PFD report

Adrian Anthony Cowan · Prevention of Future Deaths report

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Issued 7 Feb 2014•North London

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised4

  1. Failure of emergency-response policy to require requesting duty doctor attendance
    Part of recurring concern: Unreliable emergency response to patient collapse
  2. Failure of nursing staff to respond to collapses in a calm coordinated manner
    Part of recurring concern: Failure of emergency response leadership and coordinationPart of recurring concern: Unreliable emergency response to patient collapse
  3. Failure of nursing staff to apply basic life-support training
    Part of recurring concern: Inadequate staff competence to provide first aid
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.6

  1. Action

    Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2014.
  2. Action

    Review the Trust resuscitation policy to address emergency response guidance.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2014.
  3. Action

    Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.

    Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The resuscitation policy already listed actions for determining whether a collapsed patient was breathing and responding to such events.

    Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 of emergency-response policy to require requesting duty doctor attendance

Wider context from the report

“(1) That the trust policy dealing with the staff response did not include a clear set of guidance to those staff members responding to Mr Cowan’s collapse nor did the policy include the need, as part of the emergency response, to request the duty doctor to attend. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response to patient collapse.

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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 of nursing staff to respond to collapses in a calm coordinated manner

Wider context from the report

“(2) Some of the nursing staff were not able, when responding to Mr Cowan being found collapsed, act in a calm coordinated manner and were not able to apply the training they had received in basic life support. ”

Is this part of a recurring concern?

Yes — Failure of emergency response leadership and coordination; Unreliable emergency response to patient collapse.

Open source report

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 of nursing staff to apply basic life-support training

Wider context from the report

“(2) Some of the nursing staff were not able, when responding to Mr Cowan being found collapsed, act in a calm coordinated manner and were not able to apply the training they had received in basic life support. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence to provide 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of clear staff-response guidance for collapses

Wider context from the report

“(1) That the trust policy dealing with the staff response did not include a clear set of guidance to those staff members responding to Mr Cowan’s collapse nor did the policy include the need, as part of the emergency response, to request the duty doctor to attend. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response to patient collapse.

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 regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.

Verbatim wording from the response

“In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.”

Source location

2014-0111-Response
Page 2 · response
Published 7 February 2014

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review the Trust resuscitation policy to address emergency response guidance.

Verbatim wording from the response

“I would like to assure you that we have taken immediate action to review the Trust’s resuscitation policy, which at the time of Mr Cowan’s Death was up to date and was not due to be reviewed until 2015.”

Source location

2014-0111-Response
Page 1 · response
Published 7 February 2014

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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

Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.

Verbatim wording from the response

“I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

Source location

2014-0111-Response
Page 2 · response
Published 7 February 2014

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 the step-by-step emergency-response guide in all other inpatient areas.

Verbatim wording from the response

“I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

Source location

2014-0111-Response
Page 2 · response
Published 7 February 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.

Verbatim wording from the response

“In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.”

Source location

2014-0111-Response
Page 2 · response
Published 7 February 2014

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 the resuscitation policy with deteriorating-patient actions, an expanded NEWS Score, and a requirement to contact the duty doctor during medical emergencies.

Verbatim wording from the response

“The update to the policy will incorporate additional action to be taken in the future in response to the “deteriorating patient”, and we will update and expand the “NEWS” Score, which is a nationally recognised tool for assessing patients whose physical health may be deteriorating. The revised policy will make clear the need to contact the duty doctor in the event of a medical emergency.”

Source location

2014-0111-Response
Page 2 · response
Published 7 February 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The resuscitation policy already listed actions for determining whether a collapsed patient was breathing and responding to such events.

Verbatim wording from the response

“I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

Source location

2014-0111-Response
Page 2 · response
Published 7 February 2014

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

    Reiterate resuscitation-policy changes in frontline staff training after policy ratification.

    Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 February 2014.
  2. 2

    Continue actively auditing resuscitation practices within the North London Forensic Service.

    Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2014.

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

Reiterate resuscitation-policy changes in frontline staff training after policy ratification.

Verbatim wording from the response

“I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

Source location

2014-0111-Response
Page 2 · response
Published 7 February 2014

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

Continue actively auditing resuscitation practices within the North London Forensic Service.

Verbatim wording from the response

“I confirm that we have as detailed above taken clear action to address the matters of concern raised by you and I can assure you that we will continue to actively audit resuscitation practices within the North London Forensic Service. If you require any further or additional information for clarification, please feel free to contact me directly.”

Source location

2014-0111-Response
Page 3 · response
Published 7 February 2014

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