PFD report

Nyall Cye BROWN · Prevention of Future Deaths report

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Issued 15 Apr 2019•Norfolk

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised2

  1. Failure to consider the care-record review concern in investigation
    Part of recurring concern: Inadequate safety incident investigations
  2. Failure to review previous care records before assessing a service user
    Part of recurring concern: Failure to review relevant care documentation before providing care
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.2

  1. Action

    Introduce Patient Participation Leads and new Clinical Directors to strengthen clinical and service leadership and oversee learning from serious incidents.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
  2. Action

    Deliver a learning session on record keeping, communication and preparation before appointments.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 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

Failure to consider the care-record review concern in investigation

Wider context from the report

“1. Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen, which would enable Mr Brown’s full history and risks to be taken into account when assessing him. 2. This is a matter which has been raised with the Trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening. 3. This matter was not considered in the otherwise thorough investigation conducted by the Trust. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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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 review previous care records before assessing a service user

Wider context from the report

“1. Evidence was heard that Mr Brown’s care records were not reviewed prior to his being seen, which would enable Mr Brown’s full history and risks to be taken into account when assessing him. 2. This is a matter which has been raised with the Trust previously. Staff are expected to read previous records relating to a service user, but this is not always happening. 3. This matter was not considered in the otherwise thorough investigation conducted by the Trust. ”

Is this part of a recurring concern?

Yes — Failure to review relevant care documentation before providing care.

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

Introduce Patient Participation Leads and new Clinical Directors to strengthen clinical and service leadership and oversee learning from serious incidents.

Verbatim wording from the response

“To positively influence the Trust’s improvement work we are strengthening the clinical and service leadership in order to ensure there is the necessary breadth of skills and resource to lead safe and effective services. Of particular note, the Trust will be introducing Patient Participation Leads for each locality, who will work alongside new Clinical Directors to lead the components of quality and patient experience. The Trust has recruited to the majority of these roles which will be fully effective from September 2019. A key function of this new approach will be the accountability to share learning, implement and monitor recommendations from serious incidents.”

Source location

2019-0134-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019

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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 learning session on record keeping, communication and preparation before appointments.

Verbatim wording from the response

“The Trust has commissioned a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager commencing in June 2019. Alongside a focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication, the session will include content related to the importance of preparation ahead of appointments.”

Source location

2019-0134-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 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.2

  1. 1

    Use audits, user feedback and quality and safety review outcomes to gain assurance that the interventions are working.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
  2. 2

    Implement a new governance structure providing combined, tiered assurance for improvement.

    Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 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

Use audits, user feedback and quality and safety review outcomes to gain assurance that the interventions are working.

Verbatim wording from the response

“The Trust will gain assurance these interventions are working through a number of indicators. This will include audit, user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement.”

Source location

2019-0134-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 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

Implement a new governance structure providing combined, tiered assurance for improvement.

Verbatim wording from the response

“The Trust will gain assurance these interventions are working through a number of indicators. This will include audit, user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement.”

Source location

2019-0134-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 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