PFD report

Ann Doris Stillwell · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 8 Dec 2020•East London

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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 raised1

  1. Failure to authorise 1:1 care for a person at high risk of falls
    Part of recurring concern: Inadequate control of falls risks
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.3

  1. Action

    Route all one-to-one care requests to the Head of Service and senior nurse assessor for a response within two hours.

    Stated by NHS North East London Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 March 2021.
  2. Action

    Escalate care-home one-to-one requests made directly to brokerage staff to a senior clinician and embed this escalation in CHC electronic processes.

    Stated by NHS North East London Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 31 March 2021.
  3. Action

    Require supporting risk and care evidence, with reassessment before extending one-to-one care beyond the usual 14-day authorisation.

    Stated by NHS North East London Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 March 2021.

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

  1. Position

    No change to national continuing healthcare policy is considered necessary in response to the concerns.

    Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.

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 authorise 1:1 care for a person at high risk of falls

Wider context from the report

“1. Mrs Stillwell was at high risk of falls during the entirety of the period of 25th May 2020 until the 3rd July 2020. During that period the Commissioner for her care did not authorise 1:1 care. 1:1 care would have been the only way in which the particular risk presented by Mrs Stillwell to herself could have been mitigated. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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

Route all one-to-one care requests to the Head of Service and senior nurse assessor for a response within two hours.

Verbatim wording from the response

“4. We have identified that requests for 1 to 1s come through to different people in the CHC Team and the level of information given is sometimes variable. We have now introduced a requirement for requests for 1 to 1s to be sent to the Head of Service and a senior nurse assessor who will provide a response to the request within 2 hours.”

Source location

2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 31 March 2021

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

Escalate care-home one-to-one requests made directly to brokerage staff to a senior clinician and embed this escalation in CHC electronic processes.

Verbatim wording from the response

“7. We are introducing an additional safeguard to ensure that any requests for 1 to 1s submitted to the brokerage team directly by a care home are brought to the attention of a senior clinician. The following actions have been agreed:”

Source location

2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 31 March 2021

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

Require supporting risk and care evidence, with reassessment before extending one-to-one care beyond the usual 14-day authorisation.

Verbatim wording from the response

“5. If the information is not complete, then the hospital discharge team is asked to forward all falls risk assessments, care diaries and behaviour charts as appropriate to the Head of Service or senior nurse assessor so that they can confirm a decision. Evidence is needed as to whether this level of support is required during the daytime only or the full 24 hours. Many people are nursed on enhanced observations or in a cohort /bay in hospital do not go on to require this level of support in the care home.”

Source location

2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
Page 2 · response
Published 31 March 2021

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 change to national continuing healthcare policy is considered necessary in response to the concerns.

Verbatim wording from the response

“The Department has considered the concerns raised in your report and in this instance, we do not consider that a change in national policy is required. However, Departmental officials will work with NHS England, which is responsible for providing assurance on the actions of CCGs, to consider the specific circumstances of this case and whether further regional monitoring may be required.”

Source location

2021-0091-Response-from-Dept-of-Health-and-Social-Care-Redacted
Page 1 · response
Published 31 March 2021

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

Clinical commissioning groups are responsible for commissioning one-to-one care within their local areas.

Verbatim wording from the response

“CCGs are responsible for the commissioning of 1:1 care within their local areas. I understand that Barking and Dagenham Havering, and Redbridge CCGs, have provided a joint response which sets out the actions taken to learn from the findings presented, following Mrs Stillwell’s death.”

Source location

2021-0091-Response-from-Dept-of-Health-and-Social-Care-Redacted
Page 1 · response
Published 31 March 2021

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

    Work with NHS England to consider the case circumstances and whether further regional monitoring is required.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 31 March 2021.
  2. 2

    Remind staff to activate out-of-office messages naming an appropriate alternative contact, including an alternative clinician where relevant.

    Stated by NHS North East London Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 31 March 2021.

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

Work with NHS England to consider the case circumstances and whether further regional monitoring is required.

Verbatim wording from the response

“The Department has considered the concerns raised in your report and in this instance, we do not consider that a change in national policy is required. However, Departmental officials will work with NHS England, which is responsible for providing assurance on the actions of CCGs, to consider the specific circumstances of this case and whether further regional monitoring may be required.”

Source location

2021-0091-Response-from-Dept-of-Health-and-Social-Care-Redacted
Page 1 · response
Published 31 March 2021

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 staff to activate out-of-office messages naming an appropriate alternative contact, including an alternative clinician where relevant.

Verbatim wording from the response

“• To ensure all staff are reminded of the need to activate their out of office messages and that these should indicate a suitable alternative person who can respond. Where this is a clinician an alternative clinician should be named as contact. With immediate effect.”

Source location

2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
Page 3 · response
Published 31 March 2021

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