PFD report

John Charles Leyin · Prevention of Future Deaths report

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Issued 16 Dec 2014•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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

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 raised4

  1. Failure to disseminate Trust Policy and NPSA Guidance to all staff
    Part of recurring concern: Unreliable staff access to and understanding of safety-critical guidance
  2. Weaknesses in training systems
  3. Lack of knowledge of how many trained staff are on duty to carry out procedures
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.5

  1. Action

    Standardise dissemination of clinical guidelines so practice changes are identified centrally and cascaded to all clinical divisions.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2014.
  2. Action

    Appoint a Risk and Document Control Manager to oversee patient-safety alerts and corporate and clinical policy document control.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2014.
  3. Action

    Review the training system and identify weaknesses in nasogastric-tube competence training.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The Trust considers its training, compliance reporting and locally held records sufficient to mitigate the risk of a similar incident.

    Stated by Mid and South Essex NHS Foundation TrustExisting 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 disseminate Trust Policy and NPSA Guidance to all staff

Wider context from the report

“(1) There was a failure on the part of the Hospital to ensure the dissemination of Trust Policy and NPSA Guidance to all staff. ”

Is this part of a recurring concern?

Yes — Unreliable staff access to and understanding of safety-critical guidance.

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

Weaknesses in training systems

Wider context from the report

“(2) There were weaknesses in the training systems in place ”

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

Lack of knowledge of how many trained staff are on duty to carry out procedures

Wider context from the report

“(4) At any one time there seemed to be a lack of knowledge as to how many trained staff were on duty to carry out such procedures ”

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 check whether staff are up to date in training for carrying out procedures

Wider context from the report

“(3) Checks were not made as to whether or not staff were up to date in their training for carrying out procedures such as the insertion of a nasogastric tube. ”

Is this part of a recurring concern?

Yes — Unsafe management of Ryles and nasogastric tubes.

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

Standardise dissemination of clinical guidelines so practice changes are identified centrally and cascaded to all clinical divisions.

Verbatim wording from the response

“Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 1 · response
Published 16 December 2014

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

Appoint a Risk and Document Control Manager to oversee patient-safety alerts and corporate and clinical policy document control.

Verbatim wording from the response

“Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 1 · response
Published 16 December 2014

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 the training system and identify weaknesses in nasogastric-tube competence training.

Verbatim wording from the response

“The training system was reviewed as a result of this incident and weaknesses noted. The whole system and way the NG competence training was undertaken was strengthened.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 1 · response
Published 16 December 2014

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

Strengthen nasogastric-tube competence training through designated trainers and assessors, structured competency stages, verified records and monthly compliance reporting.

Verbatim wording from the response

“The training system was reviewed as a result of this incident and weaknesses noted. The whole system and way the NG competence training was undertaken was strengthened.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 1 · response
Published 16 December 2014

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 a system recording divisional action on patient-safety alerts and enabling prompt escalation of non-compliance.

Verbatim wording from the response

“Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 1 · response
Published 16 December 2014

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 Trust considers its training, compliance reporting and locally held records sufficient to mitigate the risk of a similar incident.

Verbatim wording from the response

“I hope that this has provided you with sufficient assurance that we have undertaken a series of actions to mitigate any risk of a similar incident happening again. Further assurance can be provided through training records that are held locally at the Trust.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 2 · response
Published 16 December 2014

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

Senior Ward Sisters are responsible for maintaining local staff training records, supported by monthly competence-compliance reports as a fallback.

Verbatim wording from the response

“It was clear following the incident that additional checks were required to ensure compliance with training. As the manager responsible for the team the onus is on the Senior Ward Sisters to maintain their records locally. However, the monthly competence compliance report is circulated to the Heads of Nursing and Senior Ward Sisters as a fall back mechanism and enables them to keep track of their staff records as well. Paper copies of the nurses’ Competency Framework are kept in staff records on the ward.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 2 · response
Published 16 December 2014

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.1

  1. 1

    Develop an action plan addressing care-delivery issues identified after the incident.

    Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 December 2014.

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 an action plan addressing care-delivery issues identified after the incident.

Verbatim wording from the response

“Following Mr Leyin’s death in July 2013 an investigation was undertaken to explore the circumstances leading to this event and evidenced specific issues relating to care delivery. An associated action plan was developed to ensure that rapid and robust work was undertaken to ensure that a similar incident did not happen again at the Trust. In addition, work was already underway to change the manner in which Trust policies and procedures were cascaded across the Trust. I understand that ████████ Nutritional Nurse Specialist provided evidence of this to the Inquest. Thereby I have outlined the detail of these actions alongside the concerns as you have raised them in the hope that these will reassure you that the Trust has already sought to address these issues.”

Source location

2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
Page 1 · response
Published 16 December 2014

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