PFD report

Hilda Haughton · Prevention of Future Deaths report

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Issued 29 Oct 2015•Manchester South

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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 raised3

  1. Fire doors taking increased time to close
    Part of recurring concern: Unsafe operation of door-closing systems
  2. Failure to raise cot sides as required
    Part of recurring concern: Unreliable safety controls for cots and cot sides
  3. Lack of candour by hospital staff
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

    Issue and publish an Estates and Facilities Safety Alert to NHS organisations covering self-closing fire doors and required risk-reduction actions.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 29 October 2015.
  2. Action

    Meet regularly with patients and families to discuss experiences and apologise when things go wrong.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2015.
  3. Action

    Commission independent expert reports and share them with patients, relatives, carers and staff for learning.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Controlling fire-door closing times in NHS premises is outside the Department’s power.

    Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.

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

Fire doors taking increased time to close

Wider context from the report

“2. The fire-doors are held open by electro-magnets. These are designed to be released remotely to contain any fire which may break out in the hospital. I was told that this type of door fastener is common to very many hospital wards around the U.K. The length of time it takes for the doors to close affects the speed and power with which they move. This time has been increased at Tameside hospital from 3 seconds to 6 seconds. Is this an adequate response and should this issue be raised with all hospitals having these door fasteners? (Secretary of State) ”

Is this part of a recurring concern?

Yes — Unsafe operation of door-closing systems.

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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 raise cot sides as required

Wider context from the report

“1. Mrs Haughton having sustained the head injury on the 28th April, some 7 days later she was able to fall out of her bed because the cot sides had not been raised as they should have been, and there was a lack of candour by the hospital staff, and this, inter alia, deprived the family of the possibility of seeking a second opinion as to her injuries. (Tameside) ”

Is this part of a recurring concern?

Yes — Unreliable safety controls for cots and cot sides.

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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

Lack of candour by hospital staff

Wider context from the report

“1. Mrs Haughton having sustained the head injury on the 28th April, some 7 days later she was able to fall out of her bed because the cot sides had not been raised as they should have been, and there was a lack of candour by the hospital staff, and this, inter alia, deprived the family of the possibility of seeking a second opinion as to her injuries. (Tameside) ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Issue and publish an Estates and Facilities Safety Alert to NHS organisations covering self-closing fire doors and required risk-reduction actions.

Verbatim wording from the response

“Having considered the circumstances of this particular tragic incident and made reference to the British Standard, the Department has issued an Estates and Facilities Safety Alert to the NHS in England.”

Source location

2015-0460-Response-by-Department-of-Health
Page 2 · response
Published 29 October 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

Meet regularly with patients and families to discuss experiences and apologise when things go wrong.

Verbatim wording from the response

“I along with my leadership team have a strong leadership ethos regarding candour and believe that leading by example is key in demonstrating the Trust’s commitment in relation to candour. My Director of Quality and Governance and I both regularly meet with families and patients to discuss their experiences and to apologise when things go wrong.”

Source location

Hilda-Haughton-Response
Page 2 · response
Published 29 October 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

Commission independent expert reports and share them with patients, relatives, carers and staff for learning.

Verbatim wording from the response

“In order to ensure the Trust is transparent and learns from incidents, complaints and claims we have commissioned a significant number of independent expert reports to ensure transparency and openness with our patients, relatives and carers which we share with them and with our staff for learning.”

Source location

Hilda-Haughton-Response
Page 2 · response
Published 29 October 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

Train staff in investigations, root-cause analysis, communication, reporting, openness and the Duty of Candour.

Verbatim wording from the response

“During February and March 2015 the Trust ran several workshops which were delivered by external facilitators and were attended by a wide range of staff which focused on investigations, Root Cause Analysis and incorporated communication and supported the culture of reporting and openness. We trained over 75 staff in this and Being Open and Duty of Candour was central to the training.”

Source location

Hilda-Haughton-Response
Page 2 · response
Published 29 October 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 Trust policies and continue considering statutory Duty of Candour obligations when updating policies and procedures.

Verbatim wording from the response

“The Trust has been very proactive in relation to ensuring Duty of Candour, Trust policies have been reviewed and consideration continues to be given regarding statutory obligation when reviewing and updating policies and procedures.”

Source location

Hilda-Haughton-Response
Page 2 · response
Published 29 October 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

Commission and publish patient-experience films to share patients’ and relatives’ perspectives with staff and support learning.

Verbatim wording from the response

“The Trust has commissioned a number of patient experience films with our patients and their relatives to ensure that their perspective and their experiences are shared with staff and that we learn from these. One of the consistent messages in these is the importance of communication and how this effects the patients and families perception and how this influences their view of the Services in relation to openness and candour. These are available on the Trust intranet and public internet and focus on both the negative”

Source location

Hilda-Haughton-Response
Page 2 · response
Published 29 October 2015

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

Controlling fire-door closing times in NHS premises is outside the Department’s power.

Verbatim wording from the response

“It is not therefore in the Department’s power to control how long it should take for fire doors to close in NHS premises. Such matters are for local management to decide in light of legislation, advice from relevant professional bodies and in line with recognised safety standards.”

Source location

2015-0460-Response-by-Department-of-Health
Page 2 · response
Published 29 October 2015

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

Local NHS management must decide fire-door closing times in light of legislation, professional advice and recognised safety standards.

Verbatim wording from the response

“It is not therefore in the Department’s power to control how long it should take for fire doors to close in NHS premises. Such matters are for local management to decide in light of legislation, advice from relevant professional bodies and in line with recognised safety standards.”

Source location

2015-0460-Response-by-Department-of-Health
Page 2 · response
Published 29 October 2015

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 fall did not trigger the statutory Duty of Candour under Regulation 20.

Verbatim wording from the response

“I wish to take this opportunity to make it clear that the incident on 6 May 2015 did not invoke the Statutory Duty of Candour under Regulation 20 (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. An unwitnessed fall occurred on or around 04:50 on 6 May 2015. The medical records demonstrate that following this Mrs Haughton was given a head-to-”

Source location

Hilda-Haughton-Response
Page 1 · response
Published 29 October 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