Benjamin Clark · Prevention of Future Deaths report

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Issued 8 Jul 2021•Newcastle Upon Tyne and North Tyneside

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
4

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

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 raised4

  1. Failure to maintain observational charts for patients at risk of falls
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable documentation of falls-risk management
  2. Failure to provide observation at the level and frequency required by falls-risk assessment
    Part of recurring concern: Unreliable patient observation arrangements
  3. Failure to document daily and post-change falls-risk reassessments
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable documentation of falls-risk management

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Northumbria Healthcare NHS Foundation Trust

    Implement a ward observation chart specifying enhanced-observation levels and required frequencies.

  2. Northumbria Healthcare NHS Foundation Trust

    Use AFLOAT across all hospital sites to set observation levels, with nurses documenting reasons for departing from its recommendation.

  3. Northumbria Healthcare NHS Foundation Trust

    Create electronic alerts notifying staff when scheduled patient observations are due.

  4. Northumbria Healthcare NHS Foundation Trust

    Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.

  5. Northumbria Healthcare NHS Foundation Trust

    Conduct daily safety huddles discussing patients’ observation levels, including levels 2, 3 and 4.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Northumbria Healthcare NHS Foundation Trust

    AFLOAT determines observation levels rather than falls risk; falls risk is assessed separately under the Trust’s Falls Risk Assessment document.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Northumbria Healthcare NHS Foundation Trust

    Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. Northumbria Healthcare NHS Foundation Trust

    AFLOAT was used across both hospitals and kept on wards; evidence did not show that only one hospital used it in writing.

    Disputes 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 maintain observational charts for patients at risk of falls

Wider context from the report

“3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital. Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation. There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’s case. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable documentation of falls-risk management.

Open source report

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Failure to provide observation at the level and frequency required by falls-risk assessment

Wider context from the report

“2. Matron ████████ told me that at the time of the fall, Mr. Clark was under observation as though he was a Level 1 falls risk, despite being assessed as Level 2. Note keeping was suboptimal and there was a lack of clarity as to whether he should have been observed every 30 minutes or every 60 minutes. ”

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 document daily and post-change falls-risk reassessments

Wider context from the report

“3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital. Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation. There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’s case. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable documentation of falls-risk management.

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 document justified falls-risk reassessments during hospital transfer

Wider context from the report

“1. I heard evidence from Matron ████████ who carried out a Root Cause Analysis following Mr. Clark’s fall in hospital. She told me that despite Mr. Clark having been assessed to be a Level 3 Risk of Falls in Northumbria Specialist Emergency Care Hospital (NSECH), when he was transferred to North Tyneside General Hospital his falls risk was downgraded to Level 2 without any notes being provided to justify this reassessment. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer 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

Implement a ward observation chart specifying enhanced-observation levels and required frequencies.

Verbatim wording from the response

“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021

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

Use AFLOAT across all hospital sites to set observation levels, with nurses documenting reasons for departing from its recommendation.

Verbatim wording from the response

“The evidence provided to HM Assistant Coroner was that the AFLOAT tool was used in both hospitals and the AFLOAT assessment is kept on the ward. The AFLOAT assessment is a laminated chart, kept on all wards, which staff refer to for setting a level of observation, prior to adding onto NerveCentre. The evidence heard was that the AFLOAT tool had not been included within Mr Clark’s documentation. The evidence did not suggest that only NSECH used this tool in writing.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 3 · response
Published 9 July 2021

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

Create electronic alerts notifying staff when scheduled patient observations are due.

Verbatim wording from the response

“5. Once the documentation is placed on NerveCentre, an electronic alert will be created for observations and will alert staff via a hand held electronic device that a particular patient observation is due, ensuring a more robust regime for observations. The level of observation set by a Registered Nurse is linked to the timed alert required for care rounding.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021

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

Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.

Verbatim wording from the response

“4. Discussions are ongoing between the Matrons within NTGH in order to place the AFLOAT risk assessment and observation chart onto the electronic care record NerveCentre. The Trust can confirm that this will be done before the end of August 2021. Notwithstanding this, the documents are in use in paper form.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021

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

Conduct daily safety huddles discussing patients’ observation levels, including levels 2, 3 and 4.

Verbatim wording from the response

“2. Safety huddles which take place on a daily basis discuss observations that are set for patients and include levels 2, 3 and 4 each morning.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021

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

AFLOAT determines observation levels rather than falls risk; falls risk is assessed separately under the Trust’s Falls Risk Assessment document.

Verbatim wording from the response

“As per paragraph 4, AFLOAT is in use in paper form. The Trust can confirm that AFLOAT is used by all hospital sites within the Trust to assist with setting the level of observation. However, the final decision is at the nurse’s professional judgement. The nurse should document their rationale if they do not agree with the AFLOAT recommendation.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 3 · response
Published 9 July 2021

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 observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.

Verbatim wording from the response

“1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 2 · response
Published 9 July 2021

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

AFLOAT was used across both hospitals and kept on wards; evidence did not show that only one hospital used it in writing.

Verbatim wording from the response

“The evidence provided to HM Assistant Coroner was that the AFLOAT tool was used in both hospitals and the AFLOAT assessment is kept on the ward. The AFLOAT assessment is a laminated chart, kept on all wards, which staff refer to for setting a level of observation, prior to adding onto NerveCentre. The evidence heard was that the AFLOAT tool had not been included within Mr Clark’s documentation. The evidence did not suggest that only NSECH used this tool in writing.”

Source location

2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Page 3 · response
Published 9 July 2021

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