PFD report

John Davies · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 26 Apr 2017•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.

View original report
Concerns
10

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised10

  1. Failure to identify a suitable nursing home placement when the care home no longer met residents’ needs
    Part of recurring concern: Failure to ensure people are placed in care settings suitable for their needs
  2. Insufficient communication and information sharing between the care home and District Nursing Team
    Part of recurring concern: Unreliable communication in district nursing care coordination
  3. Insufficient detail in care home notes
    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.8

  1. Action

    Address District Nursing documentation deficiencies with staff and facilitate a reflective session on nursing care.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.
  2. Action

    Provide continuity through Named Nurse visits, structured handovers, and Caseload Holder oversight.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.
  3. Action

    Remind District Nursing staff to follow the pressure-ulcer prevention guideline and pressure-relieving trigger procedures.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Care home notes are the care home's responsibility, so the concern should be forwarded to the care home.

    Stated by Stockport NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 identify a suitable nursing home placement when the care home no longer met residents’ needs

Wider context from the report

“7. A suitable nursing home placement could not be identified once it had been agreed that the Care Home was no longer the best place to meet the needs of Mr Davies ”

Is this part of a recurring concern?

Yes — Failure to ensure people are placed in care settings suitable for their needs.

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

Insufficient communication and information sharing between the care home and District Nursing Team

Wider context from the report

“5. There was little evidence of communication and information sharing between the care home and the District Nursing Team ”

Is this part of a recurring concern?

Yes — Unreliable communication in district nursing care coordination.

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

Insufficient detail in care home notes

Wider context from the report

“6. The Care Home notes were lacking in detail ”

Is this part of a recurring concern?

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

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 by District Nurses to seek advice when experiencing difficulties examining a patient

Wider context from the report

“8. Advice was not sought by the District Nurses when they had difficulties examining Mr Davies ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 involve the District Nursing Team in discussions when residents’ status changed

Wider context from the report

“2. The District Nursing Team were unaware of the change in status and there was no system in place to involve them in discussions. ”

Is this part of a recurring concern?

Yes — Unreliable communication in district nursing care coordination.

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 continuity of care by the District Nursing Team

Wider context from the report

“4. There was no continuity of care provided by the District Nursing Team. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of patient care.

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 follow the correct procedure when trigger points for pressure-relieving strategies were reached

Wider context from the report

“9. The correct procedure was not followed on previous occasions when a trigger point was reached in relation to pressure relieving strategies. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 complete District Nursing Team patient records within required timescales

Wider context from the report

“3. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales. ”

Is this part of a recurring concern?

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

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 a process for completing risk assessment plans when residents’ needs changed from care to nursing needs while awaiting a bed

Wider context from the report

“1. There was no process in place for risk assessment plans to be completed when a resident’s needs changed from care to nursing needs and a bed was awaited. ”

Is this part of a recurring concern?

Yes — Failure to reliably develop and review risk-reduction plans.

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

Insufficient detail in patient records completed by the District Nursing Team

Wider context from the report

“3. Patient records completed by the District Nursing Team lacked detail and were not completed in the required timescales. ”

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

Address District Nursing documentation deficiencies with staff and facilitate a reflective session on nursing care.

Verbatim wording from the response

“Patient records complete by the District Nursing Team lacked detail and were not completed in the required timescale.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 10 July 2017

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

Provide continuity through Named Nurse visits, structured handovers, and Caseload Holder oversight.

Verbatim wording from the response

“The Named Nurse for each care home will undertake all visits to the residents within their allocated home; however, when not on duty, the Named Nurse will hand over any relevant information to whichever nurse is assigned to visit.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 10 July 2017

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

Remind District Nursing staff to follow the pressure-ulcer prevention guideline and pressure-relieving trigger procedures.

Verbatim wording from the response

“The correct procedure was not followed on previous occasions when a trigger point was reached in relation to pressure relieving strategies”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 10 July 2017

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

Appoint a Named Nurse for the residential home.

Verbatim wording from the response

“A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients’ care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 10 July 2017

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 a multi-agency risk assessment for residents awaiting transfer from residential to nursing care.

Verbatim wording from the response

“There was no process in place for risk assessment plans to be completed when a resident’s needs changed from care to nursing needs and a bed was awaited.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 10 July 2017

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

Book new District Nursing staff onto mandatory pressure-ulcer training covering trigger points and pressure-relieving strategies.

Verbatim wording from the response

“The Trust has a Prevention and Management of Pressure Ulceration Guideline (2015). All members of staff in the District Nursing team have been reminded of the requirement to adhere to this guidance and new staff have been booked on to the mandatory pressure ulcer training which includes how to identify trigger points and provide pressure relieving strategies.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 10 July 2017

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

Hold monthly residential-home care meetings and share key information at District Nursing Time Team meetings.

Verbatim wording from the response

“A new Named Nurse has been appointed to the residential home involved in this case. This nurse will ensure communication and documentation is improved and this will be overseen by the DN Caseload Holder (Band 6 Nurse). The Named Nurse now attends monthly meetings at the residential home with the manager and the staff to ensure all aspects of patients’ care are discussed and communicated to the DN team. The home manager will also invite Adult Social Care staff, District Nursing staff, GP and home care staff to the meeting for ongoing discussion of the patients’ care.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 10 July 2017

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

Audit District Nursing patient notes and repeat the audit to confirm improvements are sustained.

Verbatim wording from the response

“The Trust accepts that the patient’s District Nursing notes did lack detail especially around the deterioration of the patient’s physical and mental health and were not completed in the required timescale. This has been addressed with the team and a reflective session has been facilitated regarding the patient’s nursing care. An audit of the team’s patients’ notes has been carried out by the DN Clinical Lead and improvements have been noted. The Patient Records audit is being repeated to ensure that the improvements have been sustained.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 10 July 2017

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

Care home notes are the care home's responsibility, so the concern should be forwarded to the care home.

Verbatim wording from the response

“The Care Home notes are not the responsibility of the Trust, and we respectfully request that this concern is forwarded to the Care Home.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 10 July 2017

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

Nursing-home placement is not the District Nursing Team's responsibility, so the concern should be addressed by the CCG's Funded Nursing Care team.

Verbatim wording from the response

“Locating and assessing Nursing Home placements is not the responsibility of the District Nursing Team, and we respectfully request that this concern is forwarded to the Stockport Clinical Commissioning Group’s Funded Nursing Care team to be addressed.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 10 July 2017

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

    Provide Community Psychiatric Nurse participation in monthly Neighbourhood Triage meetings to discuss challenging patients.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.
  2. 2

    Advise District Nursing staff through team meetings to obtain next-of-kin contact details for patients showing declining health.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.

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 Community Psychiatric Nurse participation in monthly Neighbourhood Triage meetings to discuss challenging patients.

Verbatim wording from the response

“Stockport Together, a major transformation programme across the health and social care partners in Stockport, has been instrumental in enhancing multi-professional and multi-agency working, bringing together health professionals from a variety of backgrounds, social care and the third sector to benefit patient care.”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 10 July 2017

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

Advise District Nursing staff through team meetings to obtain next-of-kin contact details for patients showing declining health.

Verbatim wording from the response

“District Nursing staff have also been advised through discussion at Caseload Holders meetings, Locality meetings and Local Leadership and Triage meetings that if they are involved in the care of any residential”

Source location

2017-0138-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 10 July 2017

Open published response
Back to top

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