PFD report

Mina TOPLEY-BIRD · Prevention of Future Deaths report

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Issued 9 Apr 2021•County Durham and Darlington

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
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
17

Described in 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.

Report evidence summary

Concerns raised5

  1. Failure to provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points
    Part of recurring concern: Failure to control ligature risks in inpatient and custodial environments
  2. Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients
    Part of recurring concern: Unreliable patient risk-assessment processes
  3. Failure to print medical notes and other documents from the Trust IT system in shared premises
    Part of recurring concern: Failure to make relevant mental health assessment information available across care settingsPart of recurring concern: Failure to reliably transfer medical records between healthcare organisations
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

    Implement a central bed management hub as the second phase of the bed management team.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
  2. Action

    Review, clarify and streamline clinical risk assessment and management processes and confirm organisation-wide risk-assessment standards.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  3. Action

    Increase Liaison Team overnight staffing to two staff members.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.

    Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.

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 provide assurance that patient-safety surveys inspect each relevant bedroom for hazards such as ligature points

Wider context from the report

“3. The Trust (TEWV) in evidence heard that the Elm Ward at West Park Hospital had been surveyed for issues related to patient safety such as ligature points. Whilst the evidence was that the Trust was confident this had been done, no assurance could be given. One such assessment did not show clearly if the deceased's bedroom had been inspected for issues such as ligature points. ”

Is this part of a recurring concern?

Yes — Failure to control ligature risks in inpatient and custodial environments.

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

Incomplete Risk Assessment/Safety Summary process for assessing and protecting patients

Wider context from the report

“5. The Trust gave evidence that the Risk Assessment/Safety Summary process for assessing and protecting patients had been improved, but accepted it was still 'a work in progress' and further work was required. It is of concern that this aspect of area of patient safeguarding appears on the evidence given at inquest not to be complete. ”

Is this part of a recurring concern?

Yes — Unreliable patient risk-assessment 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 print medical notes and other documents from the Trust IT system in shared premises

Wider context from the report

“2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT. This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments. ”

Is this part of a recurring concern?

Yes — Failure to make relevant mental health assessment information available across care settings; Failure to reliably transfer medical records between healthcare organisations.

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 upload PDF medical records and important information promptly in original form to the electronic notes system

Wider context from the report

“1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form. This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Incomplete, inaccurate or unavailable clinical and care records; Unreliable access to relevant clinical records for safe care.

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

Limited coverage of the Bed Manager function to one Trust region

Wider context from the report

“4. Evidence was heard that within the Durham & Darlington area of the TEWV Trust funding had been secured for the post of a Bed Manager, who was to manage bed allocation, transfer and discharges to better manage access to beds for patients across this area of the Durham & Darlington area of the Trust. It was heard this role would be able to more proactively arrange transfers of patients from Trust to Trust as was a need raised in this inquest. It was disclosed that this post only operated in the Durham & Darlington area of the Trust and not across the whole Trust. On the evidence heard this post has obvious benefits for ensuring patients access to beds and I raise a concern this post is not one which cover the whole of the Trust, only one region of it. ”

Is this part of a recurring concern?

Yes — Unreliable hospital bed management and allocation processes.

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

Implement a central bed management hub as the second phase of the bed management team.

Verbatim wording from the response

“In the case of MTB, the issue was there were no beds available to transfer her to her home Trust. Each locality of the Trust has staff who manage patient flow and beds and facilitate patient transfers as part of their daily roles. The Trust has now agreed a plan to implement a bed management team. This will be introduced in the following phased approach:”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 3 · response
Published 13 April 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

Review, clarify and streamline clinical risk assessment and management processes and confirm organisation-wide risk-assessment standards.

Verbatim wording from the response

“Following a CQC inspection in January 2021 where concerns were raised regarding risk assessment and management, a Rapid Process Improvement Workshop (RPIW) was held week commencing 1st February 2021. This was to review, clarify and streamline the process for assessing and managing the clinical risk of patients and to confirm the standards for risk assessment across all services of the organisation.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 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 Liaison Team overnight staffing to two staff members.

Verbatim wording from the response

“The Trust has also since taken action and increased the staffing establishment of the Liaison Team, increasing the number of staff on duty overnight night to two. This means that if a document does need to be printed urgently, one member of staff can go to our nearby Trust premises to do this.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 2 · response
Published 13 April 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

Review care documentation to assure that patient risks are assessed and safety plans meet the agreed standard.

Verbatim wording from the response

“A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 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

Implement an out-of-area patient checklist covering information gathering, care-team sharing, Safety Summary updates and forwarding information to admitting wards.

Verbatim wording from the response

“As described at the inquest hearing, immediate action was taken by the Trust to develop and implement a checklist to support the care and treatment of patients presenting at Accident and Emergency departments, who are from outside the area. (please see documents attached at Concern 2 below). This checklist includes:”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 1 · response
Published 13 April 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

Implement Cito electronic records functionality for scanning, uploading and viewing documents.

Verbatim wording from the response

“This issue regarding access to patient information will be fully resolved by the implementation of Cito, which is a full electronic records management solution and allows documents to be scanned in, uploaded or viewed. This solution will be fully implemented by August 2022.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 2 · response
Published 13 April 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

Introduce locality-based bed managers as the first phase of a Trust-wide bed management team.

Verbatim wording from the response

“In the case of MTB, the issue was there were no beds available to transfer her to her home Trust. Each locality of the Trust has staff who manage patient flow and beds and facilitate patient transfers as part of their daily roles. The Trust has now agreed a plan to implement a bed management team. This will be introduced in the following phased approach:”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 3 · response
Published 13 April 2021

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

Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.

Verbatim wording from the response

“My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required.”

Source location

2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 3 · response
Published 13 April 2021

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

Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.

Verbatim wording from the response

“Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services.”

Source location

2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 13 April 2021

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

The environmental survey had included the deceased’s bedroom, contrary to the concern that it had not been inspected for ligature risks.

Verbatim wording from the response

“For completeness, MTB was in bedroom 4 (identifier 2.04 previously). The Suicide Prevention Environmental Survey and Risk Assessment, attached below, formed part of the documentary evidence made available to the Coroner. This demonstrated that the survey in place at the time of the incident had included bedroom 4 (2.04).”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 3 · response
Published 13 April 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

    Continue eliminating inappropriate out-of-area placements in adult acute mental health inpatient services.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  2. 2

    Provide guidance to NHS trusts on out-of-area placements, including repatriation and regular review arrangements.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  3. 3

    Provide monthly progress updates and assurance to the regional Quality Board.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  4. 4

    Develop community caseload dashboards and improve clinical supervision processes through community assurance arrangements.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  5. 5

    Enhance and embed organisational learning by strengthening systems for capturing, communicating and assuring the impact of learning and improvement actions.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  6. 6

    Establish Ward-to-Board governance arrangements for executive oversight and compliance reporting against quality standards.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  7. 7

    Implement an ongoing quality-assurance programme using clinical audit, Matron walkabouts and direct clinical observation.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  8. 8

    Complete the ligature-reduction programme by replacing specified sanitary fittings with anti-ligature alternatives.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
  9. 9

    Install patient-movement and vital-sign detection technology in high-risk areas to alert staff to check patient wellbeing.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
  10. 10

    Access external expertise to support rapid improvement and sustainable changes in practice.

    Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The decision to admit the patient to Darlington was appropriate because emergency inpatient admission away from home was required.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Continue eliminating inappropriate out-of-area placements in adult acute mental health inpatient services.

Verbatim wording from the response

“The Government is committed to eliminating inappropriate out of area placements in mental health services for adults in acute inpatient care and in 2016 provided guidance on out of area placements¹ to NHS Trusts to support this ambition.”

Source location

2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 1 · response
Published 13 April 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

Provide guidance to NHS trusts on out-of-area placements, including repatriation and regular review arrangements.

Verbatim wording from the response

“The Government is committed to eliminating inappropriate out of area placements in mental health services for adults in acute inpatient care and in 2016 provided guidance on out of area placements¹ to NHS Trusts to support this ambition.”

Source location

2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 1 · response
Published 13 April 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

Provide monthly progress updates and assurance to the regional Quality Board.

Verbatim wording from the response

“A regional Quality Board has been set up by NHS England and Improvement; membership includes key external stakeholders such as CQC and members of the ICS. The Trust provides monthly updates and assurance on its progress. We are also accessing a range of external expertise to support rapid improvement and sustainable changes in practice.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 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 community caseload dashboards and improve clinical supervision processes through community assurance arrangements.

Verbatim wording from the response

“A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 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

Enhance and embed organisational learning by strengthening systems for capturing, communicating and assuring the impact of learning and improvement actions.

Verbatim wording from the response

“In addition, work is underway to enhance and embed organisational learning from a range of internal and external sources. This includes reviewing, strengthening and developing systems and mechanisms for capturing and communicating learning and importantly gaining assurance of the impact of our actions to improve care for services users and their families.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 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

Establish Ward-to-Board governance arrangements for executive oversight and compliance reporting against quality standards.

Verbatim wording from the response

“A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 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

Implement an ongoing quality-assurance programme using clinical audit, Matron walkabouts and direct clinical observation.

Verbatim wording from the response

“A review of care documentation was undertaken to provide assurance that patient risks were being assessed and each patient had a safety plan in place in line with the agreed standard. Ward to Board governance arrangements were put in place to ensure Executive oversight and the reporting of compliance with the quality standards. An ongoing programme of quality assurance was implemented. This utilises a range of methods such as clinical audit, Matron walkabouts and direct clinical observation to provide assurance to the Trust Board that the actions being taken are having a positive impact and addressing the patient safety concerns. Community assurance processes have included the development of a dashboard to support community caseload reporting and improved clinical supervision processes.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 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

Complete the ligature-reduction programme by replacing specified sanitary fittings with anti-ligature alternatives.

Verbatim wording from the response

“The Trust has recently undertaken an extensive ligature reduction programme that has included the removal of taps, toilets, shower controls and sinks and replaced with anti-ligature sanitary ware. The Trust is also in the process of installing technology that will assist with the detection of movement of patients in high risk areas such as bedrooms and en-suites. This technology responds to a patients change in vital signs or movements and will send an alert to staff to check on the wellbeing of the patient. This technology is already in place in other areas of the Trust and has been used effectively to maintain patient safety in this way.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 3 · response
Published 13 April 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

Install patient-movement and vital-sign detection technology in high-risk areas to alert staff to check patient wellbeing.

Verbatim wording from the response

“The Trust has recently undertaken an extensive ligature reduction programme that has included the removal of taps, toilets, shower controls and sinks and replaced with anti-ligature sanitary ware. The Trust is also in the process of installing technology that will assist with the detection of movement of patients in high risk areas such as bedrooms and en-suites. This technology responds to a patients change in vital signs or movements and will send an alert to staff to check on the wellbeing of the patient. This technology is already in place in other areas of the Trust and has been used effectively to maintain patient safety in this way.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 3 · response
Published 13 April 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

Access external expertise to support rapid improvement and sustainable changes in practice.

Verbatim wording from the response

“A regional Quality Board has been set up by NHS England and Improvement; membership includes key external stakeholders such as CQC and members of the ICS. The Trust provides monthly updates and assurance on its progress. We are also accessing a range of external expertise to support rapid improvement and sustainable changes in practice.”

Source location

2021-0100-Response-from-West-Park-Hospital-Redacted
Page 4 · response
Published 13 April 2021

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

The decision to admit the patient to Darlington was appropriate because emergency inpatient admission away from home was required.

Verbatim wording from the response

“NHSE/I has told my officials that the decision to admit Ms Topley-Bird to hospital in Darlington was appropriate in the circumstances of her requiring emergency inpatient admission away from home. NHSE/I notes that the decision about when to transfer Ms Topley-Bird back to London should have been clinically-led with clinicians able to access her full medical history during the interim period to ensure her care was as safe and effective as possible.”

Source location

2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
Page 2 · response
Published 13 April 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

Official responses located
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Data last updated 7 September 2026