PFD report

Keith Dransfield · Prevention of Future Deaths report

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Issued 8 Aug 2018•South Yorkshire (Western)

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised5

  1. Failure to routinely consult patients' records
    Part of recurring concern: Failure to review relevant clinical records before care decisions
  2. Failure to record the rationale for changes to patient observation regimes
    Part of recurring concern: Failure to reliably document the rationale for consequential decisions
  3. Lack of clear patient risk assessments
    Part of recurring concern: Unreliable objective criteria for safety risk assessment
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

    Provide refresher training on the policy requirement for a 72-hour post-admission service-user review.

    Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 October 2018.
  2. Action

    Roll out bespoke suicide-prevention training and continue refining its content using feedback.

    Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2018.
  3. Action

    Review and revise the inpatient record-keeping procedure to clarify consistent documentation standards.

    Stated by Sheffield Health Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2018.

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 routinely consult patients' records

Wider context from the report

“During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions.

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 record the rationale for changes to patient observation regimes

Wider context from the report

“During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”

Is this part of a recurring concern?

Yes — Failure to reliably document the rationale for consequential decisions.

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 clear patient risk assessments

Wider context from the report

“During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”

Is this part of a recurring concern?

Yes — Unreliable objective criteria for safety risk assessment.

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

Inappropriate patient observation regimes

Wider context from the report

“During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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 appropriate staff training

Wider context from the report

“During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”

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

Provide refresher training on the policy requirement for a 72-hour post-admission service-user review.

Verbatim wording from the response

“The Trust policy requires that a review takes place of each service user on the ward 72 hours after admission. We will ensure that refresher training around the policy and the requirement of the 72 hour review is provided to staff so that an opportunity is not missed for the ward team to consider the needs and presentation of service users in their care to support a clinical assessment around their risks and plan accordingly.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 3 · response
Published 30 October 2018

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

Roll out bespoke suicide-prevention training and continue refining its content using feedback.

Verbatim wording from the response

“• The Regulation 28 ruling states that Mr Dransfield was on an inappropriate level of observation at the time of his death. The Trust takes a thorough and proactive approach to the management of risk and, to support our staff in making clinical decisions about levels of risk, the Trust has initiated a programme of bespoke suicide prevention training. This programme of training has commenced, and the Trust has and will continue to review the course content in light of feedback received to improve, refocus and to ensure it is effective and fit for purpose.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 3 · response
Published 30 October 2018

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 and revise the inpatient record-keeping procedure to clarify consistent documentation standards.

Verbatim wording from the response

“• The Trust’s Standard Operating Procedure for Record Keeping has been reviewed and revised to ensure that expected standards are clear, consistent and all staff are aware & fully understand requirements.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 2 · response
Published 30 October 2018

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

Revise inpatient observation policy, remove ten-minute observations, and inform staff of the resulting safe-practice requirements.

Verbatim wording from the response

“• The Trust has reviewed and revised its Policy: Observation of Inpatients – Routine and Enhanced Observations of Patients. In light of national evidence, and in line with accepted best practice, observations at 10 minute intervals have been removed. The Trust has taken steps to ensure that all staff are aware of the new policy and the changes to practice that will be required to implement the policy safely.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 3 · response
Published 30 October 2018

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 quarterly inpatient-ward audits of care records, risk assessments and care plans for timeliness and quality.

Verbatim wording from the response

“Formal audits of care records on all inpatient wards are now conducted on a quarterly basis. These incorporate an audit of care records, risk assessments and care plans for timeliness and quality. The quarterly audits commenced in April 2018.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 2 · response
Published 30 October 2018

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

Check acute-ward care records for timely updating of risk assessments, care plans and significant care changes.

Verbatim wording from the response

“• To determine whether the lack of recording of information was a problem in other wards the Nurse Consultant undertook a care records check in each acute ward. These checks included reviewing evidence that risk assessments, care plans and significant changes to care had been regularly updated. These checks identified that records on the acute wards are being updated regularly and key clinical information recorded.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 2 · response
Published 30 October 2018

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 and update clinical risk training to strengthen its focus on suicide-risk assessment.

Verbatim wording from the response

“The content of our Clinical Risk Training has also been reviewed and updated with an enhanced focus on Suicide Risk Assessment.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 4 · response
Published 30 October 2018

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

Inform staff of named- and associate-nurse responsibilities for knowing service-user care plans and current circumstances.

Verbatim wording from the response

“that are in place for them. The Trust found no evidence that notes were looked at nor did the two staff know they were the named nurses for Mr Dransfield on this shift. Staff have been informed of their responsibilities when undertaking the named and associate nurse role and the Ward Manager is responsible for ensuring all Ward staff fulfil their responsibilities effectively.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 4 · response
Published 30 October 2018

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

Deliver the supervision-training programme for staff, including the current two-day course.

Verbatim wording from the response

“In addition staff have opportunities for clinical discussion through a range of forums such as ward handovers, incident debriefings, multi-disciplinary team meetings and Care Programme Approach (CPA) Meetings. These enable staff to discuss individual service user risks and their approach to the management of these. In collaboration with Sheffield University the Trust has developed and delivered a programme of supervision training. This year’s programme of 2 day training commenced in September 2018 offering 20 places.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 3 · response
Published 30 October 2018

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

Pilot handheld tablets on Maple Ward to improve timely clinical-record entry and identify observation-level changes and authorisation.

Verbatim wording from the response

“• Maple Ward is piloting various clinical improvements, including the use of hand held tablets to improve timeliness and ease of recording clinical information and to move away from paper systems. The system will enable the Trust to extract information about changes to observation levels and more clearly identify who made or authorised the change. ‘Insight’, the Trust’s electronic care record system is not able to provide this information which would have assisted the Coroner’s enquiries had this been available at the inquest.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 2 · response
Published 30 October 2018

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

    Fully implement the Trust-wide handover procedure to communicate key clinical information, including observation-level changes, between shifts.

    Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 October 2018.
  2. 2

    Provide whole-ward feedback on investigation lessons and required improvements.

    Stated by Sheffield Health Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2018.

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

Fully implement the Trust-wide handover procedure to communicate key clinical information, including observation-level changes, between shifts.

Verbatim wording from the response

“• The Trust has devised a Standard Operating Procedure (SOP) for handovers between each shift, across all the Trust inpatient wards, to ensure accurate and timely communication of patient information.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 2 · response
Published 30 October 2018

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 whole-ward feedback on investigation lessons and required improvements.

Verbatim wording from the response

“outcomes of the investigation and the actions identified and required of them to ensure learning from Mr Dransfield’s tragic death.”

Source location

2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
Page 2 · response
Published 30 October 2018

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