PFD report

Amanda Wood · Prevention of Future Deaths report

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Issued 7 Oct 2025•Manchester South

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 undertake a sepsis screen before Emergency Department discharge
    Part of recurring concern: Unreliable hospital discharge processes
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Existing triage, NEWS assessment and consultant review are considered sufficient; sepsis screening need not be repeated before Emergency Department discharge.

    Stated by Tameside and Glossop Integrated Care 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 undertake a sepsis screen before Emergency Department discharge

Wider context from the report

“Notwithstanding the ongoing work reported by the Trust in respect of the early identification and treatment of sepsis, I am concerned that there is no evidence of any sepsis screen being undertaken prior to Miss Wood’s discharge from the Emergency Department on 28th December 2024. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge processes.

Open source report

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 triage, NEWS assessment and consultant review are considered sufficient; sepsis screening need not be repeated before Emergency Department discharge.

Verbatim wording from the response

“Firstly, it is important to note that when patients present to the Emergency Department they are triaged in line with the Manchester Triage System, which is a clinical risk management tool used by clinicians worldwide to enable them to safely manage patient flow when clinical need far exceeds capacity. The triage system categorises patients in order of priority and all patients attending the ED should be triaged, or initially assessed, within 15 minutes. As part of this triage, observations are taken using the National Early Warning Score (NEWS) which is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. Mrs.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 1 · response
Published 9 October 2025

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.12

  1. 1

    Implement a multidisciplinary patient-safety checklist for non-patient escalation areas while electronic checklists are finalised.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  2. 2

    Place documentation reminders on every nursing computer to reinforce documentation expectations.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  3. 3

    Update the Standard Operating Procedure for non-patient escalation areas to require individual risk assessments and team-leader checklists.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  4. 4

    Redesign the intentional-rounding checklist through practice-based educators.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  5. 5

    Disseminate documentation learning through Trust-wide briefings, governance meetings, clinical forums and induction or teaching sessions.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  6. 6

    Implement formalised handover documentation to standardise transfer of patient care and management plans.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  7. 7

    Redesign the documentation audit process and assign Band 7 nurses on day and night shifts accountability for it.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  8. 8

    Revise Matrons’ walk-arounds to provide focused oversight of documentation quality and standards adherence.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  9. 9

    Audit documentation and safety checks for patients cared for in non-patient escalation areas.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
  10. 10

    Commission and undertake a doctors’ documentation audit covering ward-round, post-take and discharge records as part of the 2026/27 audit programme.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
  11. 11

    Conduct daily Emergency Department nursing documentation audits with Matron oversight and immediate action on poor compliance.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
  12. 12

    Review the 2026/27 audit programme through the non-executive-led Quality Committee.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.

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 multidisciplinary patient-safety checklist for non-patient escalation areas while electronic checklists are finalised.

Verbatim wording from the response

“In November/December 2025, an audit of 35 patients nursed in non-patient escalation areas (NPEA) of the Emergency Department was conducted. This included reviewing notes and nursing documentation for 35 patients, focusing on: A-E assessment, patient safety checklists, nutrition and hydration, body map and skin integrity, NEWS2 policy followed, documentation of wristbands and personal hygiene needs. Whilst the electronic patient safety checklists are finalised by clinical informatics, the Clinical Practice Educator has developed a new patient safety checklist document to ensure all disciplines can record essential safety checks consistently, while maintaining registered nurse oversight and accountability.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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

Place documentation reminders on every nursing computer to reinforce documentation expectations.

Verbatim wording from the response

“This audit has identified several challenges with documentation, particularly as patients are moved from high-pressure areas such as Rapid Assessment and Ambulatory Majors, where the high volume and rapid turnover of patients often result in minimal initial documentation. To address these challenges, several measures have been implemented including the new patient safety checklist in the NPEA. Matrons' walk-arounds have been revised to provide focused oversight on documentation quality and adherence to standards. The documentation audit process has also been redesigned, with responsibility assigned to the Band 7 nurse on both day and night shifts to maintain accountability and drive improvement In addition, clear documentation reminders have been placed on every nursing computer to reinforce expectations and support staff.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 9 October 2025

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

Update the Standard Operating Procedure for non-patient escalation areas to require individual risk assessments and team-leader checklists.

Verbatim wording from the response

“In the meantime, the Emergency Department nursing Team Leader completes daily documentation audits which have Matron oversight, and any poor compliance is actioned immediately at the time of the audit. Formalised handover documentation has also been implemented to ensure consistency in the handover of patient care and management plans. The Standard Operating Procedure has been updated to guide the assessment of patients being cared for in non-patient escalation areas (NPEA), to include an individual documented risk assessment and a team leader checklist. Furthermore, practice-based educators have redesigned the intentional rounding checklist.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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

Redesign the intentional-rounding checklist through practice-based educators.

Verbatim wording from the response

“In the meantime, the Emergency Department nursing Team Leader completes daily documentation audits which have Matron oversight, and any poor compliance is actioned immediately at the time of the audit. Formalised handover documentation has also been implemented to ensure consistency in the handover of patient care and management plans. The Standard Operating Procedure has been updated to guide the assessment of patients being cared for in non-patient escalation areas (NPEA), to include an individual documented risk assessment and a team leader checklist. Furthermore, practice-based educators have redesigned the intentional rounding checklist.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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 documentation learning through Trust-wide briefings, governance meetings, clinical forums and induction or teaching sessions.

Verbatim wording from the response

“All staff in the Trust are aware of the importance of documentation, which you will know is governed by both the Nursing and Midwifery Council Code (2018) and by the General Medical Council. This is instilled in staff from the point of induction and throughout regular teaching sessions at divisional meetings held throughout the year like the junior doctor induction, Patient and Staff, Quality & Safety Forum (PAPQSAF), specialty meetings as well as the Legal Conference in September 2025. Additionally, there have been seven-minute briefings disseminated Trust wide dealing with the importance of documentation, in July and November 2025.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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 formalised handover documentation to standardise transfer of patient care and management plans.

Verbatim wording from the response

“In the meantime, the Emergency Department nursing Team Leader completes daily documentation audits which have Matron oversight, and any poor compliance is actioned immediately at the time of the audit. Formalised handover documentation has also been implemented to ensure consistency in the handover of patient care and management plans. The Standard Operating Procedure has been updated to guide the assessment of patients being cared for in non-patient escalation areas (NPEA), to include an individual documented risk assessment and a team leader checklist. Furthermore, practice-based educators have redesigned the intentional rounding checklist.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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

Redesign the documentation audit process and assign Band 7 nurses on day and night shifts accountability for it.

Verbatim wording from the response

“This audit has identified several challenges with documentation, particularly as patients are moved from high-pressure areas such as Rapid Assessment and Ambulatory Majors, where the high volume and rapid turnover of patients often result in minimal initial documentation. To address these challenges, several measures have been implemented including the new patient safety checklist in the NPEA. Matrons' walk-arounds have been revised to provide focused oversight on documentation quality and adherence to standards. The documentation audit process has also been redesigned, with responsibility assigned to the Band 7 nurse on both day and night shifts to maintain accountability and drive improvement In addition, clear documentation reminders have been placed on every nursing computer to reinforce expectations and support staff.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 9 October 2025

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 Matrons’ walk-arounds to provide focused oversight of documentation quality and standards adherence.

Verbatim wording from the response

“This audit has identified several challenges with documentation, particularly as patients are moved from high-pressure areas such as Rapid Assessment and Ambulatory Majors, where the high volume and rapid turnover of patients often result in minimal initial documentation. To address these challenges, several measures have been implemented including the new patient safety checklist in the NPEA. Matrons' walk-arounds have been revised to provide focused oversight on documentation quality and adherence to standards. The documentation audit process has also been redesigned, with responsibility assigned to the Band 7 nurse on both day and night shifts to maintain accountability and drive improvement In addition, clear documentation reminders have been placed on every nursing computer to reinforce expectations and support staff.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 9 October 2025

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

Audit documentation and safety checks for patients cared for in non-patient escalation areas.

Verbatim wording from the response

“In November/December 2025, an audit of 35 patients nursed in non-patient escalation areas (NPEA) of the Emergency Department was conducted. This included reviewing notes and nursing documentation for 35 patients, focusing on: A-E assessment, patient safety checklists, nutrition and hydration, body map and skin integrity, NEWS2 policy followed, documentation of wristbands and personal hygiene needs. Whilst the electronic patient safety checklists are finalised by clinical informatics, the Clinical Practice Educator has developed a new patient safety checklist document to ensure all disciplines can record essential safety checks consistently, while maintaining registered nurse oversight and accountability.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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

Commission and undertake a doctors’ documentation audit covering ward-round, post-take and discharge records as part of the 2026/27 audit programme.

Verbatim wording from the response

“However, the Trust has observed that improvements are required to documentation, which will be overseen through the bi-monthly Clinical Effectiveness Group which is chaired by myself and is attended by the Chief Nurse, Deputy Chief Nurse, Associate Medical Directors, Divisional Nursing Directors, Clinical Directors, Divisional Director’s and the Deputy Chief Operating Officer. Through this group, I am commissioning a doctors’ documentation audit that will cover all aspects of documentation including ward rounds, post-take and discharge documentation which will be undertaken in summer 2026. As the Trust is currently compiling its annual audit programme, documenting the National and local audits that will be undertaken in 2026/27, the doctors’ documentation audit will form part of that audit programme.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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

Conduct daily Emergency Department nursing documentation audits with Matron oversight and immediate action on poor compliance.

Verbatim wording from the response

“In the meantime, the Emergency Department nursing Team Leader completes daily documentation audits which have Matron oversight, and any poor compliance is actioned immediately at the time of the audit. Formalised handover documentation has also been implemented to ensure consistency in the handover of patient care and management plans. The Standard Operating Procedure has been updated to guide the assessment of patients being cared for in non-patient escalation areas (NPEA), to include an individual documented risk assessment and a team leader checklist. Furthermore, practice-based educators have redesigned the intentional rounding checklist.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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 the 2026/27 audit programme through the non-executive-led Quality Committee.

Verbatim wording from the response

“This audit programme will be reviewed at the Trust’s non-executive led Quality Committee in April 2026.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 9 October 2025

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