PFD report

David Louis SIIRAK · Prevention of Future Deaths report

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Issued 7 Mar 2024•West 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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised1

  1. Failure to provide adequate unexpected simulation training for ward staff
    Part of recurring concern: Inadequate staff training for emergency response
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.5

  1. Action

    Train staff who facilitate simulations and provide local facilitator update training.

    Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 April 2024.
  2. Action

    Build a simulation room for staff identified as needing refresher training to attend planned sessions.

    Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2024.
  3. Action

    Deliver a Trust-wide in-situ simulation programme using standardised planning, facilitation, debriefing and recording processes for resuscitation and other emergencies.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2024.

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

  1. Position

    Existing resuscitation and in-situ simulation arrangements provide sufficient assurance that the identified training concerns are being addressed.

    Stated by Central and North West London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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 adequate unexpected simulation training for ward staff

Wider context from the report

“Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by ████████, arrived at 1703 hours. The evidence was that between those times (until ████████ took charge at 1703) the response of ward staff to the incident was "chaotic" and "panicking" (as was acknowledged by the staff). The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By "simulated emergency", I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day. One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since. The jury found that "there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020." It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training. ”

Is this part of a recurring concern?

Yes — Inadequate staff training for emergency response.

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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

Train staff who facilitate simulations and provide local facilitator update training.

Verbatim wording from the response

“Everyone involved in delivering and facilitating simulation has attended training provided by Milton Keynes University in 2022 and 2023, and local update training is planned for 2024. Since the launch of the programme over 100 insitu resuscitation simulations have been carried out across the trust, with 79 having occurred in the last year, one of these has occurred on Frays ward, including five members of staff.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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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

Build a simulation room for staff identified as needing refresher training to attend planned sessions.

Verbatim wording from the response

“The Trust is also currently building a simulation room, where staff identified as having a need to refresh can attend for planned sessions.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 3 April 2024

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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 a Trust-wide in-situ simulation programme using standardised planning, facilitation, debriefing and recording processes for resuscitation and other emergencies.

Verbatim wording from the response

“Insitu simulation: This has been developed alongside a Trust-wide insitu Simulation education programme and complements the training programme outlined above. This programme was launched and led by the head of Adult Education at CNWL in 2022. The Trust-wide programme covers many areas, with resuscitation simulation being one of those areas. This uses a unified approach to planning, running, debriefing and recording each simulation. The Resuscitation team has a suite of simulation’s developed from previous incident that have occurred across the trust.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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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 rolling in-situ simulation delivery across inpatient wards, adding sessions for areas identified as needing greater support.

Verbatim wording from the response

“Over the next 12 months, a rolling programme of insitu simulations is scheduled for every inpatient ward area, with additional sessions planned for areas identifying a greater need. Areas which may be considered as requiring additional input will include teams that have been involved in a recent resuscitation event and incident reviews.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 3 April 2024

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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 nationally accredited RCUK Level 3 Immediate Life Support training annually to substantive inpatient nurses and doctors, with compliance monitored through governance structures.

Verbatim wording from the response

“Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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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

Existing resuscitation and in-situ simulation arrangements provide sufficient assurance that the identified training concerns are being addressed.

Verbatim wording from the response

“Resuscitation training: In November 2022, the Trust updated its resuscitation training to the Nationally accredited RCUK Level 3 Resuscitation training also known as Immediate Life Support (ILS). It is a course where to be successful the participants need to successfully demonstrate the skills required to resuscitate a patient. Providing assurance to both the individual and the Trust. All participants are involved in multiple resuscitation simulations, all of which have been developed from incidents that have occurred within the Trust. All registered substantive Nurses and Doctors who work on inpatient areas are required to attend this course annually. The Trust monitors ILS training compliance in a range of groups, Committees and also at Board level. Through this monitoring we obtain assurance that all relevant staff have undertaken ILS training and simulation exercises.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 3 April 2024

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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

    Share simulation learning through ward team meetings, local care quality groups and twice-yearly committee reporting, including lessons learned and follow-on actions.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 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

Share simulation learning through ward team meetings, local care quality groups and twice-yearly committee reporting, including lessons learned and follow-on actions.

Verbatim wording from the response

“Ward Managers and Matrons share learning from local insitu simulations with the wider team via team meetings and share additional learning across the local service via their Local Care Quality Group meetings.”

Source location

Response from Central and North West London NHS Foundation Trust
Page 3 · response
Published 3 April 2024

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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