PFD report

Stephanie Cave · Prevention of Future Deaths report

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Issued 5 Dec 2017•South Wales Central

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
6

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. Lack of training on completing and recording enhanced observations
    Part of recurring concern: Failure to ensure staff competence in conducting and interpreting clinical observations
  2. Lack of written guidelines for completing and recording enhanced observations
  3. Inconsistent conduct of enhanced observations
    Part of recurring concern: Unreliable observation of patients in specialist mental health unitsPart 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

    Review, update, ratify, circulate and implement the Levels of Observation Policy.

    Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  2. Action

    Update the training package with instructional video and completed-documentation exemplars.

    Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
  3. Action

    Review current enhanced-observation recording documentation.

    Stated by Heatherwood Court Hospital and Ludlow Street HealthcareStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.

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 training on completing and recording enhanced observations

Wider context from the report

“(2) The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in conducting and interpreting clinical observations.

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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 written guidelines for completing and recording enhanced observations

Wider context from the report

“(2) The evidence also revealed that there was no training provided and no written guidelines on how such observations should be completed and how they should be recorded in the observation forms. ”

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

Inconsistent conduct of enhanced observations

Wider context from the report

“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep. ”

Is this part of a recurring concern?

Yes — Unreliable observation of patients in specialist mental health units; 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

Inconsistent recording of enhanced observations

Wider context from the report

“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording enhanced observations on patients detained under the Mental Health Act and at risk of self-harm and suicide when asleep. ”

Is this part of a recurring concern?

Yes — Unreliable recording of required observations in care and custody.

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 routinely record precise times of enhanced observations

Wider context from the report

“(3) The evidence also revealed that precise times of such observations were not routinely being recorded. ”

Is this part of a recurring concern?

Yes — Unreliable recording of required observations in care and custody.

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

Review, update, ratify, circulate and implement the Levels of Observation Policy.

Verbatim wording from the response

“Action: Review and update Levels of Observation Policy for ratification by the Policy Committee”

Source location

2017-0361-Response
Page 1 · response
Published 11 February 2018

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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

Update the training package with instructional video and completed-documentation exemplars.

Verbatim wording from the response

“Update current training package to include: video that clearly shows the correct way to complete the documentation; exemplar copies of completed for the finalised documentation record”

Source location

2017-0361-Response
Page 2 · response
Published 11 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

Review current enhanced-observation recording documentation.

Verbatim wording from the response

“Review current enhanced observation recording documentation”

Source location

2017-0361-Response
Page 1 · response
Published 11 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

Trial amended enhanced-observation documentation with guidance, actual observation times, staff coaching, monitoring and evaluation.

Verbatim wording from the response

“Introduce amended recording documentation for 2 week trial commencing 22 January, 2018 with provision for coaching of staff, monitoring and evaluation”

Source location

2017-0361-Response
Page 1 · response
Published 11 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

Introduce the evaluated amended enhanced-observation documentation.

Verbatim wording from the response

“Introduce evaluated amended documentation”

Source location

2017-0361-Response
Page 1 · response
Published 11 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.1

  1. 1

    Send copies of the Mental Health Act Code of Practice to Heatherwood Court’s operational manager and all Ludlow Street Healthcare units in Wales.

    Stated by Professor Chris JonesStated completedThe respondent said that this action was complete when they made their response on 11 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

Send copies of the Mental Health Act Code of Practice to Heatherwood Court’s operational manager and all Ludlow Street Healthcare units in Wales.

Verbatim wording from the response

“We have sent copies of the Code of Practice on the Mental Health Act to the Operational Manager of Heatherwood Court and all units in Wales under the management of Ludlow Street Healthcare.”

Source location

2017-0361-Response-by-Welsh-Government
Page 2 · response
Published 11 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