PFD report

Renate MARK · Prevention of Future Deaths report

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Issued 18 Mar 2025•Northumberland

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised5

  1. Misunderstanding of peripheral vision and witnessed or unwitnessed falls
    Part of recurring concern: Inadequate control of falls risks
  2. Insufficient scrutiny of witness accounts during investigations
    Part of recurring concern: Inadequate safety incident investigations
  3. Insufficient capacity for line-of-sight observation of patients at risk of falls
    Part of recurring concern: Unreliable patient observation arrangements
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.5

  1. Action

    Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.

    Stated by Northumbria Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
  2. Action

    Disseminate the revised falls policy through governance approval, staff training, communications bulletins, meetings, safety huddles, and mandatory refresher training.

    Stated by Northumbria Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
  3. Action

    Require trained Governance Leads to participate in all internal investigations and ensure witness statements receive managerial or Deputy Director sign-off before finalisation.

    Stated by Northumbria Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing acuity assessment, escalation, staffing support and monitoring processes are considered sufficient to manage changing numbers of patients at risk of falls.

    Stated by Northumbria Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Misunderstanding of peripheral vision and witnessed or unwitnessed falls

Wider context from the report

“(2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff's peripheral vision. The inquest heard that on 24 April 2024 8 patients were assessed as level 3 falls risk and 1 patient was assessed as level 4 falls risk. I am concerned as to the number of patients at risk of falls being observed in this way. I am further concerned that there is a misunderstanding of what is meant by peripheral vision and what constitutes a witnessed or unwitnessed fall. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 scrutiny of witness accounts during investigations

Wider context from the report

“(3) I am concerned there is not greater scrutiny of witness accounts as part of the Trust's investigation process in particular given the concerns raised by the deceased's family early in the investigation and the other witness accounts to provide earlier learning to prevent future events. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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 capacity for line-of-sight observation of patients at risk of falls

Wider context from the report

“(2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff's peripheral vision. The inquest heard that on 24 April 2024 8 patients were assessed as level 3 falls risk and 1 patient was assessed as level 4 falls risk. I am concerned as to the number of patients at risk of falls being observed in this way. I am further concerned that there is a misunderstanding of what is meant by peripheral vision and what constitutes a witnessed or unwitnessed fall. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation 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

Failure to establish accurate circumstances of falls during investigations

Wider context from the report

“(1) The deceased was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. Witness statements served in advance of the inquest stated the fall was witnessed. It was however eventually accepted in evidence that the fall was in fact unwitnessed. The precise circumstances of the fall could not be determined. All of the investigations undertaken by the Trust relied upon the incorrect understanding that the fall was witnessed and observations were in line with Trust falls policy, when they were not. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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 carry out falls observations in accordance with Trust falls policy

Wider context from the report

“(1) The deceased was assessed as a level 3 falls risk meaning she was to be kept under line of sight in case of falling. Witness statements served in advance of the inquest stated the fall was witnessed. It was however eventually accepted in evidence that the fall was in fact unwitnessed. The precise circumstances of the fall could not be determined. All of the investigations undertaken by the Trust relied upon the incorrect understanding that the fall was witnessed and observations were in line with Trust falls policy, when they were not. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.

Verbatim wording from the response

“In terms of a Trust wide response, the Trust's Strategic Falls Group provides on the strategic direction and actions that are to be taken by the Trust where there is a patient safety incident concerning a falls risk. As a direct response to the concerns raised by HM Coroner in the PFD Report, the group has been tasked with undertaking a review of the Trust's current Integrated Falls Prevention Policy and to provide further detail within this policy, including the inclusion of a glossary, citing definitions of wording contained in the policy, which is to include the definition of a 'witnessed' and 'unwitnessed' fall. The use of the term 'peripheral vision' will be removed from the policy and replaced by the wording 'in line of sight' so as to avoid any potential confusion by staff.”

Source location

Response from Northumbria NHS
Page 2 · response
Published 26 March 2025

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 the revised falls policy through governance approval, staff training, communications bulletins, meetings, safety huddles, and mandatory refresher training.

Verbatim wording from the response

“The finalised policy will be agreed at governance level through the Trust's governance structure and thereafter will be included in the syllabus for future falls training sessions and events that are attended by all staff Trust wide, that are responsible for handling patients. The revised Integrated Falls Prevention Policy will then be supported by a Trust wide communication strategy to ensure staff are aware of the revised policy, and the policy updates contained therein. The Policy updates will be shared Trust wide via the Trust Communications Bulletin, Heads of Department meetings, site meetings via team meetings and ward safety huddles, led by the ward matron and also at governance meetings. In addition, the revised policy will continually be referred to in mandatory annual refresher falls training that is undertaken by all staff involved with handling patients.”

Source location

Response from Northumbria NHS
Page 2 · response
Published 26 March 2025

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 trained Governance Leads to participate in all internal investigations and ensure witness statements receive managerial or Deputy Director sign-off before finalisation.

Verbatim wording from the response

“In response to this concern, the Trust Governance Leads, who are trained in investigation management, will be involved in all internal investigations in order to ensure in depth scrutiny of witness accounts following an incident. Where any deficiencies or further information / clarification is needed, this will be fed back to the investigating officer to action. The Governance Leads will also ensure that the statements collated as part of the Trust investigation, are signed off at a Managerial/Deputy Director level adding an additional layer of scrutiny before final sign off.”

Source location

Response from Northumbria NHS
Page 3 · response
Published 26 March 2025

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

Highlight maintaining line-of-sight observation and calling for assistance when required in staff training.

Verbatim wording from the response

“In relation to Mrs Mark’s fall, the nursing assistant was assigned to Pod 3 on Ward 9; there were 8 patients being nursed in single bedrooms each with an ensuite bathroom. Pod 3 has a circular design which would enable a member of staff to observe those 8 rooms, through windows and glass/open doors from the corridor. At the time of the incident, patients were asleep/settled, and it was only Mrs Mark that was awake requiring the toilet. As she required the toilet and was at risk of falling, in order to maintain her safety, the nursing assistant should have called for additional support from another colleague to ensure falls observations for the other patients were maintained whilst he attended to Mrs Mark's in the bathroom. This learning has been fed back to the Ward 9 Team and nursing assistant involved in the incident.”

Source location

Response from Northumbria NHS
Page 2 · response
Published 26 March 2025

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 Ward 9 clinical staff on accurate witnessed and unwitnessed fall terminology and its use in incident reporting and communications.

Verbatim wording from the response

“The incident concerning Mrs Mark occurred on Ward 9 of the Northumbria Specialist Emergency Care Hospital (NSECH). As an immediate response, the Trust is in the process of briefing the ward team, which includes all clinical staff, on what constitutes a 'witnessed' and 'unwitnessed' fall and the importance of ensuring that this terminology is understood and used accurately, where an incident occurs. The briefing will explain the importance of using accurate terminology is understood and used when information is disclosed to family following a falls incident, in order to allow for a robust internal Trust investigation and in circumstances”

Source location

Response from Northumbria NHS
Page 1 · response
Published 26 March 2025

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 acuity assessment, escalation, staffing support and monitoring processes are considered sufficient to manage changing numbers of patients at risk of falls.

Verbatim wording from the response

“The Trust is confident that robust processes are in place to assess acuity of care at ward level for all wards as detailed in Claire Simpson's statement dated 13 March 2025 (served with the court as part of the inquest process). The processes are led by Matrons and supported by Operational Managers and Operational Leads, who are responsive to increasing staffing in order to address any concerns raised regarding increased patient acuity. There is also a process in place supported by funding, where staff can request additional staffing i.e. Bank staff, in order to support high numbers of patients at risk of falls. Bank staff are a Trust employed workforce, who provide cover on a pre booked, as needed basis. They are trained to Trust standards for falls management.”

Source location

Response from Northumbria NHS
Page 2 · response
Published 26 March 2025

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