PFD report

Richard Scott-Powell · Prevention of Future Deaths report

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Issued 19 Apr 2022•Surrey

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised3

  1. Incomplete recording of vital signs
    Part of recurring concern: Unreliable recording of required observations in care and custody
  2. Failure to record the actual results of vital observations
  3. Failure to escalate NEWS2 scores and abnormal vital observations
    Part of recurring concern: Failure to reliably communicate clinically significant patient observations to medical staffPart of recurring concern: Unreliable clinical Early Warning Score systems for deteriorationPart of recurring concern: Unreliable escalation of abnormal clinical observations
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.4

  1. Action

    Train staff on the Managing a Deteriorating Patient policy after implementation.

    Stated by Holy Cross HospitalStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
  2. Action

    Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.

    Stated by Holy Cross HospitalStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
  3. Action

    Repeat clinical decision-making, patient-risk, NEWS2 and sepsis training for relevant ward staff.

    Stated by Holy Cross HospitalStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.

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

Incomplete recording of vital signs

Wider context from the report

“The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”

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 record the actual results of vital observations

Wider context from the report

“The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”

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 to escalate NEWS2 scores and abnormal vital observations

Wider context from the report

“The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”

Is this part of a recurring concern?

Yes — Failure to reliably communicate clinically significant patient observations to medical staff; Unreliable clinical Early Warning Score systems for deterioration; Unreliable escalation of abnormal clinical observations.

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

Train staff on the Managing a Deteriorating Patient policy after implementation.

Verbatim wording from the response

“• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

Source location

Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022

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

Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.

Verbatim wording from the response

“• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

Source location

Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022

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

Repeat clinical decision-making, patient-risk, NEWS2 and sepsis training for relevant ward staff.

Verbatim wording from the response

“Training (clinical decision making / patients at risk) - As part of a wider range of learning and development courses, training is provided to the ward team to facilitate clinical decision-making and escalation as follows: Clinical Decision Making (Registered Nurses), Identifying Patients at Risk (Health Care Assistants), NEWS2 (Registered Nurses and HCAs) and Sepsis (Registered Nurses and HCAs). The first two courses are in-house, with NEWS2 and Sepsis being online courses (containing standard methodologies/protocols). We are in the process of repeating training in these areas for all relevant staff.”

Source location

Response from Holy Cross Hospital
Page 1 · response
Published 27 April 2022

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 an electronic patient record system requiring measured values instead of narrative descriptions.

Verbatim wording from the response

“We are also implementing an Electronic Patient Record System in the second half of 2022/23. This will provide better standardisation over paper records, and will require measured values to be entered (rather than a narrative ‘okay’).”

Source location

Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022

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