PFD report

DANUTA Bronislawa CORBETT · Prevention of Future Deaths report

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Issued 3 Apr 2014•Brighton and Hove

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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. Failure to allocate an appropriately familiar escort for informal patient leave
    Part of recurring concern: Unsafe management of inpatient leave and absence
  2. Failure to hand over relevant patient and suicide-risk information to the leave escort
    Part of recurring concern: Failure to communicate relevant risk information during patient leavePart of recurring concern: Unreliable handover of care information and responsibility
  3. Failure to document leave reasons, risk assessments and decisions
    Part of recurring concern: Unsafe management of inpatient leave and absence
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.1

  1. Action

    Ensure proper handovers with agency nurses accompanying patients.

    Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 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 shortcomings identified were unlikely to have prevented the tragic outcome.

    Stated by Sussex Partnership 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 to allocate an appropriately familiar escort for informal patient leave

Wider context from the report

“(1) The report concerns the leave policy so far as it relates to Informal Patients. (Copy enclosed – refer to S. 4.5 and then S. 43). (2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed. No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented. On the 4th she has another Ward Review. She remained on 15 minute observations. As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November. In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home. She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before. No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort. Thus none of the decisions regarding her Leave on the 4th November are documented. This patient jumped out of her 8th floor flat window at home during this escorted leave. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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 to hand over relevant patient and suicide-risk information to the leave escort

Wider context from the report

“(1) The report concerns the leave policy so far as it relates to Informal Patients. (Copy enclosed – refer to S. 4.5 and then S. 43). (2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed. No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented. On the 4th she has another Ward Review. She remained on 15 minute observations. As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November. In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home. She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before. No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort. Thus none of the decisions regarding her Leave on the 4th November are documented. This patient jumped out of her 8th floor flat window at home during this escorted leave. ”

Is this part of a recurring concern?

Yes — Failure to communicate relevant risk information during patient leave; Unreliable handover of care information and responsibility.

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 to document leave reasons, risk assessments and decisions

Wider context from the report

“(1) The report concerns the leave policy so far as it relates to Informal Patients. (Copy enclosed – refer to S. 4.5 and then S. 43). (2) Leave was considered first on 1.11.2013 when Mrs. Corbett was on 15 minute observations. The Ward Review documents that she wants leave to go to her home to collect some papers over the next 2 – 3 days- Escorted leave agreed. No Leave occurred on 1st, 2nd or 3rd November, 2013 but no reason for this is documented. On the 4th she has another Ward Review. She remained on 15 minute observations. As to leave, none of the matters referred to in the Policy at S.4.3 are documented in the Progress Note or in the Clinical Review or in the Electronic Note of the ward review on 4th November. In the afternoon of 4th November, Mrs. Corbett repeated her request to the Charge Nurse to go home. She was apparently Risk Assessed again and an escort was allocated. The escort was an agency health care worker who had never met the patient and had never worked on this ward before. No note by the risk assessment, or the decision to allow escorted leave was made in accordance with S.4.3 of the Policy. The patient’s details and details of the reasons for her admission were not handed over to the escort, in particular neither the fact that her flat/home was central to her distress or the fact that she had threatened to kill herself by jumping from it were known to the escort. Thus none of the decisions regarding her Leave on the 4th November are documented. This patient jumped out of her 8th floor flat window at home during this escorted leave. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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

Ensure proper handovers with agency nurses accompanying patients.

Verbatim wording from the response

“Finally, it is clear that the communication with the agency nurse who was accompanying Danuta should have been much better. The nurse responsible acknowledges this and will always ensure proper handovers take place in the future.”

Source location

2014-0150-Response-by-Sussex-Partnership-NHS-Trust
Page 1 · response
Published 3 April 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 shortcomings identified were unlikely to have prevented the tragic outcome.

Verbatim wording from the response

“It seems unlikely that any of the shortcomings highlighted by this very sad case would have prevented the tragic outcome. However, all the staff involved in Danuta’s care have carefully reflected on what happened and used the learning to improve their practice.”

Source location

2014-0150-Response-by-Sussex-Partnership-NHS-Trust
Page 2 · response
Published 3 April 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.3

  1. 1

    Reflect on the case and use its learning to improve staff practice.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2014.
  2. 2

    Review ward-review notes carefully, including notes typically scribed by junior doctors.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2014.
  3. 3

    Reinforce with staff that clearly marked retrospective notes must be completed after extraordinary events when contemporaneous documentation is missed.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 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

Reflect on the case and use its learning to improve staff practice.

Verbatim wording from the response

“It seems unlikely that any of the shortcomings highlighted by this very sad case would have prevented the tragic outcome. However, all the staff involved in Danuta’s care have carefully reflected on what happened and used the learning to improve their practice.”

Source location

2014-0150-Response-by-Sussex-Partnership-NHS-Trust
Page 2 · response
Published 3 April 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

Review ward-review notes carefully, including notes typically scribed by junior doctors.

Verbatim wording from the response

“The consultant psychiatrist has learnt a great deal from this experience. She now carefully reviews the notes taken during ward review, which are typically scribed by the junior doctor present. As you heard at the Inquest, the nurse did not make a note at all. This was because she incident happened shortly after her assessment and she was so distressed by what happened that she went home and did not return to work for several days. It is quite normal for nursing staff to write in patient notes toward the end of the shift. However, on her return the nurse ought to have written a clearly marked retrospective note. She did not do this after being advised at the time by the acting Matron that this was not appropriate. We have since reinforced with staff that should these quite extraordinary circumstances arise again then a retrospective note must be completed.”

Source location

2014-0150-Response-by-Sussex-Partnership-NHS-Trust
Page 1 · response
Published 3 April 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

Reinforce with staff that clearly marked retrospective notes must be completed after extraordinary events when contemporaneous documentation is missed.

Verbatim wording from the response

“The consultant psychiatrist has learnt a great deal from this experience. She now carefully reviews the notes taken during ward review, which are typically scribed by the junior doctor present. As you heard at the Inquest, the nurse did not make a note at all. This was because she incident happened shortly after her assessment and she was so distressed by what happened that she went home and did not return to work for several days. It is quite normal for nursing staff to write in patient notes toward the end of the shift. However, on her return the nurse ought to have written a clearly marked retrospective note. She did not do this after being advised at the time by the acting Matron that this was not appropriate. We have since reinforced with staff that should these quite extraordinary circumstances arise again then a retrospective note must be completed.”

Source location

2014-0150-Response-by-Sussex-Partnership-NHS-Trust
Page 1 · response
Published 3 April 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