PFD report

Margaret Ellen Postill · Prevention of Future Deaths report

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Issued 21 Dec 2017•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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

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 raised4

  1. Failure to evaluate patients after return
    Part of recurring concern: Unreliable return-from-hospital arrangements
  2. Lack of detail in decision-making documentation
  3. Poor-quality documentation of second visits
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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

    Implement a fully electronic ED documentation system to replace handwritten clinical notes.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2018.
  2. Action

    Implement 24-hour post-incident observation records and senior clinical walk-rounds, with operational and internal inspection audits.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
  3. Action

    Reinforce full, legible documentation expectations during twice-daily ED Board Rounds.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    There is no cultural acceptance of poor Emergency Department documentation; senior clinicians reinforce standards and address non-compliance.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 evaluate patients after return

Wider context from the report

“1. There did not appear to have been any evaluation of Mrs Postill after her return on 2nd May 2017. In particular no evaluation/assessment sheets were completed.(Home) ”

Is this part of a recurring concern?

Yes — Unreliable return-from-hospital arrangements.

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

Lack of detail in decision-making documentation

Wider context from the report

“2. The document held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.(TGH) ”

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

Poor-quality documentation of second visits

Wider context from the report

“2. The document held by Tameside Hospital relating to the second visit was of poor quality .In particular there was a lack of detail around the decision making.(TGH) ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 complete evaluation or assessment sheets

Wider context from the report

“1. There did not appear to have been any evaluation of Mrs Postill after her return on 2nd May 2017. In particular no evaluation/assessment sheets were completed.(Home) ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Implement a fully electronic ED documentation system to replace handwritten clinical notes.

Verbatim wording from the response

“As advised at the inquest by the Trust’s Legal Services Manager, the Trust is to implement a fully electronic documentation system within the ED at the end of November. This system will replace handwritten documentation, which will ensure that issues regarding illegibility of handwriting are eliminated, as all clinicians within the ED will be required to type their clinical notes in to the system, thereby making it easier for subsequent clinicians involved with the care to review the notes and manage the patient accordingly.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 2 · response
Published 12 February 2018

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 24-hour post-incident observation records and senior clinical walk-rounds, with operational and internal inspection audits.

Verbatim wording from the response

“• Each accident/incident record has a 24 hour observation record and an additional clinical walk round, which is undertaken by the Deputy / Home Manager to review Residents who are unwell, have fallen, have a peg or catheter etc. to make sure their care needs are effectively met on a daily basis. This is then fed back to the team at the flash meeting where any concerns are identified. This has now been implemented to ensure that the person is checked by a senior person following a fall and this process is audited by the operational team and the internal inspection team.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 8 · response
Published 12 February 2018

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

Reinforce full, legible documentation expectations during twice-daily ED Board Rounds.

Verbatim wording from the response

“Within the ED, a Board Round is held three times a day every day, to discuss issues and concerns with all clinicians on duty. At the Board Round his overseen by a Senior ED Consultant. It is reiterated during Board Round that it is the expectation of the Trust and the Senior Consultants in charge of the ED that documentation must be completed in full and to a legible standard. This message is regularly reinforced so that clinicians are fully aware of their expectations.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 1 · response
Published 12 February 2018

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

Randomly audit ED documentation and address identified issues through the compliance process.

Verbatim wording from the response

“Where it is identified that clinicians are not complying with the expected standards in terms of documentation, a formal discussion with a Senior ED Consultant or the Clinical Lead for the ED will take place, at which time the expectations are again reiterated in respect to full and clear documentation. Reflective development of this nature is included within that clinician’s Personal Development Plan in order to ensure that they have appropriately reflected upon their mistakes in order to demonstrate learning has been undertaken to avoid future reoccurrence. ED documentation is also randomly audited to ensure compliance with the Trust expectations. Where issues are identified these will be picked up and dealt with as per the above mentioned process.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 2 · response
Published 12 February 2018

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

Apply the falls prevention and post-fall protocol, including prompt assessment, incident recording, investigation and review of care plans and risk assessments.

Verbatim wording from the response

“Post Fall Protocol”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 5 · response
Published 12 February 2018

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 daily flash meetings to discuss incidents and verify completion of follow-up actions, including referrals and risk-assessment updates.

Verbatim wording from the response

“• The daily flash meeting is undertaken 7 days per week and any accidents or incidents are discussed with the team. The Home Manager/ Deputy Home Manager records this and checks any additional actions are completed, including referral to the GP and to”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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

Discuss falls trends and share learning through quarterly Quality Governance Group meetings, with follow-up actions reviewed monthly.

Verbatim wording from the response

“Falls and serious incident trends are discussed at the quarterly Quality Governance Group (QGG) and learning is shared across the group. This is the company’s bed to Board governance structure. The frequency of follow up actions from the QGG has increased to a monthly basis, following this incident, to provide clear accountability and mapping of improvements in working to reduce falls and ensure appropriate assessment and evaluation following each fall at individual home and group level.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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

Address documentation non-compliance through senior discussions and reflective learning recorded in clinicians’ Personal Development Plans.

Verbatim wording from the response

“Where it is identified that clinicians are not complying with the expected standards in terms of documentation, a formal discussion with a Senior ED Consultant or the Clinical Lead for the ED will take place, at which time the expectations are again reiterated in respect to full and clear documentation. Reflective development of this nature is included within that clinician’s Personal Development Plan in order to ensure that they have appropriately reflected upon their mistakes in order to demonstrate learning has been undertaken to avoid future reoccurrence. ED documentation is also randomly audited to ensure compliance with the Trust expectations. Where issues are identified these will be picked up and dealt with as per the above mentioned process.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 2 · response
Published 12 February 2018

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

Increase Area Director and Quality Regulation Manager scrutiny of falls assessments and evaluations during visits and inspections.

Verbatim wording from the response

“Scrutiny at area level by the Area Directors (AD) has been increased in terms of the quality of the completion of assessment and evaluation through the review of falls as part of their monthly home visit and the Quality Regulation Managers (QRM) on their internal inspection visits.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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 falls flow chart at Sunnyside Care Home to guide post-fall actions.

Verbatim wording from the response

“• The falls flow chart has been implemented at the home giving clear guidance on what actions to take following a fall within Sunnyside.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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 requirements through new-clinician induction, Grand Rounds, training sessions and clinical meetings.

Verbatim wording from the response

“All new clinicians who join the Trust receive detailed information regarding Trust Policy and Protocol, including information regarding the expectations in respect of documentation. Documentation is an issue that is also often picked up at both the Grand Round for clinicians and at Trust training sessions/clinical meetings to ensure that the message is reinforced not only in the ED Department but on a Trust wide basis.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 2 · response
Published 12 February 2018

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 sample falls risk assessments with staff to clarify assessment and post-fall evaluation requirements.

Verbatim wording from the response

“The AD attended the home on the 24 October 2017 to share the findings from the case with the team at the home and the following actions were agreed:”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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

Establish an internal falls team to review and update risk assessments, with three-monthly audits.

Verbatim wording from the response

“update the falls risk assessment, which is completed by the senior care staff. The falls risk assessments are reviewed and updated by the home's internal falls team, which comprises all the Heads of Department in the home and are subject to audit every three months. This team was set up in the home after the incident and has been effective in pulling staff together to improve knowledge, accountability and ultimately outcomes for Residents through increased awareness, diligence and good record keeping.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 8 · response
Published 12 February 2018

Open published response

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

There is no cultural acceptance of poor Emergency Department documentation; senior clinicians reinforce standards and address non-compliance.

Verbatim wording from the response

“At the inquest hearing, I understand that submissions were sought from the Trust Legal Services Manager as to the electronic system that was to be introduced within the ED department, but information regarding the ‘culture’ of poor documentation was not considered. At the time submissions were requested, it was not possible for the Trust’s Legal Services Manager to proficiently address you on matters with respect to ‘culture’ without first obtaining some further information and clarification to assist. We would assert that the Trust is aware of the importance of good record keeping and to aid and assist this is implementing the electronic data capture system in recognition of this.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 2 · response
Published 12 February 2018

Open published response

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 documentation standards, audits, corrective processes and electronic documentation address the concerns, making a Regulation 28 report unnecessary.

Verbatim wording from the response

“Where it is identified that clinicians are not complying with the expected standards in terms of documentation, a formal discussion with a Senior ED Consultant or the Clinical Lead for the ED will take place, at which time the expectations are again reiterated in respect to full and clear documentation. Reflective development of this nature is included within that clinician’s Personal Development Plan in order to ensure that they have appropriately reflected upon their mistakes in order to demonstrate learning has been undertaken to avoid future reoccurrence. ED documentation is also randomly audited to ensure compliance with the Trust expectations. Where issues are identified these will be picked up and dealt with as per the above mentioned process.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 2 · response
Published 12 February 2018

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

    Maintain a clinical risk register identifying Residents with falls and care-plan audit dates, with monthly review and agreed risk-reduction actions.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
  2. 2

    Run monthly clinical-quality reviews and quality calls with Area Directors and Managing Directors across the homes.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
  3. 3

    Include daily accident and incident review in quality assurance and the Home Manager’s diary, including review of falls risk assessments.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
  4. 4

    Continue reviewing NICE falls guidance and implementing technologies that support Residents.

    Stated by Hc-One LimitedStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2018.
  5. 5

    Conduct home-level three-monthly falls audits, monthly clinical-indicator reviews and care-plan checks for high-risk Residents.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
  6. 6

    Use Datix reporting and analysis to identify falls trends, target preventive action and monitor outcomes.

    Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.

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

Maintain a clinical risk register identifying Residents with falls and care-plan audit dates, with monthly review and agreed risk-reduction actions.

Verbatim wording from the response

“• A clinical risk register has been implemented and shared with the operational team, which identifies any Residents with falls and the date of the last care plan audit. This is reviewed monthly and key actions agreed to reduce further risk by the Home Manager and also Area Quality Directors via monthly clinical review meetings.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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

Run monthly clinical-quality reviews and quality calls with Area Directors and Managing Directors across the homes.

Verbatim wording from the response

“The Clinical Quality team undertake a monthly review and follow up with the ADs and the Managing Directors on the ‘quality calls’, which have been initiated since the incident and have now become routine across the group of homes.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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

Include daily accident and incident review in quality assurance and the Home Manager’s diary, including review of falls risk assessments.

Verbatim wording from the response

“• The review of falls is part of our daily quality assurance and the Home Manager’s daily diary prompts a review daily of any accidents or incidents and this includes a review of the records completed by the care team which includes the falls risk assessment.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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 reviewing NICE falls guidance and implementing technologies that support Residents.

Verbatim wording from the response

“As mentioned previously, we continually review the NICE guidance in relation to falls and implement new technologies to support Residents.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 7 · response
Published 12 February 2018

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 home-level three-monthly falls audits, monthly clinical-indicator reviews and care-plan checks for high-risk Residents.

Verbatim wording from the response

“At Home level there is a three monthly falls audit, which includes details of the falls team meeting discussions and a monthly review through the Key Clinical Indicators (KCI) report, which helps identify key high risk Residents for staff at the home to follow up on and as part of the Resident of the day programme, the care plan will be checked.”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 6 · response
Published 12 February 2018

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 Datix reporting and analysis to identify falls trends, target preventive action and monitor outcomes.

Verbatim wording from the response

“Trend Analysis”

Source location

2017-0382-Response-by-Tameside-and-Glossop-NHS-Trust
Page 6 · response
Published 12 February 2018

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