PFD report

Mr Allan Taylor · Prevention of Future Deaths report

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Issued 11 Mar 2025•Sunderland

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to escalate non-compliance with Level 2 EICO observation requirements
    Part of recurring concern: Failure to take timely escalation action when safety thresholds are breachedPart of recurring concern: Inadequate Enhanced Care SupervisionPart of recurring concern: Unreliable patient observation arrangements
  2. Failure to maintain required nurse sight or sound for Level 2 EICO observations
    Part of recurring concern: Failure to maintain required continuous patient observation
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2025.
  2. Action

    Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2025.
  3. Action

    Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to escalate non-compliance with Level 2 EICO observation requirements

Wider context from the report

“1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it. 2. The evidence was that this was not escalated to the Matron or Site Manager, which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations. 3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall. ”

Is this part of a recurring concern?

Yes — Failure to take timely escalation action when safety thresholds are breached; Inadequate Enhanced Care Supervision; Unreliable patient observation arrangements.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain required nurse sight or sound for Level 2 EICO observations

Wider context from the report

“1. The evidence confirmed that the guidelines for Level 2 EICO observations, which required a nurse to be within sight or sound of Allan, were not complied with as Allan was in a Side Room 1, which was not within sight or sound of the nursing station. It has been explained that the geography of that ward is such that this is the furthest side room away from the nursing station, and a vestibule is before it. 2. The evidence was that this was not escalated to the Matron or Site Manager, which may have resulted in the movement of an additional member of staff to ensure compliance with the EICO Level 2 observations. 3. The evidence was that had Allan been within sight or sound for observations, it was likely that upon Allan attempting to get out of bed, assistance could have been provided to him, which in turn may have prevented the fall. ”

Is this part of a recurring concern?

Yes — Failure to maintain required continuous patient observation.

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

Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.

Verbatim wording from the response

“This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 11 March 2025

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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 amended Enhanced Therapeutic Observation and Care guideline across the organisation.

Verbatim wording from the response

“This amended guideline (please see attached draft) has increased the levels of observation from 3 to 4 levels, it includes clarity around the assessment of ETOC against these levels, better family involvement and the importance of escalation and requirement for accurate documentation where there are any concerns regarding patient safety including rationale for any actions taken. This guideline will be implemented across the organisation during May 2025 with a plan to evaluate the impact of this guideline after six months.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 11 March 2025

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 and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.

Verbatim wording from the response

“Our internal investigation identified omissions in care regarding the level of observation in place for Mr Taylor and the lack of escalation of concerns. Actions were undertaken to address this issue; an urgent review of the existing Enhanced Interactive Care and Observation (EICO) guideline took place which has now been amended and renamed Enhanced Therapeutic Observation and Care (ETOC) for patients in line with recent national changes in guidance as recommended by NHS England. In addition to exploring best practice nationally, the review of the guideline also took into consideration how other local Trusts manage safe observation and care of patients.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 1 · response
Published 11 March 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Oversee progress of the improvement actions, brief the Chief Executive and report progress to the Trust’s Patient Safety and Quality Committee.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2025.
  2. 2

    Monitor staff training achievements as the Enhanced Therapeutic Observation and Care guideline is introduced.

    Stated by South Tyneside and Sunderland NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 March 2025.

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

Oversee progress of the improvement actions, brief the Chief Executive and report progress to the Trust’s Patient Safety and Quality Committee.

Verbatim wording from the response

“As you will note, the Trust is addressing the shortfalls highlighted during the Inquest to prevent future deaths in similar circumstances. Progress of the actions detailed in this letter will be overseen by Melanie Johnson, Executive Director of Nursing, Midwifery and Allied Health Professionals, who will also keep me briefed and report progress to the Trust’s Patient Safety and Quality Committee.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 2 · response
Published 11 March 2025

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

Monitor staff training achievements as the Enhanced Therapeutic Observation and Care guideline is introduced.

Verbatim wording from the response

“I would like to assure you that this improvement work is progressing well, and we intend to embed this ETOC guideline and will monitor the training achievements as they are introduced.”

Source location

Response from South Tyneside and Sunderland NHS Foundation Trust
Page 2 · response
Published 11 March 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026