PFD report

Henry Denis Whitwell Powell · Prevention of Future Deaths report

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Issued 18 Feb 2015•Leicester City and South Leicestershire

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
6

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
19

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 raised6

  1. Conflict between policies governing hospital-community transfer arrangements and equipment provision and ordering
  2. Insufficient training of discharge staff on the intended and appropriate use of bed rails
  3. Inappropriate discharge care planning
    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.

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.13

  1. Action

    Develop and ratify a joint bed-rail policy covering assessment, care planning, and handover between hospital and community services.

    Stated by University Hospitals of Leicester NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2015.
  2. Action

    Require staff to forward bed-rail risk assessments and care plans to community carers, record the information on ICE transfer letters, and audit compliance.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2015.
  3. Action

    Brief authorised bed-rail ordering staff on discharge procedures and correct use of the bed-rail risk-assessment matrix.

    Stated by University Hospitals of Leicester NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 February 2015.

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

Conflict between policies governing hospital-community transfer arrangements and equipment provision and ordering

Wider context from the report

“(2) There is a conflict currently between the policies governing transfer arrangements between hospital (UHL) and community (LPT) and the provision and ordering of equipment, which can now be done directly by the hospital. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Insufficient training of discharge staff on the intended and appropriate use of bed rails

Wider context from the report

“(1) The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Inappropriate discharge care planning

Wider context from the report

“(1) The discharge care planning was inappropriate and there was a significant misunderstanding regarding the intended and appropriate use of the bed rails which suggested insufficient training of discharge staff. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge 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

Inadequate co-ordination between services

Wider context from the report

“(3) Co-ordination between services is inadequate, resulting in equipment being ordered by the hospital but not thereafter being followed up or assessed in the community. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Non-implementation of the alert system for communication between all stakeholders

Wider context from the report

“(4) Equipment is supplied by a single gatekeeper, NRS Healthcare, and an alert system is intended to ensure communication has taken place between all stakeholders, but I was advised this system has not been implemented; early implementation would assist in resolving the current difficulties. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 follow up or assess hospital-ordered equipment in the community

Wider context from the report

“(3) Co-ordination between services is inadequate, resulting in equipment being ordered by the hospital but not thereafter being followed up or assessed in the community. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Develop and ratify a joint bed-rail policy covering assessment, care planning, and handover between hospital and community services.

Verbatim wording from the response

“On your second and third concerns I am pleased to be able to confirm that my Trust and Leicestershire Partnership Trust are working together to remove any conflict between our respective bed rail policies. Our Lead Discharge Nurse is working collaboratively with representatives from community hospitals, community nursing and NRS to agree a joint working policy for the safe use of bedrails. The working group have met twice to agree the process of assessment; development of a care plan and handover arrangements following transfer from hospital. A further meeting is scheduled for 10th April 2015, to make final adjustments to the policy, before this is sent for ratification. Our Acting Chief Nurse will ensure that this work will have occurred by May 2015. In addition, our Discharge Policy will be reviewed and will advise staff to consult the joint policy for the safe use of bedrails.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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

Require staff to forward bed-rail risk assessments and care plans to community carers, record the information on ICE transfer letters, and audit compliance.

Verbatim wording from the response

“All staff authorised to order bed rails are all now aware of their responsibility to forward a copy the risk assessment and care plan undertaken by UHL staff to the person responsible for the patient's care in the community setting following discharge from UHL and the information will also be recorded on the electronic transfer letter on ICE and audited. In addition, our Acting Chief Nurse will ensure that the Manual Handling Team will review the manual handling training undertaken by Ward staff, to ensure they are able to understand and interpret the risk assessment matrix, to aid their decision making, for the use of bed rails for patients who are at risk of slipping, sliding or rolling out of bed in the hospital setting.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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

Brief authorised bed-rail ordering staff on discharge procedures and correct use of the bed-rail risk-assessment matrix.

Verbatim wording from the response

“In light of what occurred in this case, our Lead Discharge Nurse has met with all staff working in the Trust, who are authorised to order bed rails for discharge, to ensure they are up to date with the procedure for ordering bed rails and to ensure they fully understand how to use the bed rail risk assessment matrix for patients who are at risk of slipping, sliding or rolling out of bed. She has used this case to emphasise the importance of strictly”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 1 · response
Published 18 February 2015

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 discharge policy to direct staff to consult the joint policy for safe bed-rail use.

Verbatim wording from the response

“On your second and third concerns I am pleased to be able to confirm that my Trust and Leicestershire Partnership Trust are working together to remove any conflict between our respective bed rail policies. Our Lead Discharge Nurse is working collaboratively with representatives from community hospitals, community nursing and NRS to agree a joint working policy for the safe use of bedrails. The working group have met twice to agree the process of assessment; development of a care plan and handover arrangements following transfer from hospital. A further meeting is scheduled for 10th April 2015, to make final adjustments to the policy, before this is sent for ratification. Our Acting Chief Nurse will ensure that this work will have occurred by May 2015. In addition, our Discharge Policy will be reviewed and will advise staff to consult the joint policy for the safe use of bedrails.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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 electronic ordering alert that prompts bed-rail risk assessment and prevents ordering when the assessment is incomplete.

Verbatim wording from the response

“On your fourth point our Lead Discharge has confirmed that an alert system is now in place on the electronic ordering system to prompt staff to consider a bed rails risk assessment. If this information is not completed, then the system will prevent bed rails being ordered.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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 ward staff manual-handling training to ensure they can interpret the bed-rail risk-assessment matrix.

Verbatim wording from the response

“All staff authorised to order bed rails are all now aware of their responsibility to forward a copy the risk assessment and care plan undertaken by UHL staff to the person responsible for the patient's care in the community setting following discharge from UHL and the information will also be recorded on the electronic transfer letter on ICE and audited. In addition, our Acting Chief Nurse will ensure that the Manual Handling Team will review the manual handling training undertaken by Ward staff, to ensure they are able to understand and interpret the risk assessment matrix, to aid their decision making, for the use of bed rails for patients who are at risk of slipping, sliding or rolling out of bed in the hospital setting.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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 relevant staff with training on discharge processes and bed-rail risk assessment.

Verbatim wording from the response

“adhering to the approved process for discharge including when bed rails are to be provided. Supported by our Acting Chief Nurse, she will ensure that training is provided to relevant staff on the Trust's processes for discharge and this will include training on bed rails risk assessment.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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 a shared Safe Use of Bedrails policy defining roles, responsibilities and training requirements across LPT, UHL and ICES.

Verbatim wording from the response

“Our Lead Nurse for Community Services, Community Health Service division is leading the development of a shared policy for the safe use of bedrails. Representatives from LPT, UHL, ICES and West Leicestershire Clinical Commissioning Group have met and agreed the areas for development and wider consideration. The draft combined policy will be available for each organisation to adopt by the end of April 2015.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 18 February 2015

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

Continue rolling out falls training for healthcare professionals.

Verbatim wording from the response

“Our health care professionals working within an in-patient setting are trained in the appropriate use of bed rails through the essential to role falls training. All staff working within these areas have undertaken a clinical workbook that incorporates falls training. The clinical workbook is being replaced with a continuous roll out training programme for all healthcare professionals. Currently compliance records for falls training is held locally on each ward. We are in the process of establishing how training compliance can be reported on divisionally to enable wider scrutiny.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 1 · response
Published 18 February 2015

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 agree a universal bedrail risk-assessment tool, standardised care plans and consistent transfer-of-care arrangements.

Verbatim wording from the response

“Our Lead Nurse for Community Services, Community Health Service division is leading the development of a shared policy for the safe use of bedrails. Representatives from LPT, UHL, ICES and West Leicestershire Clinical Commissioning Group have met and agreed the areas for development and wider consideration. The draft combined policy will be available for each organisation to adopt by the end of April 2015.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 18 February 2015

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 minimum bedrail information and define staff responsibilities for continuing risk assessment during patient transfers and discharge.

Verbatim wording from the response

“The newly devised shared policy for the safe use of bedrails will include the responsibilities of staff when transferring patients, stating when and who will provide on-going risk assessments. For patients discharged from healthcare services with an on-going need for bed rail use with formal or informal carers a minimum standard of information will be provided. The local authorities have been involved to determine the most appropriate transfer of care arrangements for those patients who do not have a continued health care need.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 18 February 2015

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

Require confirmation of completed bedrail assessment and risk assessment before permitting bedrail orders through the NRS Healthcare system.

Verbatim wording from the response

“An alert on the NRS Healthcare ordering system has been put in place.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 3 · response
Published 18 February 2015

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

Bring relevant staff training up to date for bedrail use, including falls and mandatory moving-and-handling training.

Verbatim wording from the response

“Our health care professionals working within an in-patient setting are trained in the appropriate use of bed rails through the essential to role falls training. All staff working within these areas have undertaken a clinical workbook that incorporates falls training. The clinical workbook is being replaced with a continuous roll out training programme for all healthcare professionals. Currently compliance records for falls training is held locally on each ward. We are in the process of establishing how training compliance can be reported on divisionally to enable wider scrutiny.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 1 · response
Published 18 February 2015

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.6

  1. 1

    Discuss the case and its learning at the UHL Falls Group and Nursing Executive Team.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2015.
  2. 2

    Record bed-rail risk-assessment details in clinical safety metrics.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2015.
  3. 3

    Strengthen guidance defining patient mobility to improve bed-rail risk assessments.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2015.
  4. 4

    Monitor the LPT Action Plan through the Board’s Quality Assurance Committee.

    Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2015.
  5. 5

    Add falls-training compliance to the central uLearn database for systematic reporting and monitoring.

    Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2015.
  6. 6

    Share the ratified Safe Use of Bedrails policy with relevant groups and implement it in practice, with central training reporting and line-manager oversight.

    Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2015.

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

Discuss the case and its learning at the UHL Falls Group and Nursing Executive Team.

Verbatim wording from the response

“In addition, to ensure Trust-wide learning, this case will be discussed at UHL's Falls' Group which is chaired by a senior clinician and also at the next meeting of the Trust's Nursing Executive Team which is chaired by our Acting Chief Nurse.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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

Record bed-rail risk-assessment details in clinical safety metrics.

Verbatim wording from the response

“This case has been discussed at the recent CMG Health and Safety Board and it was agreed that details of bed rail risk assessments will be recorded in the metrics that we collect and which provide an indication of current concerns within the clinical setting. In particular, we will be strengthening our guidance on the meaning of patient mobility to improve the quality of our bed rail risk assessments.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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

Strengthen guidance defining patient mobility to improve bed-rail risk assessments.

Verbatim wording from the response

“This case has been discussed at the recent CMG Health and Safety Board and it was agreed that details of bed rail risk assessments will be recorded in the metrics that we collect and which provide an indication of current concerns within the clinical setting. In particular, we will be strengthening our guidance on the meaning of patient mobility to improve the quality of our bed rail risk assessments.”

Source location

2015-0058-Response-by-University-Hospitals-of-Leicester
Page 2 · response
Published 18 February 2015

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

Monitor the LPT Action Plan through the Board’s Quality Assurance Committee.

Verbatim wording from the response

“Please note that the scope of our response relates to adults over the age of 18 years and each concern is addressed in turn below. The LPT Action Plan that follows from our responses is at the Annex and will be monitored by Board's Quality Assurance Committee.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 1 · response
Published 18 February 2015

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

Add falls-training compliance to the central uLearn database for systematic reporting and monitoring.

Verbatim wording from the response

“Our health care professionals working within an in-patient setting are trained in the appropriate use of bed rails through the essential to role falls training. All staff working within these areas have undertaken a clinical workbook that incorporates falls training. The clinical workbook is being replaced with a continuous roll out training programme for all healthcare professionals. Currently compliance records for falls training is held locally on each ward. We are in the process of establishing how training compliance can be reported on divisionally to enable wider scrutiny.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 1 · response
Published 18 February 2015

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

Share the ratified Safe Use of Bedrails policy with relevant groups and implement it in practice, with central training reporting and line-manager oversight.

Verbatim wording from the response

“For the ratified “Safe Use of Bedrails” policy to be shared across all relevant groups to be implemented in practice.”

Source location

2015-0058-Response-by-Leicestershire-Partnership-NHS-Trust
Page 5 · response
Published 18 February 2015

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