19 Jun 2019 James William Francis · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 14 Failure to provide paramedics with basic patient information View source Unavailability of an instantly transferable key-information patient document View source Failure of staff to understand relevant patient medical history and implanted-device function View source Delays in seeking out-of-hours medical advice and requesting GP review View source NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients View source Failure to place an incapacitated patient in a position that protects the airway View source Failure to document key patient-care events and sickness details View source Failure of management records and checks to verify required observations View source Inadequate shift handover documentation for highlighting concerns and increased observations View source Failure to provide complete information about patient history and deterioration to the GP View source Failure to communicate required increased observations during shift handover View source Failure to consider NHS 111 advice for a deteriorating patient View source Failure of care staff to recognise and respond to head injury in anticoagulated patients View source Lack of current basic first-aid training for care staff View source See 11 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. 7
Action
Increase and maintain staff safety training, competency assessment, mandatory-training tracking and first-aider coverage on every shift.
Stated completedThe respondent said that this action was complete when they made their response on 23 August 2019. View source
Action
Implement and review the corporate shift-handover process, including documented handovers, incoming checks, staff allocation and accessible records.
Stated completedThe respondent said that this action was complete when they made their response on 23 August 2019. View source
Action
Recruit two Quality Improvement Managers for West Sussex homes to support service improvements, care-record completion, mentoring and supervision.
Stated completedThe respondent said that this action was complete when they made their response on 23 August 2019. View source
Action
Implement the falls-management policy, admission and post-fall risk assessments, and ongoing falls-risk tracking and review.
Stated completedThe respondent said that this action was complete when they made their response on 23 August 2019. View source
Action
Implement the adapted Hospital Passport Transport Traffic Light System across West Sussex homes and the wider company.
Stated completedThe respondent said that this action was complete when they made their response on 23 August 2019. View source
Action
Continue improving care planning and daily assessment and evaluation records at Deerswood.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019. View source
Action
Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
Stated completedThe respondent said that this action was complete when they made their response on 23 August 2019. View source See 4 more actions
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AI-generated summary
James William Francis · 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
James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.
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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide paramedics with basic patient information
Wider context from the report “They reported that they found Mr Francis on the floor leaning up against the dining room chair and over to his right side. They accepted that they were assertive but felt this was born from a frustration to find a time critical patient in such a position and staff were unable to answer basic questions about past medical history, allergies, mobility, communications for current medication .
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an instantly transferable key-information patient document
Wider context from the report “In addition, the paramedic suggested that other care homes have a key document that can be instantly handed over to them to speed up the handover procedure and ensure that clinical staff have a full history key information. This is often called a Hospital Passport and uses simple traffic light alerts to highlight key information. There was no evidence of this kind of simple document in this case
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to understand relevant patient medical history and implanted-device function
Wider context from the report “In addition one of the team leaders confirmed that she knew Mr Francis had a VP shunt in place but she was not aware of his past medical history or indeed what shunt did . This raises concerns about basic aspects of patient care and the adequacy of staff training
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in seeking out-of-hours medical advice and requesting GP review
Wider context from the report “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice
In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit . Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation NICE guidelines inadequately addressing slow intracranial bleeding after falls in elderly patients
Wider context from the report “The suggestion was that the existing guidelines may not sufficiently address the fact that this type of slow bleed fall in the elderly also needs to be considered i.e non-traumatic head injury leading to a shearing effect on the brain. The suggestion was that this type of slow bleed may take significantly longer to manifest in terms of observable symptoms such as a change in alertness or persistent vomiting. It certainly seems that the care home staff did not make the connection
As a result, this raises concerns as to whether this type of incident which must be frequent in the elderly is adequately taken into account in relevant NICE guidelines
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to place an incapacitated patient in a position that protects the airway
Wider context from the report “It would seem the care home staff had not considered placing Mr Francis on the floor into the recovery position until requested to do so by the 999 operator. From reading the transcript it suggests that when the operator asked the staff to do this, efforts were made to comply and then ensure Mr Francis head was tilted to keep the airway clear and his breathing became a little less shallow. Conversely, the ambulance crew were both very clear that their immediate concern on entering the room was the poor position of Jim in a seated/slumped position that may have compromised his airway
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document key patient-care events and sickness details
Wider context from the report “Again, it took some time to obtain all the details of the fall and sickness details
Finally, when leaving the building to get the stretcher trolley one of the paramedic crew heard care home staff arguing about the sickness details that had not been documented . This evidence raises considerable concern regarding the adequacy of documenting key events in a patient’s care such as a fall event if the patient indicates there was no acute trauma particularly when the patient is elderly and has a complicated past medical history
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of management records and checks to verify required observations
Wider context from the report “Related to item 1 above, is the fact there seem to be a failure of appropriate management records and checks to ensure that if 30 minute observations were required that these were undertaken at regular intervals
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate shift handover documentation for highlighting concerns and increased observations
Wider context from the report “I heard evidence from several staff members at different grades including two support workers responsible for Mr Francis’s daily care, a senior support worker and a team leader that they were unaware of Mr Francis recent fall or the fact that 30 minute observations needed to be carried out. In particular, both key support workers who knew Mr Francis best failed to carry out the 30 minute observations during the morning and afternoon shifts and on balance of probabilities it was likely that neither support worker was told either during the handover meeting or by the senior staff on duty that this was a requirement that day. However, it certainly seems that both support workers observed Mr Francis on a regular basis throughout the day and took appropriate action to report his condition and any change to senior staff. In another patient, this lack of handing on of vital information to key members of staff could be crucial
I was shown a shift handover form but this is basic and contains no additional guidance or method to highlight particular concerns or need for increased observations
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide complete information about patient history and deterioration to the GP
Wider context from the report “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice
In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit. Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate required increased observations during shift handover
Wider context from the report “I heard evidence from several staff members at different grades including two support workers responsible for Mr Francis’s daily care, a senior support worker and a team leader that they were unaware of Mr Francis recent fall or the fact that 30 minute observations needed to be carried out. In particular, both key support workers who knew Mr Francis best failed to carry out the 30 minute observations during the morning and afternoon shifts and on balance of probabilities it was likely that neither support worker was told either during the handover meeting or by the senior staff on duty that this was a requirement that day . However, it certainly seems that both support workers observed Mr Francis on a regular basis throughout the day and took appropriate action to report his condition and any change to senior staff. In another patient, this lack of handing on of vital information to key members of staff could be crucial
I was shown a shift handover form but this is basic and contains no additional guidance or method to highlight particular concerns or need for increased observations
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to consider NHS 111 advice for a deteriorating patient
Wider context from the report “I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice
In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit. Further, there does not appear to have been any thought given to making a call to NHS 111 for advice . It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of care staff to recognise and respond to head injury in anticoagulated patients
Wider context from the report “I heard evidence from a number of staff members that they had received no training at all or it was some time (up to 3 years) since they had had any basic first aid training. In addition, the paramedics indicated that when the care home staff were asked what their protocol and understanding was of a head injury with someone who was prescribed anticoagulant, it seemed the staff could not answer . Nor could they spot the signs and symptoms of head injury even though this is basic first-aid
” 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 Shaw Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of current basic first-aid training for care staff
Wider context from the report “I heard evidence from a number of staff members that they had received no training at all or it was some time (up to 3 years) since they had had any basic first aid training . In addition, the paramedics indicated that when the care home staff were asked what their protocol and understanding was of a head injury with someone who was prescribed anticoagulant, it seemed the staff could not answer. Nor could they spot the signs and symptoms of head injury even though this is basic first-aid
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase and maintain staff safety training, competency assessment, mandatory-training tracking and first-aider coverage on every shift.
Verbatim wording from the response “All care staff now receive training on “Recognising a Deteriorating Service User” and in addition they also receive first aid training.” Source location 2019-0202-Response-by-Shaw-Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and review the corporate shift-handover process, including documented handovers, incoming checks, staff allocation and accessible records.
Verbatim wording from the response “Prior to your inquest we had already recognised a need to improve our handover arrangements at Deerswood and in March 2018 we had set up the attached “Shift Handover Form”.” Source location 2019-0202-Response-by-Shaw-Healthcare
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 Recruit two Quality Improvement Managers for West Sussex homes to support service improvements, care-record completion, mentoring and supervision.
Verbatim wording from the response “Care planning, daily records from assessments and evaluations continue to be improved at Deerswood. For our 12 care homes in West Sussex we have recruited two Quality Improvement Managers where their primary function is to ensure improvements in service provision including the completion of care records - along with mentoring, supervising and role-modelling to care and nursing staff.” Source location 2019-0202-Response-by-Shaw-Healthcare
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 the falls-management policy, admission and post-fall risk assessments, and ongoing falls-risk tracking and review.
Verbatim wording from the response “In November 2017 we had implemented a completely revised “Prevention and Management of Falls” Policy which I have also attached for verification.” Source location 2019-0202-Response-by-Shaw-Healthcare
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the adapted Hospital Passport Transport Traffic Light System across West Sussex homes and the wider company.
Verbatim wording from the response “I also note that paramedic referred to the Hospital Passport. We have adapted the Hospital Passport - Transport Traffic Light System within all our West Sussex care homes initially and through the wider company. This is to provide the paramedic and hospital staff the most helpful information that isn't only about illness and health. This accompanies the Service User to inform and support. It is implemented within our Care Plan systems.” Source location 2019-0202-Response-by-Shaw-Healthcare
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 Continue improving care planning and daily assessment and evaluation records at Deerswood.
Verbatim wording from the response “Care planning, daily records from assessments and evaluations continue to be improved at Deerswood. For our 12 care homes in West Sussex we have recruited two Quality Improvement Managers where their primary function is to ensure improvements in service provision including the completion of care records - along with mentoring, supervising and role-modelling to care and nursing staff.” Source location 2019-0202-Response-by-Shaw-Healthcare
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 the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
Verbatim wording from the response “I also refer to the attached “Request for attendance of GP” policy which states that if a Service User develops a health problem or if the Service User requests to see their GP, the senior person on duty will assess the situation and contact the surgery, before the medication round commences. In assessing the urgency of the situation, the GP Surgery can be approached for advice or otherwise to liaise with the District Nursing service as appropriate it goes on to set very clear expectations in referring to the NHS 111 service and also the importance of clear communications.” Source location 2019-0202-Response-by-Shaw-Healthcare
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 Chief Executive of NICE is responsible for responding to concerns about the adequacy of NICE guidelines.
Verbatim wording from the response “6) Adequacy of NICE guidelines - which do not apply to ourselves, we note that a response is required from the Chief Executive of NICE. We will of course fully work to any revisited set of NICE guidelines.” Source location 2019-0202-Response-by-Shaw-Healthcare
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 NICE guidelines do not apply to the organisation, so it will not undertake work to address their adequacy.
Verbatim wording from the response “6) Adequacy of NICE guidelines - which do not apply to ourselves, we note that a response is required from the Chief Executive of NICE. We will of course fully work to any revisited set of NICE guidelines.” Source location 2019-0202-Response-by-Shaw-Healthcare
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations