PFD report

James O’Brien · Prevention of Future Deaths report

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Issued 13 Mar 2017•Inner South London

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
10

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 raised10

  1. Delays in calling an ambulance
    Part of recurring concern: Failure to call an ambulance promptly when emergency assistance is required
  2. Failure to ensure adequate staff training for emergency response
    Part of recurring concern: Inadequate staff training for emergency response
  3. Failure to ensure agency nurses read patients' care plans before starting duties
    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.7

  1. Action

    Implement an agency-nurse induction protocol requiring short-notice staff to attend early and receive policy and environmental orientation.

    Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  2. Action

    Introduce the NEWS system and train all hospital staff to use its observations-based escalation tool.

    Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  3. Action

    Arrange oxygen-therapy training for all nursing staff.

    Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.

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

  1. Position

    The existing first-aid training system is considered appropriate for psychiatric hospitals and sufficient to meet regulatory requirements.

    Stated by Cambian Adult ServicesExisting 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

Delays in calling an ambulance

Wider context from the report

“(3) There was a delay of about 6 minutes in calling the ambulance. ”

Is this part of a recurring concern?

Yes — Failure to call an ambulance promptly when emergency assistance is required.

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 adequate staff training for emergency response

Wider context from the report

“(7) There was a failure to ensure that staff were adequately trained to respond to an emergency situation. ”

Is this part of a recurring concern?

Yes — Inadequate staff training for emergency response.

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 agency nurses read patients' care plans before starting duties

Wider context from the report

“(9) The agency nurse in charge of the ward was called shortly before the shift started, was not familiar with the ward, and did not have time to read the care plans of the patients before starting his duties. ”

Is this part of a recurring concern?

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

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 attach the defibrillator appropriately

Wider context from the report

“(5) The defibrillator was not attached appropriately. ”

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

Delays in starting resuscitation

Wider context from the report

“(2) There was a delay of about 4 minutes in starting resuscitation. ”

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 ensure agency nurses are familiar with the ward before starting duties

Wider context from the report

“(9) The agency nurse in charge of the ward was called shortly before the shift started, was not familiar with the ward, and did not have time to read the care plans of the patients before starting his duties. ”

Is this part of a recurring concern?

Yes — Failure to provide adequate and accessible staff induction; Inadequate competence assurance and induction for agency staff; Unsafe reliance on agency staff for clinical 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 raise the emergency alarm

Wider context from the report

“(1) There was a failure to press the alarm. ”

Is this part of a recurring concern?

Yes — Failure of emergency alarm response; Unreliable access to emergency communication.

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 provide adequate staff induction

Wider context from the report

“(8) There was a failure to provide adequate induction to staff. ”

Is this part of a recurring concern?

Yes — Failure to provide adequate and accessible staff induction.

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 information given to the ambulance service

Wider context from the report

“(6) Inadequate information was given to the London Ambulance Service. ”

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

Delays in bringing the defibrillator

Wider context from the report

“(4) There was a delay of about 8 minutes in bringing the defibrillator. ”

Is this part of a recurring concern?

Yes — Unreliable availability and readiness of defibrillators for emergency response.

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 an agency-nurse induction protocol requiring short-notice staff to attend early and receive policy and environmental orientation.

Verbatim wording from the response

“However, notwithstanding the commitment to no longer employing agency staff on an ad hoc basis, it is impossible to say that this could “never” occur because of the obvious need to ensure appropriate staffing levels and the fact that emergencies might arise where additional staff cover is required. Accordingly, our client has developed and implemented an “agency nurse induction protocol” aimed specifically at any staff who may be booked at short notice to cover a shift. They are required to attend work one hour before the shift commences to go through an induction, and receive orientation to key policies and the environment.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 3 · response
Published 24 March 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 the NEWS system and train all hospital staff to use its observations-based escalation tool.

Verbatim wording from the response

“1. Cambian Adult Services have introduced at the hospital the NEWS system (National early warning signs for acutely unwell patients) developed recently by the Royal College of psychiatrists. This is a”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 3 · response
Published 24 March 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

Arrange oxygen-therapy training for all nursing staff.

Verbatim wording from the response

“1. First Aid Training – corporately, Cambian Adult Services have adopted a first aid training system which is rated between basic life support and intermediate life support. This is felt to be appropriate for psychiatric hospitals and the hospital has never had any concerns raised at inspections by CQC, as the regulator of the services that it provides, to suggest that that does not meet their requirements for such units. In addition, as they may have patients with physical health care needs that include the need for oxygen, our client has arranged for all nursing staff to be trained in oxygen therapy. To ensure however that practice is in accordance with best practice, our client has commissioned an external expert review of their Resuscitation Policy procedure and practices.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 2 · response
Published 24 March 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

Run twice-monthly unannounced resuscitation simulations, audit outcomes and feed learning into staff feedback and clinical governance.

Verbatim wording from the response

“4. Practice Drills – to assist in identifying any skills gaps, unannounced resuscitation simulations take place twice a month at the Cambian Churchill Hospital with the outcomes discussed in monthly clinical governance meetings. A resuscitation doll has been purchased specifically for these drills and this enables the resuscitation exercise to be as realistic as possible. Practice drills are recorded and audited. Areas of good practice and learning points are recorded and this information is fed back to the staff team who attended that particular simulation exercise. It is then further discussed in clinical governance meetings so that any themes or trends can be identified and addressed.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 3 · response
Published 24 March 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

Commission an external expert review of resuscitation policies, procedures and practices.

Verbatim wording from the response

“1. First Aid Training – corporately, Cambian Adult Services have adopted a first aid training system which is rated between basic life support and intermediate life support. This is felt to be appropriate for psychiatric hospitals and the hospital has never had any concerns raised at inspections by CQC, as the regulator of the services that it provides, to suggest that that does not meet their requirements for such units. In addition, as they may have patients with physical health care needs that include the need for oxygen, our client has arranged for all nursing staff to be trained in oxygen therapy. To ensure however that practice is in accordance with best practice, our client has commissioned an external expert review of their Resuscitation Policy procedure and practices.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 2 · response
Published 24 March 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

Establish local emergency-response and alarm protocols covering escalation, responder responsibilities and radio use.

Verbatim wording from the response

“3. Responding to Emergencies – all staff are required to undertake the on-line training provided by Cambian Adult Services on responding to emergencies.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 3 · response
Published 24 March 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

Review induction processes to cover record keeping, observation and emergency response, including orientation tours for unfamiliar staff.

Verbatim wording from the response

“5. Induction – the hospital had already reviewed its induction processes. This specifically includes the topics of record keeping, observation and responding to emergencies. Staff that are not familiar with the hospital are provided with a “tour” by more experienced staff when they first start work at the hospital. The hospital is committed to using its own staff and their pool of bank staff wherever possible rather than agency staff. To ensure appropriate staffing levels on any particular shift, managers are required to plan bank staff cover in advance to address planned staff absences. Since August 2016, no agency staff have been used at the hospital.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 3 · response
Published 24 March 2017

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

The existing first-aid training system is considered appropriate for psychiatric hospitals and sufficient to meet regulatory requirements.

Verbatim wording from the response

“1. First Aid Training – corporately, Cambian Adult Services have adopted a first aid training system which is rated between basic life support and intermediate life support. This is felt to be appropriate for psychiatric hospitals and the hospital has never had any concerns raised at inspections by CQC, as the regulator of the services that it provides, to suggest that that does not meet their requirements for such units. In addition, as they may have patients with physical health care needs that include the need for oxygen, our client has arranged for all nursing staff to be trained in oxygen therapy. To ensure however that practice is in accordance with best practice, our client has commissioned an external expert review of their Resuscitation Policy procedure and practices.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 2 · response
Published 24 March 2017

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

The former operator no longer controls future hospital safety steps, which fall to the successor operator.

Verbatim wording from the response

“The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 1 · response
Published 24 March 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.5

  1. 1

    Plan bank-staff cover in advance to address planned absences and maintain appropriate shift staffing levels.

    Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  2. 2

    Implement a training matrix to record classroom attendance and identify staff training gaps.

    Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  3. 3

    Include issues raised at inquests in debriefing sessions for staff after incidents.

    Stated by Cambian Adult ServicesStated plannedThe respondent said that this action was planned when they made their response on 24 March 2017.
  4. 4

    Produce weekly hospital-wide staff training-compliance reports for the Hospital Director and senior managers.

    Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  5. 5

    Aggregate staff across hospital wards at night to support emergency response.

    Stated by Cambian Adult ServicesStated completedThe respondent said that this action was complete when they made their response on 24 March 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

Plan bank-staff cover in advance to address planned absences and maintain appropriate shift staffing levels.

Verbatim wording from the response

“5. Induction – the hospital had already reviewed its induction processes. This specifically includes the topics of record keeping, observation and responding to emergencies. Staff that are not familiar with the hospital are provided with a “tour” by more experienced staff when they first start work at the hospital. The hospital is committed to using its own staff and their pool of bank staff wherever possible rather than agency staff. To ensure appropriate staffing levels on any particular shift, managers are required to plan bank staff cover in advance to address planned staff absences. Since August 2016, no agency staff have been used at the hospital.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 3 · response
Published 24 March 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 training matrix to record classroom attendance and identify staff training gaps.

Verbatim wording from the response

“2. Training Records – to ensure that staff training is up to date, our client uses a new training matrix that captures the attendance of staff at classroom based training sessions. They are therefore now able to review the training records of all staff members and identify any gaps. This supplements the database available from Cambian Adult Services’ own on-line training system known as “Achieve”.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 2 · response
Published 24 March 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

Include issues raised at inquests in debriefing sessions for staff after incidents.

Verbatim wording from the response

“2. The issues raised at the inquest (and indeed at any inquest) will form part of a debriefing session for all staff after such incidents.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 4 · response
Published 24 March 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

Produce weekly hospital-wide staff training-compliance reports for the Hospital Director and senior managers.

Verbatim wording from the response

“2. Training Records – to ensure that staff training is up to date, our client uses a new training matrix that captures the attendance of staff at classroom based training sessions. They are therefore now able to review the training records of all staff members and identify any gaps. This supplements the database available from Cambian Adult Services’ own on-line training system known as “Achieve”.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 2 · response
Published 24 March 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

Aggregate staff across hospital wards at night to support emergency response.

Verbatim wording from the response

“Further, to ensure a prompt staff response, staff are aggregated across all wards at the hospital at night to assist with responding to emergencies.”

Source location

2017-0082-Response-by-Cambian-Group-PLC
Page 3 · response
Published 24 March 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