PFD report

Susan Beverley George · Prevention of Future Deaths report

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Issued 29 Feb 2016•Manchester (North)

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
11

Raised in this report

Recipients
3

Named on the report

Responses found
2

Of 3 recipients

Stated actions
16

Described in 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.

Report evidence summary

Concerns raised11

  1. Failure to involve the patient’s Primary/Associate Nurse in discharge
    Part of recurring concern: Unreliable hospital discharge processes
  2. Failure to review discharge decisions after material changes in patient presentation
    Part of recurring concern: Unreliable clinical review and authorisation of discharge decisionsPart of recurring concern: Unreliable hospital discharge processes
  3. Inadequacy of the discharge policy
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

    Develop staff briefing and guidance on accessing support, advocacy, second opinions, Triangle of Care principles and multidisciplinary-team involvement.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 February 2016.
  2. Action

    Undertake a targeted organisational development review to embed a positive ward culture and support team development.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 February 2016.
  3. Action

    Implement a robust discharge process with pre-discharge assessment, discharge-day completion, crisis information, emergency contacts, seven-day follow-up and consent-based communication.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 February 2016.

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

  1. Position

    Psychological input is available through weekly ward sessions and psychology student placements, despite no dedicated full-time inpatient clinical psychologist.

    Stated by Pennine 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 involve the patient’s Primary/Associate Nurse in discharge

Wider context from the report

“2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse. ”

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

Failure to review discharge decisions after material changes in patient presentation

Wider context from the report

“1. No review of the decision to discharge was sought or conducted when it became apparent that there had been a material change in Susan’s presentation on the 10th November. Had a review taken place then it is likely that the discharge would have been deferred or cancelled. ”

Is this part of a recurring concern?

Yes — Unreliable clinical review and authorisation of discharge decisions; 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

Inadequacy of the discharge policy

Wider context from the report

“3. The Discharge Policy was perfunctory and staff failed to follow it in any event. ”

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 nursing advocacy for patients

Wider context from the report

“7. Poor advocacy on the part of the nursing staff whose decisions appear to have been clouded by the rigidity of the medical decision to discharge. ”

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

Absence of protocol or guidance for inpatient contact with emergency services

Wider context from the report

“5. There is no protocol/guidance on what steps should be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment/management. ”

Is this part of a recurring concern?

Yes — Unsafe emergency call handling.

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

Disjointed and uncoordinated discharge processes

Wider context from the report

“2. The discharge process was disjointed, lacked co-ordination and did not involve Susan’s Primary/Associate Nurse. ”

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

Poor nursing record keeping

Wider context from the report

“4. Poor record keeping, predominantly on the part of the nursing staff. ”

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 follow the discharge policy

Wider context from the report

“3. The Discharge Policy was perfunctory and staff failed to follow it in any event. ”

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

Unprofessional staff attitudes towards patients and care provision

Wider context from the report

“6. Unprofessional staff attitudes towards patient/care provision – two qualified nurses involved in Susan’s care used inappropriate language and demonstrated negative ways of thinking during both conversations with colleagues and the police communications operator. Prevailing attitudes such as this, particularly towards vulnerable adult, puts care standards at risk. ”

Is this part of a recurring concern?

Yes — Failure to provide respectful and empathetic care to vulnerable patients.

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

Unavailability of an inpatient Clinical Psychologist service

Wider context from the report

“9. There is no inpatient Clinical Psychologist service available within Pennine Care. This is the second (possibly third) PFD Form on the same issue. The Trust maintains that this is as a result of commissioning issues. Without inpatient clinical psychology, there is a marked service gap that puts patients such as Susan at risk. ”

Is this part of a recurring concern?

Yes — Unreliable specialist mental health support in hospital 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

Staff unawareness of how to support patients seeking a second medical opinion

Wider context from the report

“8. Staff were unaware of how to support and advise patients on the issue of obtaining a second medical opinion where the patient disagrees with the first doctor’s decision (in this case, to proceed to discharge). ”

Is this part of a recurring concern?

Yes — Unreliable clinical second-opinion processes.

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 staff briefing and guidance on accessing support, advocacy, second opinions, Triangle of Care principles and multidisciplinary-team involvement.

Verbatim wording from the response

“To develop a briefing on guidelines for staff to follow on how service users can access support if they are unhappy with the decision made about their care.”

Source location

Susan-George-Response
Page 6 · response
Published 29 February 2016

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

Undertake a targeted organisational development review to embed a positive ward culture and support team development.

Verbatim wording from the response

“There have been some specific actions taken as regards the two nurses identified via the coroner. Although of course we cannot divulge the full details of this action it is appropriate to the allegations highlighted and being managed through the Trusts Conduct and Disciplinary processes and the NMC Fitness to Practice processes. In relation to the overall culture and attitudes on the ward, as previously mentioned the ward now has a substantive ward manager who has instilled a more proactive and positive culture but it is recognised that ward environments have many challenges, with difficulties cases to manage safely, staffing levels and acuity challenges and the need to have a stabilised ward team to foster a positive culture led by senior clinical leaders who are excellent role models and instil expectations”

Source location

Susan-George-Response
Page 5 · response
Published 29 February 2016

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 robust discharge process with pre-discharge assessment, discharge-day completion, crisis information, emergency contacts, seven-day follow-up and consent-based communication.

Verbatim wording from the response

“The ward has appointed a substantive Ward Manager since this case and the development of a more robust discharge process has now been implemented.”

Source location

Susan-George-Response
Page 3 · response
Published 29 February 2016

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 agreed staff protocol and guidance for responding when service users contact emergency services via 999, including risk review and safeguarding actions.

Verbatim wording from the response

“5. There is no protocol/guidance on what steps to be taken when an inpatient contacts the emergency services (e.g. police via 999). This is important as it goes to risk assessment and management.”

Source location

Susan-George-Response
Page 5 · response
Published 29 February 2016

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

Pilot a nursing shift pattern assigning the meetings nurse dedicated time to complete discharge documentation.

Verbatim wording from the response

“All relevant parties are informed of the planned discharge with the patients’ consent. This is also in line with the revised Mental Health Act Code of Practice 2015. We are also undertaking a pilot of shift pattern for nurses which means the ‘meetings’ nurse will work 08:30–10:00 in order to ensure full completion of discharge documentation by the same staff member and thus avoids this task being handed over to a nurse who may not have been involved in the discharge meeting. This is supported with the development of the Triangle of Care initiatives, in which the involvement of family members providing information regarding the patient, even if the service user does not give consent to share information, is still included in the information that informs the discharge process.”

Source location

Susan-George-Response
Page 4 · response
Published 29 February 2016

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, update and ratify the discharge protocol and guidance for similar situations through the Acute Care Forum and governance process.

Verbatim wording from the response

“The current discharge protocol will be reviewed to ensure it is still reflective of all required processes and add a note of guidance to staff should they be faced with a similar situation.”

Source location

Susan-George-Response
Page 4 · response
Published 29 February 2016

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

Fully implement monthly ward-level Standard of Record Keeping audits with supervision feedback, performance monitoring and benchmarking.

Verbatim wording from the response

“Since this case the ward has now appointed a substantive ward manager and has fully implemented the Standard of Record Keeping audit on the ward. This process includes each set of notes being audited on a monthly basis with individual results being fed back to each named nurse/qualified nurse during their supervision with any performance issues being addressed and monitored through this process. This”

Source location

Susan-George-Response
Page 4 · response
Published 29 February 2016

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

Psychological input is available through weekly ward sessions and psychology student placements, despite no dedicated full-time inpatient clinical psychologist.

Verbatim wording from the response

“PCFT acknowledges there is no dedicated Clinical Psychologist available to the inpatient unit on a full time basis. This is due in part to the level of funding available to the service.”

Source location

Susan-George-Response
Page 7 · response
Published 29 February 2016

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

A dedicated full-time inpatient clinical psychologist cannot currently be provided partly because available service funding is limited.

Verbatim wording from the response

“PCFT acknowledges there is no dedicated Clinical Psychologist available to the inpatient unit on a full time basis. This is due in part to the level of funding available to the service.”

Source location

Susan-George-Response
Page 7 · response
Published 29 February 2016

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.9

  1. 1

    Develop Triangle of Care initiatives to incorporate family information into discharge processes.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 February 2016.
  2. 2

    Progress the co-produced acute-care transformation programme, including service redesign, skills review, action planning and committed 2016/17 investment.

    Stated by NHS Heywood, Middleton and Rochdale Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 29 February 2016.
  3. 3

    Maintain weekly psychology sessions on both inpatient wards for formulation, difficult-case discussion, reflection, support and practice supervision.

    Stated by NHS Heywood, Middleton and Rochdale Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 29 February 2016.
  4. 4

    Implement a positive quote of the day display for staff and patients on Moorside ward.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 February 2016.
  5. 5

    Implement the Safe Wards initiative across adult wards, including positive handover practices and psychological understanding of difficult behaviour.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 February 2016.
  6. 6

    Appoint a substantive ward manager.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 February 2016.
  7. 7

    Reiterate nursing staff accountability for decisions and the available escalation process through ward, inpatient-service and on-call managers.

    Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 February 2016.
  8. 8

    Recognise Birch Hill wards as psychology student learning placements with regular psychology input.

    Stated by NHS Heywood, Middleton and Rochdale Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 29 February 2016.
  9. 9

    Implement written weekend handovers reviewed during Monday board rounds.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 February 2016.

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 Triangle of Care initiatives to incorporate family information into discharge processes.

Verbatim wording from the response

“All relevant parties are informed of the planned discharge with the patients’ consent. This is also in line with the revised Mental Health Act Code of Practice 2015. We are also undertaking a pilot of shift pattern for nurses which means the ‘meetings’ nurse will work 08:30–10:00 in order to ensure full completion of discharge documentation by the same staff member and thus avoids this task being handed over to a nurse who may not have been involved in the discharge meeting. This is supported with the development of the Triangle of Care initiatives, in which the involvement of family members providing information regarding the patient, even if the service user does not give consent to share information, is still included in the information that informs the discharge process.”

Source location

Susan-George-Response
Page 4 · response
Published 29 February 2016

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

Progress the co-produced acute-care transformation programme, including service redesign, skills review, action planning and committed 2016/17 investment.

Verbatim wording from the response

“In addition, since the case in question, the wards at Birch Hill are now a recognised learning placement for psychology students and benefit from regular input from this perspective. The Trust would welcome further investment in psychological input into its in-patient unit and is working with the CCG on a programme of Transformation for the whole acute care pathway that will include re-design of the service and a review of skills required with a corresponding action plan to realise the aspiration.’”

Source location

Susan-George-Response
Page 2 · response
Published 29 February 2016

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

Maintain weekly psychology sessions on both inpatient wards for formulation, difficult-case discussion, reflection, support and practice supervision.

Verbatim wording from the response

“‘To support the required response from the commissioners, the Trust would like to inform them that whilst we acknowledge there is no dedicated Clinical Psychologist available to the In-patient unit on a full time basis, and that this is due, in part, to the level of funding available to the service, a session is available on both wards on a weekly basis for the staff to utilise. These sessions are designed to discuss formulation, difficult cases, to use as reflection and support and to supervise practice. This is greatly welcomed by all staff and well engaged with at all bands.”

Source location

Susan-George-Response
Page 1 · response
Published 29 February 2016

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 positive quote of the day display for staff and patients on Moorside ward.

Verbatim wording from the response

“In addition to this and in order to promote a positive milieu on the ward Moorside are implementing a ‘positive quote of the day’ This would be displayed for both staff and patients.”

Source location

Susan-George-Response
Page 6 · response
Published 29 February 2016

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 the Safe Wards initiative across adult wards, including positive handover practices and psychological understanding of difficult behaviour.

Verbatim wording from the response

“All adult wards, including Moorside are implementing safe wards initiative. When giving handover staff should say something positive about what each patient has been doing during the shift, or draw attention to some positive quality they have, or if this is not possible something positive about the way in which staff supported the patient (positive appreciation). In addition, if any difficult or disruptive behaviour is reported, a possible psychological understanding of the patient's behaviour must be offered.”

Source location

Susan-George-Response
Page 6 · response
Published 29 February 2016

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 substantive ward manager.

Verbatim wording from the response

“The ward has appointed a substantive Ward Manager since this case and the development of a more robust discharge process has now been implemented.”

Source location

Susan-George-Response
Page 3 · response
Published 29 February 2016

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

Reiterate nursing staff accountability for decisions and the available escalation process through ward, inpatient-service and on-call managers.

Verbatim wording from the response

“Point 7 and 8 can be taken together.”

Source location

Susan-George-Response
Page 6 · response
Published 29 February 2016

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

Recognise Birch Hill wards as psychology student learning placements with regular psychology input.

Verbatim wording from the response

“In addition, since the case in question, the wards at Birch Hill are now a recognised learning placement for psychology students and benefit from regular input from this perspective. The Trust would welcome further investment in psychological input into its in-patient unit and is working with the CCG on a programme of Transformation for the whole acute care pathway that will include re-design of the service and a review of skills required with a corresponding action plan to realise the aspiration.’”

Source location

Susan-George-Response
Page 2 · response
Published 29 February 2016

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 written weekend handovers reviewed during Monday board rounds.

Verbatim wording from the response

“This process is further assured by an annual Trust wide record keeping audit and the ward has shown continued high compliance rates within this audit in the last 12 months. There is an annual Integrated Quality Matrix (IQM) conducted on each ward and as part of this matrix, documentation is scrutinised. The audit conducted in September 2015 on Moorside has shown an improvement in identifying and liaising with patients’ carers’ and also in care planning and risk management. The ward staff have also implemented a written weekend handover, which is read out in Mondays’ board round, detailing how each patient has been, any incidents and their mental state over the weekend.”

Source location

Susan-George-Response
Page 5 · response
Published 29 February 2016

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

Official responses located
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Data last updated 7 September 2026