PFD report

Ann Margaret Smith · Prevention of Future Deaths report

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Issued 5 Nov 2020•Essex

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 raised1

  1. Lack of a local protocol for managing anticoagulated patients over 65 receiving treatment-dose clexane who sustain head trauma
    Part of recurring concern: Unsafe anticoagulant management
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

    Update, approve and distribute falls policies and post-fall guides covering anticoagulation decisions, observation requirements and documented action plans.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
  2. Action

    Amend Nerve Centre to require completion of every section of neurological observations and communicate the change to ward leaders.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
  3. Action

    Make falls prevention and management training mandatory for clinical staff and incorporate the updated anticoagulation and neurological observation requirements.

    Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 December 2020.

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Lack of a local protocol for managing anticoagulated patients over 65 receiving treatment-dose clexane who sustain head trauma

Wider context from the report

“1. There was uncertainty as to how to deal with the anti-coagulation aspect of the deceased’s care in the wake of the fall. There is the lack of a local protocol (part of the Falls Policy) for the management of the sub-group of patients over 65 on anticoagulants and being given treatment dose of clexane for another clinical reason eg suspected pulmonary embolus, who sustain head trauma. ”

Is this part of a recurring concern?

Yes — Unsafe anticoagulant management.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update, approve and distribute falls policies and post-fall guides covering anticoagulation decisions, observation requirements and documented action plans.

Verbatim wording from the response

“Goal: 2. To review the current falls prevention policy and to provide an update to include the management of this sub group of patients. This will include the quick reference guides on post falls management that are included in the appendices of the policy”

Source location

Response from The Princess Alexandra Hospital NHS Trust 2
Page 4 · response
Published 21 December 2020

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Amend Nerve Centre to require completion of every section of neurological observations and communicate the change to ward leaders.

Verbatim wording from the response

“4b. For an update to be made to Nerve Centre to ensure that completion of all parts of neurological observations are mandatory”

Source location

Response from The Princess Alexandra Hospital NHS Trust 2
Page 6 · response
Published 21 December 2020

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Make falls prevention and management training mandatory for clinical staff and incorporate the updated anticoagulation and neurological observation requirements.

Verbatim wording from the response

“5. For all of the above actions to be included in mandatory falls prevention and management training for all clinical staff”

Source location

Response from The Princess Alexandra Hospital NHS Trust 2
Page 7 · response
Published 21 December 2020

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish a multidisciplinary task and finish group to review and improve anticoagulation and falls protocols.

Verbatim wording from the response

“Goal: 1. To establish a task and finish group to review the current protocols and make necessary changes”

Source location

Response from The Princess Alexandra Hospital NHS Trust 2
Page 3 · response
Published 21 December 2020

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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.3

  1. 1

    Add the falls-related improvement action to the Trust’s Strategic Quality Improvement Programme.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.
  2. 2

    Complete a formal falls-related risk assessment and seek approval for adding the risk to the Corporate Nursing Risk Register.

    Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 December 2020.
  3. 3

    Add a mandatory Datix question identifying whether a patient who has fallen is receiving anticoagulant therapy.

    Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 December 2020.

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

Add the falls-related improvement action to the Trust’s Strategic Quality Improvement Programme.

Verbatim wording from the response

“7. Trust strategic Quality Improvement Plan”

Source location

Response from The Princess Alexandra Hospital NHS Trust 2
Page 7 · response
Published 21 December 2020

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete a formal falls-related risk assessment and seek approval for adding the risk to the Corporate Nursing Risk Register.

Verbatim wording from the response

“8. Corporate risk register”

Source location

Response from The Princess Alexandra Hospital NHS Trust 2
Page 7 · response
Published 21 December 2020

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

Add a mandatory Datix question identifying whether a patient who has fallen is receiving anticoagulant therapy.

Verbatim wording from the response

“6. Mandatory question to be added to the Datix incident management system as to whether patient who has fallen is on anticoagulant therapy”

Source location

Response from The Princess Alexandra Hospital NHS Trust 2
Page 7 · response
Published 21 December 2020

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