Henry Curtis-Williams · Prevention of Future Deaths report

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Issued 19 Dec 2018•West London

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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
7

Described in responses

Recipients and published responses

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 record contemporaneous clinical notes, including presence or absence of suicidal ideation
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable recording of suicide-risk information
  2. Failure to require senior clinical reference before discharge by very junior doctors
    Part of recurring concern: Failure to provide effective senior clinical oversight of patient carePart of recurring concern: Unreliable clinical review and authorisation of discharge decisionsPart of recurring concern: Unreliable hospital discharge processes
  3. Failure to formally record and communicate important messages between staff members
    Part of recurring concern: Unreliable communication of patient-care information between clinical staff
Statements in published responses

Each statement is shown once, whether or not it is linked to an individual 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.7

  1. Action

    Audit discharge records to examine whether senior doctors or Consultants participated in discharge decisions.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2019.
  2. Action

    Issue an internal alert directing inpatient wards to reflect on how information from different sources is received and captured.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2019.
  3. Action

    Receive feedback from the internal alert and share it across wards to promote wider learning.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2019.
  4. Action

    Provide learning to Consultant Psychiatrists about senior involvement in discharge decisions.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2019.
  5. Action

    Examine barriers to clinical curiosity and develop staff skills and frameworks to support its consistent application.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2019.
  6. Action

    Provide junior doctors with discharge-related teaching during Trust induction.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 April 2019.
  7. Action

    Disseminate learning from Henry’s case through the patient safety newsletter, practice education teams and staff education.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 April 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    No single evidence-based communication tool can currently be implemented to eliminate the risk of important information failing to reach ward rounds.

    Stated by Norfolk and Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 contemporaneous clinical notes, including presence or absence of suicidal ideation

Wider context from the report

“(1) That following admission to Southgate Ward Henry Curtis-Williams was seen by a number of different staff members. It became evident that there was a culture of not recording contemporaneous notes. This was very obvious with reference to recording presence or absence of suicidal ideation. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable recording of suicide-risk information.

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 require senior clinical reference before discharge by very junior doctors

Wider context from the report

“(2) There was an acceptance that patients could be discharged by very junior doctors without prior reference to Consultant or Senior colleagues even though Henry had been admitted after being assessed by 2 Section 12 approved doctors and an Appointed Mental Health Professional who felt he needed a prolonged inpatient stay. ”

Is this part of a recurring concern?

Yes — Failure to provide effective senior clinical oversight of patient care; Unreliable clinical review and authorisation of discharge decisions; Unreliable hospital discharge processes.

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 formally record and communicate important messages between staff members

Wider context from the report

“(3) Communication between staff members was very informal with no record kept of important messages relayed. For example, the member of staff who held a one to one meeting with Henry was not present at the ward round where Henry’s case was discussed but said she had verbally passed a message to the ward round nurse. This was normal practice on this ward. There was no record of the message, or of it being passed or that it was considered at the ward round. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff.

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

Audit discharge records to examine whether senior doctors or Consultants participated in discharge decisions.

Verbatim wording from the response

“You identified concern that Henry was discharged by a junior doctor without prior reference to a Consultant or senior colleague. Discharge from hospital can represent a period of uncertainty and risk for the service user. Therefore, it is right to observe that such decisions must be made using members of the multi-disciplinary team who have the required knowledge and skills to support a safe and supportive discharge. Following receipt of your report the Trust has completed an audit to examine the current practice applied. Reviewing eighty-two records, from discharges completed in August and September 2018, the audit confirmed 96% had evidence within the health record that a senior doctor or Consultant had been part of the decision of discharge. To strengthen this, the Medical Director has”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 5 April 2019

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 an internal alert directing inpatient wards to reflect on how information from different sources is received and captured.

Verbatim wording from the response

“There is no current single evidence-based tool which can be implemented to eliminate this potential. However, shared understanding amongst staff of the processes of receiving information is critical to reduce variance. Following some recent learning, the Trust has issued an internal alert to all inpatient wards directing reflection on the points where information is received from differing sources eg service users, families and carers and whether there is a shared process or understanding of how to ensure that information is captured. Where there may not be a shared understanding the ward will work to address this. Feedback from this alert is being received currently which will then be shared across the wards to promote wider learning.”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 5 April 2019

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

Receive feedback from the internal alert and share it across wards to promote wider learning.

Verbatim wording from the response

“There is no current single evidence-based tool which can be implemented to eliminate this potential. However, shared understanding amongst staff of the processes of receiving information is critical to reduce variance. Following some recent learning, the Trust has issued an internal alert to all inpatient wards directing reflection on the points where information is received from differing sources eg service users, families and carers and whether there is a shared process or understanding of how to ensure that information is captured. Where there may not be a shared understanding the ward will work to address this. Feedback from this alert is being received currently which will then be shared across the wards to promote wider learning.”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 5 April 2019

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 learning to Consultant Psychiatrists about senior involvement in discharge decisions.

Verbatim wording from the response

“You identified concern that Henry was discharged by a junior doctor without prior reference to a Consultant or senior colleague. Discharge from hospital can represent a period of uncertainty and risk for the service user. Therefore, it is right to observe that such decisions must be made using members of the multi-disciplinary team who have the required knowledge and skills to support a safe and supportive discharge. Following receipt of your report the Trust has completed an audit to examine the current practice applied. Reviewing eighty-two records, from discharges completed in August and September 2018, the audit confirmed 96% had evidence within the health record that a senior doctor or Consultant had been part of the decision of discharge. To strengthen this, the Medical Director has”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 5 April 2019

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

Examine barriers to clinical curiosity and develop staff skills and frameworks to support its consistent application.

Verbatim wording from the response

“The Trust’s Health record policy provides guidance that entries should be made into the health record as soon as possible from the time of the event. The policy further outlines the requirement of clinical judgement to determine what information to record. To support staff, the Trust will be using Henry’s case in the provision of learning via our patient safety newsletter and through the range of practice education teams and staff receive. Linked to this, under the leadership of the Medical Director, the Trust is commencing a programme of work to examine the barriers to using ‘clinical curiosity’ and develop the skills and frameworks for staff to ensure this critical aspect of care is consistently applied.”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 5 April 2019

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 junior doctors with discharge-related teaching during Trust induction.

Verbatim wording from the response

“provided learning to Consultant Psychiatrists and teaching will be provided to junior doctors as part of their induction to the Trust.”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 5 April 2019

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

Disseminate learning from Henry’s case through the patient safety newsletter, practice education teams and staff education.

Verbatim wording from the response

“The Trust’s Health record policy provides guidance that entries should be made into the health record as soon as possible from the time of the event. The policy further outlines the requirement of clinical judgement to determine what information to record. To support staff, the Trust will be using Henry’s case in the provision of learning via our patient safety newsletter and through the range of practice education teams and staff receive. Linked to this, under the leadership of the Medical Director, the Trust is commencing a programme of work to examine the barriers to using ‘clinical curiosity’ and develop the skills and frameworks for staff to ensure this critical aspect of care is consistently applied.”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 5 April 2019

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 single evidence-based communication tool can currently be implemented to eliminate the risk of important information failing to reach ward rounds.

Verbatim wording from the response

“There is no current single evidence-based tool which can be implemented to eliminate this potential. However, shared understanding amongst staff of the processes of receiving information is critical to reduce variance. Following some recent learning, the Trust has issued an internal alert to all inpatient wards directing reflection on the points where information is received from differing sources eg service users, families and carers and whether there is a shared process or understanding of how to ensure that information is captured. Where there may not be a shared understanding the ward will work to address this. Feedback from this alert is being received currently which will then be shared across the wards to promote wider learning.”

Source location

2018-0397-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 5 April 2019

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