PFD report

Karen THOMASON · Prevention of Future Deaths report

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Issued 2 May 2024•Cumbria

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

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 raised3

  1. Failure to notify support services of vulnerable patients' discharge
    Part of recurring concern: Failure to communicate clinically important information reliably between care servicesPart of recurring concern: Failure to ensure safe post-discharge arrangements for vulnerable patients and residentsPart of recurring concern: Unreliable hospital discharge processes
  2. Failure to distinguish mental capacity from vulnerability in safeguarding decisions
    Part of recurring concern: Failure to recognise vulnerability in safeguarding decisions
  3. Failure to complete safeguarding questions accurately and meaningfully
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

    Ensure relevant staff attend mandated safeguarding training at the appropriate level and review attendance through governance meetings.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
  2. Action

    Consider changing Symphony’s safeguarding question to distinguish new concerns from existing concerns under control.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
  3. Action

    Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.

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

  1. Position

    The Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.

    Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes 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 notify support services of vulnerable patients' discharge

Wider context from the report

“(2) There is evidence that Cumbria Housing staff had asked to be notified of the discharge of a vulnerable patient so that they could provide support to her but that they received no communications on several occasions. I am concerned that this may mean that other patients are discharged without appropriate support being alerted to their needs. ”

Is this part of a recurring concern?

Yes — Failure to communicate clinically important information reliably between care services; Failure to ensure safe post-discharge arrangements for vulnerable patients and residents; Unreliable hospital discharge processes.

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 distinguish mental capacity from vulnerability in safeguarding decisions

Wider context from the report

“(3)The evidence I received places an emphasis on the fact that Ms Thomason had capacity and indicated that she felt safe. It is certainly correct that this meant that there could be no question of her being held in hospital. It is also correct that her view of her situation was of relevance. However, it does not mean that obvious vulnerability or safeguarding concerns could not be addressed. Regardless of what Ms Thomason said, her vulnerability was obvious. I am concerned that the concepts of 'having capacity' and 'not being vulnerable' are being elided. ”

Is this part of a recurring concern?

Yes — Failure to recognise vulnerability in safeguarding decisions.

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 complete safeguarding questions accurately and meaningfully

Wider context from the report

“(1) There were errors in the completion of the hospital's safeguarding questions. The clinician answered 'no' to the question 'Is there a safeguarding concern?'. The clinician's evidence was that, in fact, she did have a safeguarding concern and explored it with Ms Thomason, but that she completed the electronic form in error. I am concerned that the form is regarded as a 'tick box' exercise rather than a vital safeguarding tool. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Ensure relevant staff attend mandated safeguarding training at the appropriate level and review attendance through governance meetings.

Verbatim wording from the response

“Currently our mandatory Safeguarding Adults Level 3 Training for all clinicians is completed every 3 years and stands at 80% completion across our Emergency Care Collaborative (88% for the organisation overall and 80.5% for our individual EDs). This needs to improve in order that all our staff have an understanding of vulnerability and how to recognise it and act accordingly. We also recognise that while this training is important, there needs to be some additional supplementary means of ensuring that staff are continually learning and using safeguarding best practice.”

Source location

Response from North Cumbria Integrated Care
Page 4 · response
Published 14 May 2024

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

Consider changing Symphony’s safeguarding question to distinguish new concerns from existing concerns under control.

Verbatim wording from the response

“RECOMMENDATION 1: change the symphony safeguarding question. Consider “are there any new safeguarding concerns?” “Is there an existing safeguarding concern that is under control?” Is there something new today that needs action today to deal with something different or unusual today?”

Source location

Response from North Cumbria Integrated Care
Page 3 · response
Published 14 May 2024

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

Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.

Verbatim wording from the response

“RECOMMENDATION 2: Update Symphony to include discharge discussions for all patients. Include an ask “is there anything we can do or anyone we can notify before you go home?” Explore the “discharge screen” options on symphony to include a vulnerable adult question set.”

Source location

Response from North Cumbria Integrated Care
Page 3 · response
Published 14 May 2024

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 an Emergency Department safeguarding supervision programme for adult patients, supported by the Trust Safeguarding Team.

Verbatim wording from the response

“Safeguarding supervision for staff working with children is mandated within the Intercollegiate Document. Staff working with children are offered Safeguarding Children’s supervision which is attended quarterly. Safeguarding adults supervision is not mandated or recommended as best practice. Safeguarding supervision sessions can help staff explore their own experiences as well as support colleagues to understand, change, and improve their approach collectively. The ED Team recognise that engaging with this approach for all ages of patients would ensure our staff regularly discuss this and debate patient vulnerability, options for managing them safely, improve professional understanding, provide peer to peer support through professional conversations, and potentially offer suggestions around improvements to systems and processes.”

Source location

Response from North Cumbria Integrated Care
Page 4 · response
Published 14 May 2024

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 Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.

Verbatim wording from the response

“Unfortunately, the ED Team were not made aware at any stage during Ms Thomason’s ED attendance, of any ask or requirement to notify the Housing Officer of Ms Thomason discharge or that the Housing officer had any concerns, either by the Housing Officer themselves, the Ambulance Service, or Ms Thomason. This was not conveyed verbally nor was it documented in the Ambulance records that were shared with ED on Ms Thomason’s arrival into the department.”

Source location

Response from North Cumbria Integrated Care
Page 3 · response
Published 14 May 2024

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 safeguarding response was not a box-checking error; the clinician conducted a full safety and welfare discussion.

Verbatim wording from the response

“The clinician’s statements coupled with the symphony record for this patient provides evidence that on this occasion the safeguarding of Ms Thomason was taken incredibly seriously. The ACP clinician has demonstrated that they had a full safety and welfare conversation with Ms Thomason. We do not believe the safeguarding box was checked in error on this occasion.”

Source location

Response from North Cumbria Integrated Care
Page 2 · response
Published 14 May 2024

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

A capacitous adult’s liberty and choice limited the Trust’s ability to intervene despite risky behaviours or an unsafe lifestyle.

Verbatim wording from the response

“We do recognise however that this case highlights how vulnerable adults such as Ms Thomason could be better supported and safeguarded in particular when leaving the department and even in the knowledge of them being known to support services. Notwithstanding that even if people have what we regard as risky behaviours or unsafe lifestyles they do have the capacity and choice (freedom of liberty) to do as they wish.”

Source location

Response from North Cumbria Integrated Care
Page 3 · response
Published 14 May 2024

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.2

  1. 1

    Consider developing future routine-enquiry and domestic-abuse training, ensure relevant staff attendance and learning, and consider sharing it with Emergency Department clinicians.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
  2. 2

    Re-launch public messaging in the Emergency Department encouraging patients to report vulnerability, feeling unsafe, or concerns about leaving.

    Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing support from relevant services meant the treating team identified no new safeguarding concerns or need for further vulnerability measures.

    Stated by North Cumbria Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Consider developing future routine-enquiry and domestic-abuse training, ensure relevant staff attendance and learning, and consider sharing it with Emergency Department clinicians.

Verbatim wording from the response

“• Trust Safeguarding Team to consider the development of future routine enquiry/domestic abuse training for the Trust (761 staff trained to date), and ensure attendance and learning for relevant staff. Consider how this can be best shared with ED clinicians.”

Source location

Response from North Cumbria Integrated Care
Page 4 · response
Published 14 May 2024

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

Re-launch public messaging in the Emergency Department encouraging patients to report vulnerability, feeling unsafe, or concerns about leaving.

Verbatim wording from the response

“RECOMMENDATION 3: Re-launch our public messaging within the ED and promoting and encouraging patients to let us know if they feel vulnerable, feel unsafe, don’t feel safe to leave.”

Source location

Response from North Cumbria Integrated Care
Page 3 · response
Published 14 May 2024

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 support from relevant services meant the treating team identified no new safeguarding concerns or need for further vulnerability measures.

Verbatim wording from the response

“When asked specifically if anyone cared for her at home, which is part of the safeguarding routine enquiry questions within Symphony, Ms Thomason responded “no”, but that a Housing Officer was keeping a close eye on her. Considering all of this information, the treating team felt there were no new safeguarding concerns; she was well known to all relevant services and relevant support was already in place for Ms Thomason.”

Source location

Response from North Cumbria Integrated Care
Page 2 · response
Published 14 May 2024

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