PFD report

Dennis Keith Price · Prevention of Future Deaths report

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Issued 20 Jan 2026•South Yorkshire (Eastern)

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
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 follow up Nerve Centre system escalation triggers
    Part of recurring concern: Unreliable recording and follow-up of clinical escalations
  2. Lack of clear direction from the attending doctor following a fall
    Part of recurring concern: Unreliable post-fall assessment and clinical response
  3. Lack of a clear plan for the frequency and duration of neurological observations following a fall
    Part of recurring concern: Failure to carry out required neurological observationsPart of recurring concern: Unreliable post-fall assessment and clinical response
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

    Deliver and reinforce multidisciplinary training on complete, contemporaneous clinical documentation, including post-fall records and neurological observations.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  2. Action

    Reinforce Nerve Centre escalation procedures so triggers are actioned, followed up and fully documented, including the receiving clinician’s name and role.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
  3. Action

    Embed requirements for attending doctors to document individualised post-fall neurological observation plans covering frequency, duration, review and escalation criteria.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.

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 up Nerve Centre system escalation triggers

Wider context from the report

“3. The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and properly completed on the system for the nerve centre system to be fully effective. ”

Is this part of a recurring concern?

Yes — Unreliable recording and follow-up of clinical escalations.

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 direction from the attending doctor following a fall

Wider context from the report

“2. No clear plan for frequency of neurological observations and duration of the same and associated lack of clear direction from the attending Doctor following a fall. ”

Is this part of a recurring concern?

Yes — Unreliable post-fall assessment and clinical response.

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 clear plan for the frequency and duration of neurological observations following a fall

Wider context from the report

“2. No clear plan for frequency of neurological observations and duration of the same and associated lack of clear direction from the attending Doctor following a fall. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations; Unreliable post-fall assessment and clinical response.

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 inpatient post-fall reviews

Wider context from the report

“1. Failure to properly complete the inpatient post fall review. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable post-fall assessment and clinical response.

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 properly complete Nerve Centre system escalation records

Wider context from the report

“3. The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and properly completed on the system for the nerve centre system to be fully effective. ”

Is this part of a recurring concern?

Yes — Unreliable recording and follow-up of clinical escalations.

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

Deliver and reinforce multidisciplinary training on complete, contemporaneous clinical documentation, including post-fall records and neurological observations.

Verbatim wording from the response

“The Trust recognises that training is fundamental in reinforcing the importance of complete, accurate and contemporaneous clinical documentation, and this remains a core component of all education delivered by the Patient Safety Team. In addition, targeted documentation training has been delivered by the Trust’s Solicitor/Legal Manager to Foundation Year 1 doctors on 11 September 2025, and to Preceptorship Nurses on 11 and 25 November 2025. This programme of education forms part of an ongoing initiative, with further lectures and seminars planned to ensure continued reinforcement of documentation standards across the organisation.”

Source location

2026-0037 - Response from Doncaster Royal Infirmary
Page 2 · response
Published 26 January 2026

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

Reinforce Nerve Centre escalation procedures so triggers are actioned, followed up and fully documented, including the receiving clinician’s name and role.

Verbatim wording from the response

“The Trust recognises the importance of the Nerve Centre system in supporting timely escalation and clinical decision-making and acknowledges the concern raised regarding the effectiveness of escalations where system triggers are not fully completed. Review of Mr Price’s care identified a documentation gap within Nerve Centre, specifically the absence of a recorded name confirming to whom the escalation was made, which limited assurance that the escalation process had been completed as intended. For the Nerve Centre system to function effectively, it is essential that all triggers are acted upon, followed up and fully documented, including clear identification of the clinician to whom concerns are escalated.”

Source location

2026-0037 - Response from Doncaster Royal Infirmary
Page 2 · response
Published 26 January 2026

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

Embed requirements for attending doctors to document individualised post-fall neurological observation plans covering frequency, duration, review and escalation criteria.

Verbatim wording from the response

“The Trust acknowledges the concern regarding the absence of consistently documented medical direction for the frequency and duration of neurological observations following Mr Price’s fall. While the Patient Falls Prevention and Management Policy (PAT/PS 11) provides guidance on post-fall management, learning has identified the need for clearer, explicit documentation by the attending doctor to ensure that neurological observation requirements, review arrangements and escalation plans are clearly defined and understood by the multidisciplinary team. As part of ongoing improvement, the Trust is reinforcing the expectation that a clear, individualised post-fall monitoring plan is documented following every fall, supported through strengthened documentation standards, targeted multidisciplinary training and continued emphasis on completion of the Inpatient Post-Fall Review.”

Source location

2026-0037 - Response from Doncaster Royal Infirmary
Page 2 · response
Published 26 January 2026

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