PFD report

Joyce Hartford · Prevention of Future Deaths report

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Issued 15 Jul 2015•Manchester North

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.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

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 of nurse record-keeping audits to produce material improvement in standards
  2. Incomplete or inaccurate nursing records and associated documentation
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.10

  1. Action

    Continue developing and governing nursing documentation through the Nursing Documentation Group and Nursing and Midwifery Board, including wider professional documentation.

    Stated by Pennine Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2015.
  2. Action

    Use Nursing Metrics across the Trust to audit nursing-documentation quality in case notes.

    Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
  3. Action

    Recruit registered nurses to Ward T7 and provide induction competency observations covering documentation and related clinical tasks.

    Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.

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 nurse record-keeping audits to produce material improvement in standards

Wider context from the report

“1. During the course of the inquest hearing it became apparent that the nursing tools (in particular, the ‘Purpose T’), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate. Whilst I was told that the Trust, to its credit, had been conducting audits since the Summer of 2014 in order to improve nurse record keeping, Mrs Hartford died in January 2015 and the evidence at inquest did not disclose any material improvement in overall standards. As this was not the first case over which I had presided that involved concerns arising from record keeping that fell below expectation (over and above the aforementioned) I considered that I was under an obligation to bring this to your attention. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Incomplete or inaccurate nursing records and associated documentation

Wider context from the report

“1. During the course of the inquest hearing it became apparent that the nursing tools (in particular, the ‘Purpose T’), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate. Whilst I was told that the Trust, to its credit, had been conducting audits since the Summer of 2014 in order to improve nurse record keeping, Mrs Hartford died in January 2015 and the evidence at inquest did not disclose any material improvement in overall standards. As this was not the first case over which I had presided that involved concerns arising from record keeping that fell below expectation (over and above the aforementioned) I considered that I was under an obligation to bring this to your attention. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Continue developing and governing nursing documentation through the Nursing Documentation Group and Nursing and Midwifery Board, including wider professional documentation.

Verbatim wording from the response

“• Over the last 12 months we have also reviewed the process of developing, reviewing and ratifying nursing documents to implement a more rigorous governance process through our Nursing Documentation Group and the Nursing and Midwifery Board. This project is ongoing. The Nursing Documentation Group has widened its remit to cover Allied Health Professionals and Maternity documentation. The main objective is to align documentation control and development processes across specialties.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 3 · response
Published 15 July 2015

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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 Nursing Metrics across the Trust to audit nursing-documentation quality in case notes.

Verbatim wording from the response

“• Over the past 18 months Nursing Metrics have been introduced, part of which involves audit of the quality of nursing documentation in the case notes.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 3 · response
Published 15 July 2015

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

Recruit registered nurses to Ward T7 and provide induction competency observations covering documentation and related clinical tasks.

Verbatim wording from the response

“• Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts; as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are being performed competently – this includes completion of documentation such as District Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools (involves nursing staff using predetermined questions to ask patients on a regular basis about care needs and includes checks on the patient environment.)”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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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 EVOLVE electronic case-note system, beginning with a pilot of nursing assessments, care plans, referrals and specified risk documentation.

Verbatim wording from the response

“• The Trust has also commenced the implementation of the ‘EVOLVE’ system which will introduce electronic records across the Trust. This will be piloted later this year and is projected to start on 17th November and run for 4 weeks with a Trust wide rollout projected to take 4 months starting in January 2016. The Project brief is to replace all clinical documentation with electronic forms hosted within the Evolve electronic case-note system. This will help mandate the completion of key patient assessments. The first phase of forms to be piloted on two wards at NMGH will focus on nursing assessment documents, associated care plans and referrals and will include nutritional assessments, falls and bed rails risk assessments, dementia screening and the pressure ulcer care plan.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 3 · response
Published 15 July 2015

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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

Secure Trust Development Agency support and carry out a Trust-wide documentation standardisation project.

Verbatim wording from the response

“• With the support of the Chief Nurse, we have now secured support of a team from the Trust Development Agency to help improve record keeping and a Trust wide documentation standardisation project is underway.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 3 · response
Published 15 July 2015

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 scenario training on completing the Purpose T tool for early pressure-ulcer detection and management.

Verbatim wording from the response

“• For early detection and management of pressure ulcers the use of scenario training on the completion of the Purpose T tool is now in place. The introduction of an air flow mattress store on the unit now ensures that patients who have suffered a fractured neck of femur are admitted to the Unit from A&E directly onto a ‘pre-socio’ mattress.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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 Ward T7 documentation against Trust standards and conduct monthly nursing-metrics audits of record keeping.

Verbatim wording from the response

“• We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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 weekly Ward T7 documentation audits with immediate feedback on risk assessments, care plans and reassessments.

Verbatim wording from the response

“• There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant member of staff at the time of the audit. These include accurate and timely completion of risk assessments, use of appropriate care plans and timely reassessments.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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 Ward Accreditation to monitor ward-team nursing-care quality, including record keeping and patient assessments.

Verbatim wording from the response

“• The Trust is also introducing Ward Accreditation, a new project which will help us to monitor safe practice by measuring the quality of nursing care delivered by ward teams. As part of this project we will be checking and monitoring the quality of record keeping including patient assessments.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 3 · response
Published 15 July 2015

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

Run Nursing Care Indicators audits and respond to reduced results through corrective action.

Verbatim wording from the response

“• Since February 2015, the Unit has achieved 90% and above in the Nursing Care Indicators Audit except for May when the results reduced to 84% and this reduction was responded to immediately recognising that this was related to a trial of incorporating nursing documentation within the medical records. This was addressed and results improved to 92% in June, 95% in July and 93% in August.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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.3

  1. 1

    Provide SKIN bundle training through the Tissue Viability team’s Equipment Co-ordinator.

    Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
  2. 2

    Introduce an air-flow mattress store so eligible fractured-neck-of-femur patients transfer directly from A&E onto pre-socio mattresses.

    Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
  3. 3

    Disseminate actions and lessons learned through newsletters, safety huddles, handover sheets, training boards and individual feedback.

    Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.

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 SKIN bundle training through the Tissue Viability team’s Equipment Co-ordinator.

Verbatim wording from the response

“• SKIN bundle training has also been provided by the Equipment Co-ordinator who is a member of the Tissue Viability team.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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 an air-flow mattress store so eligible fractured-neck-of-femur patients transfer directly from A&E onto pre-socio mattresses.

Verbatim wording from the response

“• For early detection and management of pressure ulcers the use of scenario training on the completion of the Purpose T tool is now in place. The introduction of an air flow mattress store on the unit now ensures that patients who have suffered a fractured neck of femur are admitted to the Unit from A&E directly onto a ‘pre-socio’ mattress.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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

Disseminate actions and lessons learned through newsletters, safety huddles, handover sheets, training boards and individual feedback.

Verbatim wording from the response

“• Communication and dissemination of actions and lessons learnt is made through a variety of methods including: newsletters, safety huddles, handover sheets, and resource and training boards and when indicated on a one to one basis.”

Source location

2015-0279-Response-by-Pennine-Acute-Hositals-NHS-Trust
Page 2 · response
Published 15 July 2015

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