PFD report

Ruth Milne · Prevention of Future Deaths report

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Issued 16 May 2017•Lincolnshire

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
18

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. Lack of continuity in medical staff dispatched by the GP's practice
    Part of recurring concern: Failure to provide continuity of care staffing
  2. Failure to ensure the appropriateness of medical staff dispatched by the GP's practice
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

    Lower limb training is not mandatory because workplace training, competency assessment and tissue viability nurse sign-off provide alternative safeguards.

    Stated by Lincolnshire Community Health Services NHS 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

Lack of continuity in medical staff dispatched by the GP's practice

Wider context from the report

“(1) The lack of continuity and the appropriateness of the medical staff dispatched by the GP's ████████ at Hawthorn Medical Practice, Skegness. The Safeguarding report by ████████ Unstone Head of Safeguarding dated November 2015 identified this. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing.

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 ensure the appropriateness of medical staff dispatched by the GP's practice

Wider context from the report

“(1) The lack of continuity and the appropriateness of the medical staff dispatched by the GP's ████████ at Hawthorn Medical Practice, Skegness. The Safeguarding report by ████████ Unstone Head of Safeguarding dated November 2015 identified this. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Lower limb training is not mandatory because workplace training, competency assessment and tissue viability nurse sign-off provide alternative safeguards.

Verbatim wording from the response

“Staff can access a “lower limb course” and whilst this is highly recommended it is not mandated. All training needs are fed into a centralised training needs analysis, this then informs a competency matrix which identifies which staff require training in a specific area. If staff do not attend the “lower limb course” then training is provided within the workplace and sign off is supported by the tissue viability associate nurse. Staff within the Skegness team have received bespoke training of this nature.”

Source location

Ruth-Milne-Response
Page 3 · response
Published 16 August 2017

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.18

  1. 1

    Present the action-plan tracker at the monthly Patient Safety and Safeguarding Committee to monitor progress, target dates and evidence.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  2. 2

    Hold a Saturday leg-ulcer clinic from late July through September to provide additional seasonal service capacity.

    Stated by Lincolnshire Community Health Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 16 August 2017.
  3. 3

    Provide annual level 3 safeguarding training to team staff.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  4. 4

    Implement a standard operating procedure and competency requirements for handheld Dopplex vascular Doppler ultrasound use.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  5. 5

    Hold monthly operational meetings involving Heads of Clinical Services, Matrons and Clinical Team Leads.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  6. 6

    Allocate case managers to GP practices and dedicate weekly time to patient-by-patient caseload review, care verification, cleansing and discharge checks.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  7. 7

    Complete population and productivity reviews and implement the proposed Skegness staffing model to reflect transient-patient needs.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  8. 8

    Use an implemented caseload review tool across LCHS to review caseloads and ambulatory-clinic utilisation.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  9. 9

    Provide integrated visits and specialist nurse support through established communication and shared accommodation with community nursing staff.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  10. 10

    Appoint a new clinical team leader for the community team.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  11. 11

    Develop and implement a community dependency tool for plotting visits and assessing caseload complexity.

    Stated by Lincolnshire Community Health Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 August 2017.
  12. 12

    Operate weekday leg-ulcer clinics in Skegness and Mablethorpe, evaluate patient care through care planning, and manage ambulatory patients through case management.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  13. 13

    Provide lower-limb-care training and workplace competency sign-off supported by the tissue viability associate nurse.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  14. 14

    Implement clinical guidelines for lower-limb ulceration assessment and management in adult community services.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  15. 15

    Introduce adult safeguarding competencies for band 7 nurses.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  16. 16

    Introduce an action-plan tracker requiring evidence and monitoring actions through completion.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  17. 17

    Allocate a deputy named nurse for safeguarding to each team to provide supervision.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.
  18. 18

    Provide regular clinical and safeguarding supervision for the team.

    Stated by Lincolnshire Community Health Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 August 2017.

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

Present the action-plan tracker at the monthly Patient Safety and Safeguarding Committee to monitor progress, target dates and evidence.

Verbatim wording from the response

“The action plan and outcomes are monitored as identified in the report. In addition LCHS have recently introduced an action plan tracker. All actions from an action plan are added to the tracker for monitoring through to completion. Any stated evidence on the action plan is required in order to be marked as complete. The tracker headings are as below:”

Source location

Ruth-Milne-Response
Page 3 · response
Published 16 August 2017

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

Hold a Saturday leg-ulcer clinic from late July through September to provide additional seasonal service capacity.

Verbatim wording from the response

“There are now two leg ulcer clinics held 5 days a week within Skegness and one clinic held 5 days a week in Mablethorpe. There is also a plan to hold a Saturday clinic from late July to September to provide extra service provision for holiday makers. Provision of care to these patients is evaluated as part of care planning.”

Source location

Ruth-Milne-Response
Page 1 · response
Published 16 August 2017

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 annual level 3 safeguarding training to team staff.

Verbatim wording from the response

“The Clinical Team Leader (CTL) in post at the time of Mrs Milne’s death has now left the Trust. With the appointment of a new CTL into that post the team have evolved, progressed and become more cohesive. Communication has enhanced. Clinical and safeguarding supervision takes place on a regular basis and the team recognise when support is required and access that support readily. The team also receive annual level 3 safeguarding training and there is a deputy named nurse for safeguarding allocated to each team to provide the supervision. Adult safeguarding competencies have also been introduced for each band 7 nurses. Monthly operation meetings now take place which include the Heads of Clinical Services, Matrons and Clinical Team Leads.”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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 standard operating procedure and competency requirements for handheld Dopplex vascular Doppler ultrasound use.

Verbatim wording from the response

“There are also two documents that support lower limb care these being:”

Source location

Ruth-Milne-Response
Page 3 · response
Published 16 August 2017

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

Hold monthly operational meetings involving Heads of Clinical Services, Matrons and Clinical Team Leads.

Verbatim wording from the response

“The Clinical Team Leader (CTL) in post at the time of Mrs Milne’s death has now left the Trust. With the appointment of a new CTL into that post the team have evolved, progressed and become more cohesive. Communication has enhanced. Clinical and safeguarding supervision takes place on a regular basis and the team recognise when support is required and access that support readily. The team also receive annual level 3 safeguarding training and there is a deputy named nurse for safeguarding allocated to each team to provide the supervision. Adult safeguarding competencies have also been introduced for each band 7 nurses. Monthly operation meetings now take place which include the Heads of Clinical Services, Matrons and Clinical Team Leads.”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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

Allocate case managers to GP practices and dedicate weekly time to patient-by-patient caseload review, care verification, cleansing and discharge checks.

Verbatim wording from the response

“4. Allocation of case managers within the team”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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 population and productivity reviews and implement the proposed Skegness staffing model to reflect transient-patient needs.

Verbatim wording from the response

“17.3 Carry out an in depth review of the team’s activity in relation to the transient population and their long term conditions both internal and external to Lincolnshire”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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

Use an implemented caseload review tool across LCHS to review caseloads and ambulatory-clinic utilisation.

Verbatim wording from the response

“3. Review of caseloads and utilisation of ambulatory clinics”

Source location

Ruth-Milne-Response
Page 1 · response
Published 16 August 2017

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 integrated visits and specialist nurse support through established communication and shared accommodation with community nursing staff.

Verbatim wording from the response

“2. Integrated support/review with specialist nurses i.e. heart failure, lymphoedema and continence”

Source location

Ruth-Milne-Response
Page 1 · response
Published 16 August 2017

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

Appoint a new clinical team leader for the community team.

Verbatim wording from the response

“17.2 Team dynamic, to review the current culture of the team including the integration of specialist nurses Review of clinical leadership to the community team and to develop appropriate support mechanisms”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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 and implement a community dependency tool for plotting visits and assessing caseload complexity.

Verbatim wording from the response

“There have been a lot of recent journal articles on the development of caseload dependency / complexity tools for the community, as until recently many of those developed were for secondary care use. A good document from this year is by NHS Improvement ‘An improvement resource for district nursing service’ and gives examples of case studies where patient complexity tools have been implemented - this followed on the back of the work from NICE and other sources. As a result LCHS undertook a project looking at the use of a dependency tool. Two senior community nurses were asked to implement this within the teams and its use in plotting visits (Appendix B). The action plan is relation this project, as you will see is very current and as yet hasn’t been signed off as the project is not yet at its final stage (Appendix C)”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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

Operate weekday leg-ulcer clinics in Skegness and Mablethorpe, evaluate patient care through care planning, and manage ambulatory patients through case management.

Verbatim wording from the response

“1. Ambulatory patients to be managed through case management identifying appropriate management through clinics and evaluated through care plan”

Source location

Ruth-Milne-Response
Page 1 · response
Published 16 August 2017

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 lower-limb-care training and workplace competency sign-off supported by the tissue viability associate nurse.

Verbatim wording from the response

“17.4 Staff needing competencies around lower limb care signing off to be supported by the tissue viability associate nurse”

Source location

Ruth-Milne-Response
Page 3 · response
Published 16 August 2017

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 clinical guidelines for lower-limb ulceration assessment and management in adult community services.

Verbatim wording from the response

“There are also two documents that support lower limb care these being:”

Source location

Ruth-Milne-Response
Page 3 · response
Published 16 August 2017

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 adult safeguarding competencies for band 7 nurses.

Verbatim wording from the response

“The Clinical Team Leader (CTL) in post at the time of Mrs Milne’s death has now left the Trust. With the appointment of a new CTL into that post the team have evolved, progressed and become more cohesive. Communication has enhanced. Clinical and safeguarding supervision takes place on a regular basis and the team recognise when support is required and access that support readily. The team also receive annual level 3 safeguarding training and there is a deputy named nurse for safeguarding allocated to each team to provide the supervision. Adult safeguarding competencies have also been introduced for each band 7 nurses. Monthly operation meetings now take place which include the Heads of Clinical Services, Matrons and Clinical Team Leads.”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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 an action-plan tracker requiring evidence and monitoring actions through completion.

Verbatim wording from the response

“Monitoring arrangements (Page 12)”

Source location

Ruth-Milne-Response
Page 3 · response
Published 16 August 2017

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

Allocate a deputy named nurse for safeguarding to each team to provide supervision.

Verbatim wording from the response

“The Clinical Team Leader (CTL) in post at the time of Mrs Milne’s death has now left the Trust. With the appointment of a new CTL into that post the team have evolved, progressed and become more cohesive. Communication has enhanced. Clinical and safeguarding supervision takes place on a regular basis and the team recognise when support is required and access that support readily. The team also receive annual level 3 safeguarding training and there is a deputy named nurse for safeguarding allocated to each team to provide the supervision. Adult safeguarding competencies have also been introduced for each band 7 nurses. Monthly operation meetings now take place which include the Heads of Clinical Services, Matrons and Clinical Team Leads.”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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 regular clinical and safeguarding supervision for the team.

Verbatim wording from the response

“The Clinical Team Leader (CTL) in post at the time of Mrs Milne’s death has now left the Trust. With the appointment of a new CTL into that post the team have evolved, progressed and become more cohesive. Communication has enhanced. Clinical and safeguarding supervision takes place on a regular basis and the team recognise when support is required and access that support readily. The team also receive annual level 3 safeguarding training and there is a deputy named nurse for safeguarding allocated to each team to provide the supervision. Adult safeguarding competencies have also been introduced for each band 7 nurses. Monthly operation meetings now take place which include the Heads of Clinical Services, Matrons and Clinical Team Leads.”

Source location

Ruth-Milne-Response
Page 2 · response
Published 16 August 2017

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