PFD report

Hazel Fleur Wiltshire · Prevention of Future Deaths report

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Issued 1 Sep 2021•South 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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
18

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 raised3

  1. Failure to monitor call bell response times
    Part of recurring concern: Unreliable call bell systems for summoning assistance
  2. Inadequate staffing levels for patients with higher dependency needs
    Part of recurring concern: Insufficient qualified healthcare staffing capacity
  3. Failure to complete falls risk assessments
    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.8

  1. Action

    Provide proactive continence care, including scheduled assistance to the bathroom.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  2. Action

    Increase recruitment and retention activity to attract, develop and retain the nursing workforce.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  3. Action

    Conduct daily senior-led staffing calls to mitigate staffing risks and maintain safe patient-to-staff ratios.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.

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 call bell response times

Wider context from the report

“(1) The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times. ”

Is this part of a recurring concern?

Yes — Unreliable call bell systems for summoning assistance.

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 staffing levels for patients with higher dependency needs

Wider context from the report

“(2) Staffing levels were inadequate due to higher dependency of patients with Covid. I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs. Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell. The family could hear other patients on the ward crying out for help. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

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 falls risk assessments

Wider context from the report

“(3) Although Mrs Wiltshire was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed. This suggests a systemic problem across the hospital that requires remedial action. ”

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

Provide proactive continence care, including scheduled assistance to the bathroom.

Verbatim wording from the response

“We recognise that falls in hospital are often connected with patients using the bathroom or trying to get to the bathroom. We are working to ensure that our continence care is pro-active, e.g. patients assisted to the bathroom before they go to sleep and early in the morning. Our Practice Development, Clinical Safety and Bowel and Bladder Clinical Nurse Specialist Teams are currently working collaboratively to share learnings from poor practice, like you describe, in order to raise awareness and show case best practice. We are ensuring, in line with our Trust wide competency matrix and training needs analysis, that our senior nurses and practice development nurses have the appropriate skills and knowledge to provide gold standard continence care to all our patients and will role model this at all times.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Increase recruitment and retention activity to attract, develop and retain the nursing workforce.

Verbatim wording from the response

“Throughout the waves of COVID-19 our recruitment and retention activity did continue although since wave 2 we have increased this work which is happening alongside HR colleagues across all sites to ensure we have robust plans to attract, develop and retain our current and future workforce.”

Source location

Response from Princess Royal University Hospital
Page 2 · response
Published 9 September 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

Conduct daily senior-led staffing calls to mitigate staffing risks and maintain safe patient-to-staff ratios.

Verbatim wording from the response

“A review of staffing rates at the PRUH in January shows that the average fill rate for day staff was 86.7% (the lowest rate recorded for day staffing at the PRUH site in the last 12 months) and the average fill rate for night staff was 91.6% (also the lowest rate recorded for night staffing at the PRUH site in the last 12 months). Although we experienced more stretched nurse to patient ratios during the pandemic as we were in extremis I want to provide assurance that daily staffing calls took place, led by senior nursing staff at the PRUH/SS, to mitigate risks and ensure ratios were as safe as possible.”

Source location

Response from Princess Royal University Hospital
Page 2 · response
Published 9 September 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

Develop Epic functionality for live monitoring of falls risk-assessment compliance and incident learning.

Verbatim wording from the response

“The Falls Team routinely review falls data, including completion of risk assessments, and this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical update (described in more detail below.) We are currently working with Epic (the new Electronic Patient Record which is currently being developed for the Trust) to input learning from patient safety incidents and to ensure that the system can be used for live monitoring of risk assessment compliance to drive Trust and local improvement. The falls team are also reviewing working with the Business Intelligence Unit (BIU) to move to a more automated approach using the current patients’ electronic health records in the interim.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Progress replacement of the PRUH call-bell system to enable response-time reporting.

Verbatim wording from the response

“The current call bell system at the PRUH is approximately 20 years old and is due for replacement. Unfortunately it does not automatically generate reports on response times. The replacement plans are now being progressed and we expect this to take place in 2022. A project group has been identified including nursing representation to ensure this is implemented in a way that most benefits our patients. The upgraded system will enable reporting of response times.”

Source location

Response from Princess Royal University Hospital
Page 1 · response
Published 9 September 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

Audit call-bell response times, functionality and accessibility through monthly ward audits, monitor results, and share findings through governance and staff committees.

Verbatim wording from the response

“We will also be including an audit of response time to call bells in our monthly ward audit cycle through the Perfect Ward app. The audit will include response times, checks to the call bell functionality prior to admission of a new patient and checks to see if call bells are within reach of patients whilst in bed. If any bells are found to faulty, they will be reported to Estates immediately and an incident report form will be completed. The Heads of Nursing and Director of Nursing will be connecting these audits alongside the ward teams. The wards and care groups will monitor the audit results via the Perfect Ward reports and improvements made accordingly. These results will be monitored locally whilst also being shared at Nursing and Midwifery Board monthly as a standing agenda item.”

Source location

Response from Princess Royal University Hospital
Page 2 · response
Published 9 September 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

Use falls data and risk-assessment completion findings in ward teaching, nursing induction and annual clinical updates.

Verbatim wording from the response

“The Falls Team routinely review falls data, including completion of risk assessments, and this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical update (described in more detail below.) We are currently working with Epic (the new Electronic Patient Record which is currently being developed for the Trust) to input learning from patient safety incidents and to ensure that the system can be used for live monitoring of risk assessment compliance to drive Trust and local improvement. The falls team are also reviewing working with the Business Intelligence Unit (BIU) to move to a more automated approach using the current patients’ electronic health records in the interim.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Work with the Business Intelligence Unit toward automated falls risk-assessment monitoring using electronic health records.

Verbatim wording from the response

“The Falls Team routinely review falls data, including completion of risk assessments, and this is fed into teaching sessions on the wards, induction for nursing staff and annual clinical update (described in more detail below.) We are currently working with Epic (the new Electronic Patient Record which is currently being developed for the Trust) to input learning from patient safety incidents and to ensure that the system can be used for live monitoring of risk assessment compliance to drive Trust and local improvement. The falls team are also reviewing working with the Business Intelligence Unit (BIU) to move to a more automated approach using the current patients’ electronic health records in the interim.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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.10

  1. 1

    Share continence-care learning and best practice collaboratively across clinical teams.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  2. 2

    Deliver falls refresher training through the annual clinical update for PRUH nursing staff.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  3. 3

    Run a multidisciplinary operational falls-prevention programme with an action plan and defined deliverables.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  4. 4

    Reintroduce matron-led local quality audits and Trust-wide integrated quality checks covering call-bell documentation.

    Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
  5. 5

    Launch Executive Quality walk-rounds across hospital sites.

    Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 September 2021.
  6. 6

    Deliver and audit continence-care teaching through the annual Topic of the Month programme.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  7. 7

    Reconvene the Harm Free Care Forum to review falls incidents, share learning and implement actions addressing identified trends.

    Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2021.
  8. 8

    Support falls training and appoint ward Falls Champions to promote best practice with the Falls Practitioner Team.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  9. 9

    Ensure senior and practice-development nurses have the skills and knowledge to provide and role-model high-standard continence care.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2021.
  10. 10

    Deliver and evaluate falls-prevention awareness teaching through Falls Awareness Week and the Topic of the Month programme.

    Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 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

Share continence-care learning and best practice collaboratively across clinical teams.

Verbatim wording from the response

“We recognise that falls in hospital are often connected with patients using the bathroom or trying to get to the bathroom. We are working to ensure that our continence care is pro-active, e.g. patients assisted to the bathroom before they go to sleep and early in the morning. Our Practice Development, Clinical Safety and Bowel and Bladder Clinical Nurse Specialist Teams are currently working collaboratively to share learnings from poor practice, like you describe, in order to raise awareness and show case best practice. We are ensuring, in line with our Trust wide competency matrix and training needs analysis, that our senior nurses and practice development nurses have the appropriate skills and knowledge to provide gold standard continence care to all our patients and will role model this at all times.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Deliver falls refresher training through the annual clinical update for PRUH nursing staff.

Verbatim wording from the response

“The Practice Development Nurses are now supporting with falls training and promoting best practice across the PRUH wards. We also have named staff from each ward at the PRUH who will be the Falls Champions and are working closely with our Falls Practitioner Team. Falls refresher training sessions, delivered by the Falls team, have also been included as part of the annual clinical update (commenced in April 2021), which Band 5, 6 and 7PRUH nursing staff have been attending. Feedback from these sessions has been very positive.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Run a multidisciplinary operational falls-prevention programme with an action plan and defined deliverables.

Verbatim wording from the response

“In September 2021, the Trust ran a number of events to mark Falls Awareness Week which focussed on falls prevention. This occurred alongside Falls being the Topic of the Month for September 2021 which also included further training and bite-size teaching which is currently being evaluated and feedback shared with the teams. The PRUH are also doing some focussed work on falls prevention, led by the Site Director of Nursing, who chairs an operational falls meeting. This has focussed on collaborative working across professions to identify risks and common themes in relation to falls prevention with a clear action plan and deliverables from this working group. Since April 2021 the number of falls have reduced significantly, and work continues to further reduce the number of falls and lessen the impact on our patients.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Reintroduce matron-led local quality audits and Trust-wide integrated quality checks covering call-bell documentation.

Verbatim wording from the response

“Prior to the implementation of the upgraded call bell system, we have re-introduced local Quality Audits led by the Matrons at the PRUH, alongside Trust wide integrated quality checks, which look specifically at documentation including. In November 2021 we are also launching Executive Quality walk-rounds across the hospital sites.”

Source location

Response from Princess Royal University Hospital
Page 2 · response
Published 9 September 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

Launch Executive Quality walk-rounds across hospital sites.

Verbatim wording from the response

“Prior to the implementation of the upgraded call bell system, we have re-introduced local Quality Audits led by the Matrons at the PRUH, alongside Trust wide integrated quality checks, which look specifically at documentation including. In November 2021 we are also launching Executive Quality walk-rounds across the hospital sites.”

Source location

Response from Princess Royal University Hospital
Page 2 · response
Published 9 September 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

Deliver and audit continence-care teaching through the annual Topic of the Month programme.

Verbatim wording from the response

“Continence care is also part of our rolling annual ‘Topic of the Month’ programme with the Practice Development Nurses who will deliver specific bite-size teaching co-produced with the Bowel and Bladder CNS Team. This will be audited the following month and fed back so we can follow a continuous cycle of improvement.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Reconvene the Harm Free Care Forum to review falls incidents, share learning and implement actions addressing identified trends.

Verbatim wording from the response

“The Trust’s Harm Free Care Forum, was reconvened following Wave 2 of the pandemic. This is a forum which champions falls prevention and helps to focus on the implementation of actions arising from trends and themes in falls incidents. The main purpose of the forum is to review recent incidents and share what went wrong, why and the learning from this to ensure we are creating a good safety culture in the Trust. I trust that this response provides you with an assurance that the Trust have taken this seriously and are actively working to ensure we mitigate the risks of falls to all patients in our”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Support falls training and appoint ward Falls Champions to promote best practice with the Falls Practitioner Team.

Verbatim wording from the response

“The Practice Development Nurses are now supporting with falls training and promoting best practice across the PRUH wards. We also have named staff from each ward at the PRUH who will be the Falls Champions and are working closely with our Falls Practitioner Team. Falls refresher training sessions, delivered by the Falls team, have also been included as part of the annual clinical update (commenced in April 2021), which Band 5, 6 and 7PRUH nursing staff have been attending. Feedback from these sessions has been very positive.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Ensure senior and practice-development nurses have the skills and knowledge to provide and role-model high-standard continence care.

Verbatim wording from the response

“We recognise that falls in hospital are often connected with patients using the bathroom or trying to get to the bathroom. We are working to ensure that our continence care is pro-active, e.g. patients assisted to the bathroom before they go to sleep and early in the morning. Our Practice Development, Clinical Safety and Bowel and Bladder Clinical Nurse Specialist Teams are currently working collaboratively to share learnings from poor practice, like you describe, in order to raise awareness and show case best practice. We are ensuring, in line with our Trust wide competency matrix and training needs analysis, that our senior nurses and practice development nurses have the appropriate skills and knowledge to provide gold standard continence care to all our patients and will role model this at all times.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 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

Deliver and evaluate falls-prevention awareness teaching through Falls Awareness Week and the Topic of the Month programme.

Verbatim wording from the response

“In September 2021, the Trust ran a number of events to mark Falls Awareness Week which focussed on falls prevention. This occurred alongside Falls being the Topic of the Month for September 2021 which also included further training and bite-size teaching which is currently being evaluated and feedback shared with the teams. The PRUH are also doing some focussed work on falls prevention, led by the Site Director of Nursing, who chairs an operational falls meeting. This has focussed on collaborative working across professions to identify risks and common themes in relation to falls prevention with a clear action plan and deliverables from this working group. Since April 2021 the number of falls have reduced significantly, and work continues to further reduce the number of falls and lessen the impact on our patients.”

Source location

Response from Princess Royal University Hospital
Page 3 · response
Published 9 September 2021

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