PFD report

Paige Louise Bell · Prevention of Future Deaths report

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Issued 3 Mar 2015•Sunderland

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
8

Raised in this report

Recipients
2

Named on the report

Responses found
2

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 raised8

  1. Failure to ensure medical personnel have immediate electronic access to complete patient notes
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable access to relevant clinical records for safe care
  2. Failure to include the RIO reference on observation record front sheets
    Part of recurring concern: Unreliable RIO clinical-record functions
  3. Insufficient time for staff to complete records promptly
    Part of recurring concern: Insufficient workload capacity for timely clinical record completion
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.2

  1. Action

    Provide regular staff training reinforcing timely and detailed record keeping.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2015.
  2. Action

    Provide staff training on the revised Engagement and Observation Policy and completion of the new observation record as the policy is rolled out.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 March 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Choice and implementation of electronic patient-record systems are matters for individual NHS Trusts.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 medical personnel have immediate electronic access to complete patient notes

Wider context from the report

“The case notes were not held in one place and not all transferred with the patient. I wondered if there were any ongoing plans to allow medical personnel to have immediate access to all notes electronically rather than notes following the patient as they will contain essential information for a patient’s healthcare and treatment. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable access to relevant clinical records for safe 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 include the RIO reference on observation record front sheets

Wider context from the report

“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

Is this part of a recurring concern?

Yes — Unreliable RIO clinical-record functions.

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 time for staff to complete records promptly

Wider context from the report

“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

Is this part of a recurring concern?

Yes — Insufficient workload capacity for timely clinical record completion.

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 space for commentary in observation records

Wider context from the report

“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

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

Unavailability of relevant, up-to-date and accurate information from notes

Wider context from the report

“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

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 of observation forms to accommodate changes in observation rationale

Wider context from the report

“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

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 of observation records to clearly require completion of all parts

Wider context from the report

“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

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

Difficulties navigating records to establish event chronology and decision rationale

Wider context from the report

“Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

Is this part of a recurring concern?

Yes — Failure to reliably document the rationale for consequential decisions.

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

Provide regular staff training reinforcing timely and detailed record keeping.

Verbatim wording from the response

“With regard to the concerns about the lack of completion of the observation record, staff acknowledged at the inquest that this was not done on this occasion but they were aware that it should have been. Staff are aware that all parts of the document should be completed and this should include a rationale as to why a level of observation is changed. As discussed in ████████ evidence, the importance of record keeping has been reiterated to staff. Furthermore, ████████ confirmed that as the revised policy is rolled out across the Trust, staff will receive training on the policy which will include appropriate completion of the new observation record.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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

Provide staff training on the revised Engagement and Observation Policy and completion of the new observation record as the policy is rolled out.

Verbatim wording from the response

“With regard to the concerns about the lack of completion of the observation record, staff acknowledged at the inquest that this was not done on this occasion but they were aware that it should have been. Staff are aware that all parts of the document should be completed and this should include a rationale as to why a level of observation is changed. As discussed in ████████ evidence, the importance of record keeping has been reiterated to staff. Furthermore, ████████ confirmed that as the revised policy is rolled out across the Trust, staff will receive training on the policy which will include appropriate completion of the new observation record.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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

Choice and implementation of electronic patient-record systems are matters for individual NHS Trusts.

Verbatim wording from the response

“In addition, there are a number of versions of electronic patient record and health record systems being used in many hospitals across the UK. These systems are being used to provide accurate, up-to-date, and complete information about patients at the point of care. However, the choice and implementation of these systems is a matter for individual NHS Trusts.”

Source location

2015-0075-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2015

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

Individual NHS Trusts are responsible for developing and implementing patient observation policies appropriate to their patients.

Verbatim wording from the response

“The Code of Practice provides a legal framework for the NHS. Individual NHS Trusts are expected to develop and implement their own patient observation policies that are appropriate to the needs of their patients and in line with this statutory guidance.”

Source location

2015-0075-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2015

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 national guidance and statutory frameworks provide guidance on patient observation, with local policies expected to align with them.

Verbatim wording from the response

“You ask if there is a national policy on patient engagement and observation. NHS England is planning to update its Suicide Prevention Audit Tool for Emergency Care, in light of learning from suicides in acute care settings. This stresses the importance of engagement with the patient, the recording of observations and timeliness of mental health assessment.”

Source location

2015-0075-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2015

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

Immediate recording of every decision or action is impracticable in a busy mental health ward, so entries are made as soon as practically possible.

Verbatim wording from the response

“In respect to the stated over the presentation of written copies of RiO records, ████████ explained that this is something which was identified in the Serious Incident Review. He explained that the RiO records are used by staff electronically, and a printed version does not properly reflect how they would be seen or used by staff. In particular the date and time of a meeting or incident is recorded in addition to when the record was made. This allows the entries to be recorded chronologically in relation to the date and time of the meeting or incident. As you heard in evidence, in a very busy and demanding mental health ward”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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

Electronic RiO records and information-sharing through team meetings and handovers provide a more appropriate account than printed records alone.

Verbatim wording from the response

“In respect to the stated over the presentation of written copies of RiO records, ████████ explained that this is something which was identified in the Serious Incident Review. He explained that the RiO records are used by staff electronically, and a printed version does not properly reflect how they would be seen or used by staff. In particular the date and time of a meeting or incident is recorded in addition to when the record was made. This allows the entries to be recorded chronologically in relation to the date and time of the meeting or incident. As you heard in evidence, in a very busy and demanding mental health ward”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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 observation record’s front sheet need not include the RiO number because the patient’s name and hospital number enable electronic record retrieval.

Verbatim wording from the response

“In relation to the concerns about space on the new observation record, staff are aware that they can write in the box below if necessary. The RiO number (on our electronic patient record system) is not required on the front sheet, as unlike the continuation sheets, the front sheet has the patient's name and hospital number written on it which will enable the patient to be found on RiO.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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.4

  1. 1

    Review the Mental Health Act 1983 Code of Practice.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 March 2015.
  2. 2

    Roll out the web-based electronic incident-reporting system across the organisation.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2015.
  3. 3

    Continue considering electronic completion of observation records.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2015.
  4. 4

    Implement a revised Engagement and Observation Policy emphasizing clinical assessment and patient engagement over time-based observations.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2015.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    NICE concluded that the borderline personality disorder guideline did not need updating at present and scheduled its next review for March 2017.

    Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.
  2. 2

    The primary concern concerned clinicians’ observation-level decisions, not ambiguity or contradictions in the Engagement and Observation Policy.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. 3

    The Engagement and Observation Policy clearly defines observation categories and provides sufficient guidance, with final levels determined clinically for each patient.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 the Mental Health Act 1983 Code of Practice.

Verbatim wording from the response

“Further guidelines for patient observation are contained in the Mental Health Act 1983 Code of Practice. This has recently been reviewed by the Department of Health and the revised edition came into effect on 1st April 2015. Within this code is a section which advises on enhanced observation for patients in hospital wards and services.”

Source location

2015-0075-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2015

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

Roll out the web-based electronic incident-reporting system across the organisation.

Verbatim wording from the response

“In relation to observation records and incident report forms being completed electronically, as ████████ explained, this is something which the Trust has considered and will continue to do so for observation records. As you will appreciate, introducing such an electronic system is complex. In relation to electronic incident reporting, I can confirm the web based incident reporting project has commenced, with the first site reporting on 1 April 2015, a potential for Hopewood Park to report electronically in June 2015, and the full organisation reporting electronic incidents by October 2015. It is worthy to note that this project has been planned for a number of years, and pre-project planning commenced in July 2014.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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 considering electronic completion of observation records.

Verbatim wording from the response

“In relation to observation records and incident report forms being completed electronically, as ████████ explained, this is something which the Trust has considered and will continue to do so for observation records. As you will appreciate, introducing such an electronic system is complex. In relation to electronic incident reporting, I can confirm the web based incident reporting project has commenced, with the first site reporting on 1 April 2015, a potential for Hopewood Park to report electronically in June 2015, and the full organisation reporting electronic incidents by October 2015. It is worthy to note that this project has been planned for a number of years, and pre-project planning commenced in July 2014.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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 revised Engagement and Observation Policy emphasizing clinical assessment and patient engagement over time-based observations.

Verbatim wording from the response

“As set out in the evidence of ████████ the Trust has already invested a significant amount of time and resource into developing the new Engagement and Observation Policy. This has included consultation amongst internal senior clinical staff, obtaining external expertise from national leading figures, looking carefully at the approach of other Trusts and considering available research into the usefulness of the NICE observation guidelines.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 1 · response
Published 3 March 2015

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

NICE concluded that the borderline personality disorder guideline did not need updating at present and scheduled its next review for March 2017.

Verbatim wording from the response

“NICE very recently reviewed this guidance. In January 2015 it concluded that the guideline did not need to be updated at present, and will next review the guideline in March 2017. NICE would be happy to answer any further questions you might have about this.”

Source location

2015-0075-Response-by-Department-of-Health
Page 2 · response
Published 3 March 2015

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 primary concern concerned clinicians’ observation-level decisions, not ambiguity or contradictions in the Engagement and Observation Policy.

Verbatim wording from the response

“While the Trust must and does accept the conclusion of the jury, I believe it is important for me to express concern that our staff present throughout the proceedings were confused by the finding that there were contradictions and ambiguities in the Observation Policy. I am informed that the primary issue of concern at the inquest related to the choice made by the relevant clinicians regarding the level of observation (which is of course a complex and challenging clinical issue for patients with Emotionally Unstable Personality Disorder) rather than the policy or its implementation.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 1 · response
Published 3 March 2015

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 Engagement and Observation Policy clearly defines observation categories and provides sufficient guidance, with final levels determined clinically for each patient.

Verbatim wording from the response

“As you heard in some detail in the evidence, the Engagement and Observation Policy clearly sets out the different categories of observation available and gives guidance as to when each of these categories should be considered. Having already invested significant time and both internal and external expertise in the revision of this policy, we do not feel that it is ambiguous. As explained at the inquest, all staff are aware of what each category requires of them. The policy sets out guidance as to when a particular level of observation should be used. However, this is no more than guidance and will need to be considered in conjunction with other factors. Ultimately, observation is a clinical decision and must be specific to the patient and the circumstances.”

Source location

2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
Page 2 · response
Published 3 March 2015

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