PFD report

James Southern · Prevention of Future Deaths report

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Issued 4 Oct 2024•Nottinghamshire

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.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised3

  1. Inadequate communication with patients
  2. Poor record keeping
  3. Inadequate communication between professionals
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.7

  1. Action

    Develop and disseminate additional clinical record-keeping standards to Trust staff and Care Units.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2024.
  2. Action

    Develop place-based interface meetings to oversee internal care transfers and strengthen communication between teams.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2024.
  3. Action

    Add a clinical conversation and agreed care-plan communication standard to Crisis Team discharge instructions.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2024.

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 communication with patients

Wider context from the report

“• That there remain potential issues of poor record keeping. • There are concerns over the level of communication between professionals within the Trust and communication with patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Poor record keeping

Wider context from the report

“• That there remain potential issues of poor record keeping. • There are concerns over the level of communication between professionals within the Trust and communication with patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 communication between professionals

Wider context from the report

“• That there remain potential issues of poor record keeping. • There are concerns over the level of communication between professionals within the Trust and communication with patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Develop and disseminate additional clinical record-keeping standards to Trust staff and Care Units.

Verbatim wording from the response

“We also appreciate that the systems in place need to protect patients from individual errors or omissions and therefore we have also looked at this in the wider context of services and developed some additional clinical quality standards for all staff in relation to record keeping (Appendix A). This information forms part of the current policy in relation to records management and will support staff awareness and personal responsibility. This document along with other similar documents for differing grades and professional backgrounds have been shared with all Care Units within the Trust.”

Source location

Response from Nottinghamshire NHS
Page 1 · response
Published 4 October 2024

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 place-based interface meetings to oversee internal care transfers and strengthen communication between teams.

Verbatim wording from the response

“This standard has been added to the Crisis Team Internal Working Instructions (IWI) and will be further discussed within their local QOG meetings from a wider learning perspective to support learning. Further work relating to place-based interface meetings between teams is currently in progress which will oversee the current process of internal transfers of care, ensure compliance and support wider team communications and closer working relationships to ensure patients receive the standard of care expected. In terms of caseload oversight and allocation there is now an improved process which is incorporated within the LMHT Internal Working Instructions that has been shared and discussed with all teams with further oversight of assurance from weekly oversight meetings, supervision and audits to inform any further potential developments required.”

Source location

Response from Nottinghamshire NHS
Page 2 · response
Published 4 October 2024

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

Add a clinical conversation and agreed care-plan communication standard to Crisis Team discharge instructions.

Verbatim wording from the response

“It was deeply concerning to hear the experience of Mr Southern and how the pathway for Mr Southern following his contact with the Crisis Team into the Local Mental Health Team (LMHT) was not properly agreed or communicated between teams, this then led to an avoidable delay which is not acceptable. We have reviewed the pathway between Crisis and LMHT services to ensure that clinical safety standards are in place. There are expected standards that Crisis teams have a clinical conversation with respective LMHT services before discharging a patient from the service. This will ensure that both teams are in agreement to the plan of care required and that this is further communicated to the patient.”

Source location

Response from Nottinghamshire NHS
Page 2 · response
Published 4 October 2024

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 bespoke record-keeping training for registered and unregistered professionals with the Royal College of Nursing.

Verbatim wording from the response

“In reference to this incident and other incidents, individual accountability is a current focus of development and in collaboration with the Royal College of Nursing the trust is developing bespoke”

Source location

Response from Nottinghamshire NHS
Page 1 · response
Published 4 October 2024

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 specific record-keeping training for all staff into the existing training programme and oversee compliance.

Verbatim wording from the response

“training, for registered and unregistered professionals. Further work that has been completed in relation to ensuring quality and accurate record keeping is the development of specific training for all staff which join the current training programme and compliance overseen for assurance.”

Source location

Response from Nottinghamshire NHS
Page 2 · response
Published 4 October 2024

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 mandatory clinical supervision processes and documentation to review the quality of care evidenced in patient records.

Verbatim wording from the response

“To provide a continual flow of assurance we have also changed the process and documentation used within mandatory supervision sessions with all clinical staff to include a specific review of the quality of care being evidenced within the patient records. Further work is in progress to change the current content of the quarterly patient records audit to be more specific to patients being cared for in the community alongside increasing the frequency of the audit to monthly. The outcome of the audits will then be reviewed and overseen within the Care Unit’s Quality Oversight Group (QOG) and Care Group QOG to ensure senior clinical oversight and assurance.”

Source location

Response from Nottinghamshire NHS
Page 2 · response
Published 4 October 2024

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 quarterly patient-record audits for community patients and increase their frequency to monthly, with quality-group oversight.

Verbatim wording from the response

“To provide a continual flow of assurance we have also changed the process and documentation used within mandatory supervision sessions with all clinical staff to include a specific review of the quality of care being evidenced within the patient records. Further work is in progress to change the current content of the quarterly patient records audit to be more specific to patients being cared for in the community alongside increasing the frequency of the audit to monthly. The outcome of the audits will then be reviewed and overseen within the Care Unit’s Quality Oversight Group (QOG) and Care Group QOG to ensure senior clinical oversight and assurance.”

Source location

Response from Nottinghamshire NHS
Page 2 · response
Published 4 October 2024

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.1

  1. 1

    Implement an improved caseload oversight and allocation process within Local Mental Health Team instructions and share it with teams.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2024.

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

Implement an improved caseload oversight and allocation process within Local Mental Health Team instructions and share it with teams.

Verbatim wording from the response

“This standard has been added to the Crisis Team Internal Working Instructions (IWI) and will be further discussed within their local QOG meetings from a wider learning perspective to support learning. Further work relating to place-based interface meetings between teams is currently in progress which will oversee the current process of internal transfers of care, ensure compliance and support wider team communications and closer working relationships to ensure patients receive the standard of care expected. In terms of caseload oversight and allocation there is now an improved process which is incorporated within the LMHT Internal Working Instructions that has been shared and discussed with all teams with further oversight of assurance from weekly oversight meetings, supervision and audits to inform any further potential developments required.”

Source location

Response from Nottinghamshire NHS
Page 2 · response
Published 4 October 2024

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