PFD report

Sarah-Louise Jennifer Doyle · Prevention of Future Deaths report

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Issued 4 Mar 2022•Liverpool and the Wirral

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
8

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 raised2

  1. Failure to conduct five-minute observations at frequent but unpredictable times
    Part of recurring concern: Unreliable patient observation arrangements
  2. Inadequate recording of individual five-minute observations
    Part of recurring concern: Unreliable recording of required observations in care and custody
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.6

  1. Action

    Conduct local audits, spot checks and additional dip audits to verify accurate, random-time recording of supportive observations.

    Stated by Mersey Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2022.
  2. Action

    Standardize language and roll out recording observations at unpredictable times within five-, ten- or fifteen-minute windows.

    Stated by Mersey Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2022.
  3. Action

    Issue urgent instructions on using and recording intermittent supportive observations.

    Stated by Mersey Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2022.

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 conduct five-minute observations at frequent but unpredictable times

Wider context from the report

“On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations. The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations. ”

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

Inadequate recording of individual five-minute observations

Wider context from the report

“On a review of the five minute observations these were recorded exactly on each five minutes after the hour – 05, 10, 15, 20 etc. It will be a matter for evidence to be heard at the inquest whether these times were precise or whether they were written in anticipation of future observations. The observations were covered by one signature with a downward arrow. In other settings it is better practice for five minute observations to be 12 frequent but unpredictable observations within each hour – to minimise the risk of a self-harm attempt being planned from the timing of previous observations. ”

Is this part of a recurring concern?

Yes — Unreliable recording of required observations in care and custody.

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

Conduct local audits, spot checks and additional dip audits to verify accurate, random-time recording of supportive observations.

Verbatim wording from the response

“4. A local audit has been developed with Inpatient Matrons to check and provide assurance that recording the actual time service users were checked is taking place, as opposed to rounding to the nearest 5-minute time window. As additional assurance, spot checks are being undertaken by the Senior Leadership Team and Inpatient Matron/Ward Manager group.”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 8 March 2022

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

Standardize language and roll out recording observations at unpredictable times within five-, ten- or fifteen-minute windows.

Verbatim wording from the response

“2. On March the 8th 2022 the Regulation 28 was discussed at the local division safety huddle with all inpatient Matrons present. An immediate action was for them to discuss with their”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 8 March 2022

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

Issue urgent instructions on using and recording intermittent supportive observations.

Verbatim wording from the response

“I can confirm that in relation to supportive observations the following actions are already either complete or well underway:”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 8 March 2022

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

Introduce an electronic system supporting unpredictable-interval supportive observations.

Verbatim wording from the response

“9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 3 · response
Published 8 March 2022

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

Complete annual supportive-observation competency assessments and observed practice checks for inpatient staff across Clock View and other Local Division wards.

Verbatim wording from the response

“6. Inpatient staff are required to have yearly competence assessments regarding supportive observations. All of the staff on the wards in Clock View will have had their yearly competency updated on the supportive observation policy and will have been observed in practice carrying out at least 2 supportive observations checks by the end of April 2022. All of the other wards across Local Division will be completed by the end of May 2022.”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 8 March 2022

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 the Ward Assurance Audit, operate interim recording changes and conduct weekly audits with findings shared through safety and clinical meetings.

Verbatim wording from the response

“9. The Trust has reviewed the existing Ward Assurance Audit in relation to supportive observations. An interim change to recording has been made ahead of a scheduled electronic system going live in May 2022 which will reflect the need for supportive observations to be at unpredictable intervals. These audits are taking place weekly, and the highlights are shared in safety huddles and at divisional clinical meetings.”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 3 · response
Published 8 March 2022

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

    Share the Regulation 28 report and related safety learning through Trust-wide and divisional safety huddles.

    Stated by Mersey Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2022.
  2. 2

    Require clinical documentation of the rationale for retaining clinically appropriate five-minute unpredictable observations instead of one-to-one observation.

    Stated by Mersey Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2022.

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

Share the Regulation 28 report and related safety learning through Trust-wide and divisional safety huddles.

Verbatim wording from the response

“The Trust always takes the death of any service users seriously and is keen to learn lessons where possible. I can confirm that your report has already been shared in the Trust Wide Executive Safety Huddle which is attended by Trust Executives and representatives from each clinical Division and also via Divisional Safety Huddle meetings. Safety Huddles are weekly meetings held at both a Trust Wide and Divisional level and have in attendance clinical and other professional managers from each service area. The purpose of the meetings is to highlight any new safety issues, incident trends or immediate learning to be shared.”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 1 · response
Published 8 March 2022

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 clinical documentation of the rationale for retaining clinically appropriate five-minute unpredictable observations instead of one-to-one observation.

Verbatim wording from the response

“5. Inpatient Multi Disciplinary teams have been reminded that if it is deemed clinically appropriate for a service user to remain on 5-minute unpredictable times, that a clear rationale is given in the clinical notes as to why this is required and not a full level 3 one to one observation. Ward Managers and Inpatient Matrons are overseeing this.”

Source location

2022-0070-Response-from-Mersey-Care-NHS-Foundation-Trust_Published
Page 2 · response
Published 8 March 2022

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