PFD report

Frederick Chisnall · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 30 Jan 2017•Cheshire

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
2

Of 1 recipient

Stated actions
1

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 raised3

  1. Failure to produce proper documentation
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure to obtain medical or nursing help urgently when appropriate
    Part of recurring concern: Failure to seek medical attention when a person's condition warrants it
  3. Failure to monitor changes in clinical condition
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 produce proper documentation

Wider context from the report

“During the inquest concerns were raised about the actions of the Agency staff regarding producing proper documentation, and being aware of how to monitor changes in clinical condition and obtaining medical or nursing help urgently when appropriate. Although in this case this did not cause any serious sequelae, I wonder if you could assess the adequacy of the training given to the staff you commission, to ensure this does not happen in the future. ”

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 to obtain medical or nursing help urgently when appropriate

Wider context from the report

“During the inquest concerns were raised about the actions of the Agency staff regarding producing proper documentation, and being aware of how to monitor changes in clinical condition and obtaining medical or nursing help urgently when appropriate. Although in this case this did not cause any serious sequelae, I wonder if you could assess the adequacy of the training given to the staff you commission, to ensure this does not happen in the future. ”

Is this part of a recurring concern?

Yes — Failure to seek medical attention when a person's condition warrants it.

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 monitor changes in clinical condition

Wider context from the report

“During the inquest concerns were raised about the actions of the Agency staff regarding producing proper documentation, and being aware of how to monitor changes in clinical condition and obtaining medical or nursing help urgently when appropriate. Although in this case this did not cause any serious sequelae, I wonder if you could assess the adequacy of the training given to the staff you commission, to ensure this does not happen in the future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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.1

  1. 1

    Liaised directly with the agencies involved to obtain assurance that safeguarding actions had been taken.

    Stated by NHS Cheshire and Merseyside Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    Warrington Local Authority led the safeguarding investigation because the placement was located within its borough, consistent with national guidance.

    Stated by NHS Cheshire and Merseyside Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    No action was taken regarding Challenge Recruitment because the safeguarding investigation made no findings against it.

    Stated by NHS Cheshire and Merseyside Integrated Care BoardNo action considered necessaryThe respondent said that no further action was needed.
  3. 3

    Existing contractual and quality-monitoring processes were considered robust for placements funded by the commissioning and local authorities.

    Stated by NHS Cheshire and Merseyside Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  4. 4

    Responsibility for agency staff training, supervision and policy compliance rests with the care or nursing home and the agency.

    Stated by NHS Cheshire and Merseyside Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Liaised directly with the agencies involved to obtain assurance that safeguarding actions had been taken.

Verbatim wording from the response

“The Team Manager for St Helens Contracts and Quality Monitoring service also liaised directly with the agencies involved for assurance of actions taken following the conclusion of the safeguarding investigation.”

Source location

2017-0017-Response-by-St-Helens-Clinical-Commissioning-Group
Page 2 · response
Published 19 February 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

Warrington Local Authority led the safeguarding investigation because the placement was located within its borough, consistent with national guidance.

Verbatim wording from the response

“The safeguarding investigation was led by Warrington Local Authority as St Marys where Mr Chisnall resided was within the borough of Warrington this is in line with national guidance and procedures.”

Source location

2017-0017-Response-by-St-Helens-Clinical-Commissioning-Group
Page 1 · response
Published 19 February 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

No action was taken regarding Challenge Recruitment because the safeguarding investigation made no findings against it.

Verbatim wording from the response

“• Challenge Recruitment- no action taken as no findings”

Source location

2017-0017-Response-by-St-Helens-Clinical-Commissioning-Group
Page 2 · response
Published 19 February 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

Existing contractual and quality-monitoring processes were considered robust for placements funded by the commissioning and local authorities.

Verbatim wording from the response

“Further to the above I would like to offer assurance that robust contractual and quality monitoring processes are in place in respect of all placements funded by St Helens CCG and St Helens Local Authority.”

Source location

2017-0017-Response-by-St-Helens-Clinical-Commissioning-Group
Page 2 · response
Published 19 February 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

Responsibility for agency staff training, supervision and policy compliance rests with the care or nursing home and the agency.

Verbatim wording from the response

“In respect of the use of agency staff the agency contract is with the care/nursing home. There is a clear expectation that agency staff will be provided with the relevant training, and supervision from the agency and that they work to the care/nursing homes policies and procedures as part of its CQC registration.”

Source location

2017-0017-Response-by-St-Helens-Clinical-Commissioning-Group
Page 2 · response
Published 19 February 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