PFD report

Anthony John Friend · Prevention of Future Deaths report

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Issued 18 Sep 2023•Worcestershire

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
8

Raised in this report

Recipients
5

Named on the report

Responses found
2

Of 5 recipients

Stated actions
12

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 remove unsuitable slings from the service user's property
    Part of recurring concern: Unsafe use and management of patient slings
  2. Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns
    Part of recurring concern: Unreliable handover of care information and responsibility
  3. Failure by incoming care providers to identify previous care providers and seek a handover
    Part of recurring concern: Unreliable handover of care information and responsibility
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.7

  1. Action

    Follow the enhanced handover process for all customers transitioning to or from Bluebird Care, not only CHC-funded customers.

    Stated by Bluebird Care (Bromsgrove & Redditch)Stated plannedThe respondent said that this action was planned when they made their response on 18 September 2023.
  2. Action

    Write to Herefordshire and Worcestershire CHC to seek clarification on handover protocols and establish best-practice standards for potential improvements.

    Stated by Bluebird Care (Bromsgrove & Redditch)Stated completedThe respondent said that this action was complete when they made their response on 18 September 2023.
  3. Action

    Proactively seek opportunities to observe care calls when taking over packages, where circumstances require, to support assessment and handover.

    Stated by Bluebird Care (Bromsgrove & Redditch)Stated completedThe respondent said that this action was complete when they made their response on 18 September 2023.

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

  1. Position

    The existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.

    Stated by Bluebird Care (Bromsgrove & Redditch)Existing 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

Failure to remove unsuitable slings from the service user's property

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

Is this part of a recurring concern?

Yes — Unsafe use and management of patient slings.

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 by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death ); 2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist; 3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.; 4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies”, but that it “was not something which we had ever done”; 5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care. In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so. ”

Is this part of a recurring concern?

Yes — Unreliable handover of care information and responsibility.

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 by incoming care providers to identify previous care providers and seek a handover

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death ); 2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist; 3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.; 4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies”, but that it “was not something which we had ever done”; 5) At no time did Divine Health Services Ltd. make any efforts to identify, contact or seek a handover about Mr. Friend from the previous care agency Bluebird Care. In his evidence to the inquest, ████████, Director of Divine Health Services Ltd., agreed that it would be “a matter of good practice” to have done so. ”

Is this part of a recurring concern?

Yes — Unreliable handover of care information and responsibility.

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 handovers between care agencies about care needs and safety concerns

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) Bluebird Care provided care at home for Mr. Friend up to 16.4.23 ( two days before the accident which led to Mr. Friend’s death ); 2) the reason Bluebird Care stopped providing care for Mr. Friend was that they had concerns about the sling which was still being used with his hoist; 3) Bluebird Care knew by 12.4.23 that Mr. Friend’s care at home after 16.4.23 would be provided by Divine Health Services Ltd.; 4) At no time did Bluebird Care try to make contact with, or provide any sort of handover to Divine Health Services Ltd. about Mr. Friend’s needs, or about any concerns they had concerning the sling. In her evidence to the inquest, ████████, Bluebird Care’s registered care manager, agreed that it was “common sense...for there to be a good handover between care agencies”, but that it “was not something which we had ever done”. ”

Is this part of a recurring concern?

Yes — Unreliable handover of care information and responsibility; Unreliable inter-agency information sharing for coordinated 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 communicate concerns about continued unsafe sling use in writing to care agencies

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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 ensure carers' participation in sling assessments

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in safety-critical care decisions; Unsafe use and management of patient slings.

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 discuss sling use with new carers

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in safety-critical care decisions; Incomplete and unreliable information about carers and care arrangements; Unsafe use and management of patient slings.

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 demonstrate safer sling use to carers

Wider context from the report

“In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

Is this part of a recurring concern?

Yes — Unsafe use and management of patient slings.

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

Follow the enhanced handover process for all customers transitioning to or from Bluebird Care, not only CHC-funded customers.

Verbatim wording from the response

“From our perspective, this process will not be limited to handovers concerning CHC funded patients and will be followed for all customers that are transitioning to or from our care.”

Source location

Response from Bluebird Care
Page 4 · response
Published 18 September 2023

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

Write to Herefordshire and Worcestershire CHC to seek clarification on handover protocols and establish best-practice standards for potential improvements.

Verbatim wording from the response

“Whilst, as above, we do consider that in this case the handover process captured all the relevant information we had to share with the new provider, in an effort to improve this process going forward we have written to Herefordshire and Worcestershire CHC to seek guidance and clarification on the existing handover protocol for care providers when either taking on, or serving notice on, a package of care from CHC, as well as establishing best practice standards to implement any possible improvements. We are dedicated to continuing to be a high-quality care provider, and although the circumstances are unfortunate, we want to take this opportunity to work in partnership with other health care professionals to provide the best care and support to all those that we support.”

Source location

Response from Bluebird Care
Page 3 · response
Published 18 September 2023

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

Proactively seek opportunities to observe care calls when taking over packages, where circumstances require, to support assessment and handover.

Verbatim wording from the response

“5. We would also value the opportunity, should it be required, to observe a care call being carried out by an outgoing provider if we were to take over a package of care. We have proactively sought out these opportunities ourselves and have found them beneficial when circumstances require this, for example visiting a customer in hospital to make observations prior to returning home, and visiting another customer at home who had an existing homecare provider visiting daily.”

Source location

Response from Bluebird Care
Page 4 · response
Published 18 September 2023

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 a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.

Verbatim wording from the response

“We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 3 · response
Published 18 September 2023

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 a standardised letter for service leads to send when patients or others resist removal of unsafe equipment, storing copies in electronic patient records.

Verbatim wording from the response

“We have also designed a standardised template letter (a copy is attached for your information) for service leads to send to patients if our clinicians experience resistance when removing equipment from a patient’s home and these will be stored on our electronic patient record.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 18 September 2023

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 and disseminate a step-by-step focus card for identifying unsafe equipment, documenting removal warnings, and educating occupational therapy staff on its use.

Verbatim wording from the response

“As a Trust we recognise that more timely action was required about removal of older slings so we have in partnership with a range of professionals designed a focus-on-card around a step by step guide for staff when they identify unsafe equipment in a patient’s home. This is a direct impact from this serious incident. This will act as a useful reminder document that staff will have access to when visiting patients in their homes and will be a vital part of new starter’s induction packs.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 18 September 2023

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

Develop and operationalize a policy specifying timely removal of unsafe equipment from patients’ homes, with staff dissemination through team meetings and Trust-wide communications.

Verbatim wording from the response

“As a Trust we recognise that at the time of this incident we did not have a robust policy and procedure in place to support our staff in the community with regard to the removal of unsafe equipment. Since the incident we have formulated a working group to design a new policy around equipment provision and this will cover the necessary steps and procedures for our staff, around timely removal of unsafe equipment from a patient’s home. We will have this new policy signed and operational by the 1st April 2024. A key element will be sharing this new policy which will be completed at individual team meetings and via our global all staff communication emails. Whilst we are developing the new policy we have issued more immediate instructions to staff via a focus on card approach.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 18 September 2023

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 existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.

Verbatim wording from the response

“As part of this meeting, the management team reviewed the detailed care plan that had been prepared by CHC based on information provided by ourselves and provided to Divine Health Care as part of the process of finding a new care provider. Although the handover was from CHC to Divine Health Care and not directly from Bluebird Care to Divine Health Care, all of Bluebird Care’s concerns regarding the sling were very clearly documented within this detailed 14-page document. Our identity as the outgoing care provider was also included within this document. This document was shared with Divine Health Care in advance of them carrying out their assessment and agreeing to take over Mr Friend's package of care.”

Source location

Response from Bluebird Care
Page 2 · response
Published 18 September 2023

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.5

  1. 1

    Conduct a lessons-learned review of the case and identify potential improvements to care processes.

    Stated by Bluebird Care (Bromsgrove & Redditch)Stated completedThe respondent said that this action was complete when they made their response on 18 September 2023.
  2. 2

    Review manual-handling and sling training to ensure it adequately supports community patients’ needs.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 September 2023.
  3. 3

    Provide patients with a contact-details leaflet at HASE initial assessment for sharing with families, care agencies, and other stakeholders.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 September 2023.
  4. 4

    Create an algorithm supporting staff decisions about suitable sling types in different situations.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 September 2023.
  5. 5

    Implement a quality-improvement record-keeping audit across HASE and occupational therapy services to monitor compliance with record-keeping requirements.

    Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 September 2023.

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 a lessons-learned review of the case and identify potential improvements to care processes.

Verbatim wording from the response

“Following the inquest, the senior management team at Bluebird Care Bromsgrove & Redditch carried out a ‘Lessons Learned’ meeting on 5 October 2023 to review Mr Friend's case in more detail. The aim of this meeting was to highlight and discuss what went well with his care, what could have gone better and also if there were any improvements to be made to any processes. This meeting provided an opportunity for us to consider the Regulation 28 report carefully.”

Source location

Response from Bluebird Care
Page 2 · response
Published 18 September 2023

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 manual-handling and sling training to ensure it adequately supports community patients’ needs.

Verbatim wording from the response

“We are also reviewing our manual handling and sling training that is provided to our staff to ensure this is adequate to support patients needs in the community. We are creating an algorithm to support staff decision making around when and what type of sling is suitable in a variety of situations. We hope to have this operational in the next 3 months. Early discussions have taken place regarding additional online training that illustrates various clinical scenarios, identifying risks and potential equipment that could be recommended.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 18 September 2023

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 patients with a contact-details leaflet at HASE initial assessment for sharing with families, care agencies, and other stakeholders.

Verbatim wording from the response

“The Trust fully recognises that there was a breakdown in communication between the external agencies involved in the care of Mr Anthony Friend. We have since requested and introduced a new leaflet (copy attached) that is given to all our patients on initial assessment with the Housing, Adaptation and Specialist Equipment service (HASE). This leaflet has our contact details on. Any family can then easily and accessibly share these details with care agencies if required. This leaflet can also be used by other stakeholders including our GP colleagues when they refer patients to our service.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 3 · response
Published 18 September 2023

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 an algorithm supporting staff decisions about suitable sling types in different situations.

Verbatim wording from the response

“We are also reviewing our manual handling and sling training that is provided to our staff to ensure this is adequate to support patients needs in the community. We are creating an algorithm to support staff decision making around when and what type of sling is suitable in a variety of situations. We hope to have this operational in the next 3 months. Early discussions have taken place regarding additional online training that illustrates various clinical scenarios, identifying risks and potential equipment that could be recommended.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 2 · response
Published 18 September 2023

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 quality-improvement record-keeping audit across HASE and occupational therapy services to monitor compliance with record-keeping requirements.

Verbatim wording from the response

“We also identified that as a service we need to ensure we have more robust documentation. All staff attend annual clinical records training but since this inquest we have also implemented a quality improvement record keeping audit with our HASE/OT services to ensure compliance with national, regional, professional and local record keeping requirements.”

Source location

Response from Herefordshire and Worcestershire Health and Care
Page 3 · response
Published 18 September 2023

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