PFD report

John Patrick Doyle · Prevention of Future Deaths report

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Issued 3 Jul 2019•East 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
4

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 raised4

  1. Lack of refresher training for occupational therapists as emergency equipment technology changes
  2. Training for occupational therapists not adequately covering the ordering process for emergency alarm equipment
  3. Training for occupational therapists not adequately covering available emergency alarm equipment
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

    Add pendant-alarm ordering information, including clinical reasoning and equipment follow-up, to the occupational therapy induction checklist.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.
  2. Action

    Deliver an inpatient teaching session on pendant-alarm telephone compatibility requirements.

    Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
  3. Action

    Complete training on individual borough pendant-alarm ordering processes for inpatient and IRS staff.

    Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.

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 refresher training for occupational therapists as emergency equipment technology changes

Wider context from the report

“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”

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

Training for occupational therapists not adequately covering the ordering process for emergency alarm equipment

Wider context from the report

“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”

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

Training for occupational therapists not adequately covering available emergency alarm equipment

Wider context from the report

“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”

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

Training for occupational therapists not adequately covering compatibility between alarm and home telephone systems

Wider context from the report

“the evidence heard around the training provided to occupational therapists in relation to the emergency equipment available from Telecare. It is requested that the training for occupational therapists is reviewed to consider: I. The emergency alarm equipment available II. The order process required for such equipment, and III. The compatibility between the alarm system and the telephone systems within the home setting. It was also noted that technology changes frequently and therefore it is requested that a form of refresher training is also considered. ”

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

Add pendant-alarm ordering information, including clinical reasoning and equipment follow-up, to the occupational therapy induction checklist.

Verbatim wording from the response

“Recommendation 3 To ensure that the training for pendant alarms is firmly embedded within the service.”

Source location

Response from North East London NHS Foundation Trust
Page 4 · response
Published 13 September 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

Deliver an inpatient teaching session on pendant-alarm telephone compatibility requirements.

Verbatim wording from the response

“Action 1 Patient safety alert distributed and an inpatient session to emphasise the following requirements:”

Source location

Response from North East London NHS Foundation Trust
Page 2 · response
Published 13 September 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

Complete training on individual borough pendant-alarm ordering processes for inpatient and IRS staff.

Verbatim wording from the response

“• This is to include any specific training related to assessment and provision of the pendant alarms as well as different types of equipment.”

Source location

Response from North East London NHS Foundation Trust
Page 3 · response
Published 13 September 2019

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.5

  1. 1

    Raise the report and action plan with the Trust AHP lead and arrange occupational therapy-wide safety awareness work.

    Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
  2. 2

    Distribute the patient safety alert to occupational therapy service leads.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.
  3. 3

    Contact Barking and Dagenham, Havering and Redbridge authorities to establish pendant-alarm ordering processes.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.
  4. 4

    Discuss the coroner’s report findings at the divisional business meeting for wider learning.

    Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
  5. 5

    Issue patient safety alert 29-19001 to all intermediate care services.

    Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.

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

Raise the report and action plan with the Trust AHP lead and arrange occupational therapy-wide safety awareness work.

Verbatim wording from the response

“By Whom: Assistant Director Intermediate Care By When: 12/08/19 Progress/comments: Trust AHP lead to be made aware of the report and action plan. Identify CHS Occupational Therapy AD to work with CHS occupational therapy services to present to all OT’s and create awareness of safety for OT’s within the Trust.”

Source location

Response from North East London NHS Foundation Trust
Page 4 · response
Published 13 September 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

Distribute the patient safety alert to occupational therapy service leads.

Verbatim wording from the response

“Action 1 Patient safety alert distributed and an inpatient session to emphasise the following requirements:”

Source location

Response from North East London NHS Foundation Trust
Page 2 · response
Published 13 September 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

Contact Barking and Dagenham, Havering and Redbridge authorities to establish pendant-alarm ordering processes.

Verbatim wording from the response

“• If no landline or mobile phone available then there must be discussion with the patient/family for urgent arrangements to be made for access to suitable phone to enable a request for a pendant alarm.”

Source location

Response from North East London NHS Foundation Trust
Page 3 · response
Published 13 September 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

Discuss the coroner’s report findings at the divisional business meeting for wider learning.

Verbatim wording from the response

“Recommendation 4 Improving learning and lessons learnt.”

Source location

Response from North East London NHS Foundation Trust
Page 4 · response
Published 13 September 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 patient safety alert 29-19001 to all intermediate care services.

Verbatim wording from the response

“Action 4 Findings of the coroner’s court report to be discussed in August’s Divisional Business Meeting (DBM) for wider learning. Patient safety alert (29-19001) issued 28/07/2019 to all intermediate care services.”

Source location

Response from North East London NHS Foundation Trust
Page 4 · response
Published 13 September 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