health nurse who has had appropriate training. The Trust is not a provider of mental health services and this service is provided on site by Barnet, Enfield & Haringey Mental Health Trust. Therefore North Middlesex University Hospital NHS Trust does not employ registered mental health nurses with the authority to detain patients under section 5.4 of the mental health act.” Source location Knox-Hooke-Response
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 Mental health services and registered mental health nurse support are provided by Barnet, Enfield & Haringey Mental Health Trust.
Verbatim wording from the response “In summary, Mr Knox-Hooke was able to leave the Emergency Department whilst he awaited psychiatric assessment at a time when he was not being observed. The Trust does not provide mental health services and these services are provided on site, in the Emergency Department, by Barnet, Enfield & Haringey Mental Health Trust. In order to reduce the risk of high risk mental health patients leaving the department before they are assessed, the Trust has implemented action to reduce the waiting time for assessment for these patients. The Trust has also implemented a Mental Health Triage Form (MHTF) and prioritisation tool, a copy of which is enclosed. This tool has improved the identification of mental health risk factors at triage and enables high risk patient to be systematically identified so that their mental health assessment is prioritised.” Source location Knox-Hooke-Response
Open published response
1 Dec 2015 Barbara Rawlinson · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of CT scanning prior to hysterectomy 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
Barbara Rawlinson · 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
Barbara Rawlinson was diagnosed with uterine sarcoma after a hysterectomy undertaken following investigation of post-menopausal bleeding, and later died from complications after further treatment. The principal concern was that no CT scan was performed before hysterectomy, with reliance on ultrasonography potentially allowing uterine sarcoma to be missed.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of CT scanning prior to hysterectomy
Wider context from the report “(1) The lack of CT scanning prior to hysterectomy, with reliance only on ultrasonography , raises the concern that the diagnosis of uterine sarcoma could be missed in the future and consideration should be given as to whether steps can be taken to address this risk.
” Open source report
12 Nov 2014 Neophytos Constantinou · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of clear procedures for arranging transportation in these circumstances 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.
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AI-generated summary
Neophytos Constantinou · 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
Neophytos Constantinou died aged 73 at the Royal Free Hospital on 22 March 2013 from the consequences of biliary stone disease. He missed a scheduled ERCP after planned transport did not arrive, and the principal concern was a lack of clarity about responsibility and procedures for arranging transport, potentially leading to missed necessary procedures.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedures for arranging transportation in these circumstances
Wider context from the report “I am concerned that there should be clarity as to the procedures for arranging transportation in these circumstances , to avoid the situation where a necessary procedure is missed seemingly because of administrative issues .
” Open source report
1 Sep 2014 Thomas Charles TAYLOR · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 11 Insufficient continuous nursing cover on the ward View source Failure to promptly re-check blood sugar after significant hyperglycaemia View source Failure to establish clear nursing responsibility for patient care View source Failure to alert medical staff after significant hyperglycaemia View source Failure to communicate accurate diabetic status to medical staff View source Lack of clarity of ward leadership and support View source Failure to perform neurological observations after significant hyperglycaemia View source Failure to provide insulin promptly when required View source Lack of a well-understood protocol for rechecking and escalating refused blood glucose checks View source Delays and lack of focus in locating missing clinical records View source Lack of a protocol for loss of clinical notes and drug charts View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Thomas Charles TAYLOR · 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
Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient continuous nursing cover on the ward
Wider context from the report “1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support.
On 21 February, a bank nurse worked alone in the morning , though was joined by another agency nurse at lunch time, with only a senior nurse in the office .
On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients.
Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse .
There was a conflict of views among the nurses that day about who had primary care of Mr Taylor.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to promptly re-check blood sugar after significant hyperglycaemia
Wider context from the report “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar , perform neurological observations or alert medical staff.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear nursing responsibility for patient care
Wider context from the report “1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support.
On 21 February, a bank nurse worked alone in the morning, though was joined by another agency nurse at lunch time, with only a senior nurse in the office.
On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients .
Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse.
There was a conflict of views among the nurses that day about who had primary care of Mr Taylor .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to alert medical staff after significant hyperglycaemia
Wider context from the report “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff .
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate accurate diabetic status to medical staff
Wider context from the report “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic .
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity of ward leadership and support
Wider context from the report “1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support .
On 21 February, a bank nurse worked alone in the morning, though was joined by another agency nurse at lunch time, with only a senior nurse in the office.
On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients.
Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse.
There was a conflict of views among the nurses that day about who had primary care of Mr Taylor.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to perform neurological observations after significant hyperglycaemia
Wider context from the report “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide insulin promptly when required
Wider context from the report “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin , and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a well-understood protocol for rechecking and escalating refused blood glucose checks
Wider context from the report “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation . Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic.
When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays and lack of focus in locating missing clinical records
Wider context from the report “2. There was no protocol for the loss of notes and drug chart. Attempts by the ward staff to locate these were not prompt, focused or sustained . The notes and chart were later found simply in a drawer on the ward.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Royal Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for loss of clinical notes and drug charts
Wider context from the report “2. There was no protocol for the loss of notes and drug chart . Attempts by the ward staff to locate these were not prompt, focused or sustained. The notes and chart were later found simply in a drawer on the ward.
” Open source report
Concerns raised 1 Unavailability of a specialist diabetic nurse at the hospital over weekends 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
Grace Mary Bates · 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
Grace Mary Bates died in hospital on 21 April 2013 from complications associated with poorly managed diabetic episodes. The report raised concern that no specialist diabetic nurse was available at the hospital over the weekend, during which her blood sugar management was poor.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a specialist diabetic nurse at the hospital over weekends
Wider context from the report “(1) That should be a specialist diabetic nurse available over the weekend at the hospital .
” 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 Appoint at least one whole-time-equivalent inpatient diabetes specialist nurse to provide hospital-wide cover across the calendar week.
Verbatim wording from the response “Our Head of Diabetes & Endocrinology; Business Manager for Diabetes and our Lead Diabetes Nurse submitted a business case for the approval for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week.” Source location 2014-0007-Response
Open published response
Concerns raised 3 Failure to investigate the causes or potential causes of falls View source Insufficient training and knowledge of falls policies and witnessed-fall recording protocols among hospital staff View source Failure to make appropriate electronic records of falls 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
John William Wright · 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
John William Wright, who had a history of paranoid schizophrenia and COPD, was admitted to hospital with pneumonia and suffered several falls, including a fall that caused a fractured spine and left humerus. He died on 15 April 2013 from recurrent chest infections; the inquest concluded that his death resulted from an accident. Concerns included the lack of investigation into the cause of the fall and uncertainty about whether all relevant staff were trained in falls protocols and recording requirements.
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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the causes or potential causes of falls
Wider context from the report “1. There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved – water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation . The North Middlesex University Hospital NHS Trust Serious Incident Policy defines as ‘serious’ an ‘Accident while in hospital’ and I consider that such a fall should be considered to be an accident. The policy then details actions that should be taken by staff dependent on the urgency of the incident and the evidence that I was given confirmed that the appropriate electronic records were not made following the incident.
2. It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital, the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training and knowledge of falls policies and witnessed-fall recording protocols among hospital staff
Wider context from the report “1. There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved – water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation. The North Middlesex University Hospital NHS Trust Serious Incident Policy defines as ‘serious’ an ‘Accident while in hospital’ and I consider that such a fall should be considered to be an accident. The policy then details actions that should be taken by staff dependent on the urgency of the incident and the evidence that I was given confirmed that the appropriate electronic records were not made following the incident.
2. It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital , the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality.
” 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 Free London NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate electronic records of falls
Wider context from the report “1. There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved – water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation. The North Middlesex University Hospital NHS Trust Serious Incident Policy defines as ‘serious’ an ‘Accident while in hospital’ and I consider that such a fall should be considered to be an accident. The policy then details actions that should be taken by staff dependent on the urgency of the incident and the evidence that I was given confirmed that the appropriate electronic records were not made following the incident .
2. It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital, the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality.
” Open source report
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Addressed to North Middlesex University Hospital NHS Trust, now represented here by Royal Free London NHS Foundation Trust.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations