PFD report

Mr. Brian David BUTTON · Prevention of Future Deaths report

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Issued 19 Feb 2021•Brighton and Hove

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
18

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. Failure to maintain socially distanced bed spacing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Position

    Removing beds to increase spacing would create greater patient and staff risks through reduced capacity, emergency-department crowding and delayed admission.

    Stated by University Hospitals Sussex 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 maintain socially distanced bed spacing

Wider context from the report

“(1) That on 29th October 2020 Catharine James Ward at The Royal Sussex county Hospital in Brighton contained 13 beds. These beds are not socially distanced. A patient safety review confirms this. Mr. Button contracted COVID-19 pneumonia on Catharine James Ward. Whilst patients on the ward now have to wear masks (on a respiratory ward!) and there is much more regular and faster testing the beds are still not socially distanced. In October there were 13 beds in the ward. As at today’s date (12th February 2021 there are still 13 beds in the ward. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Removing beds to increase spacing would create greater patient and staff risks through reduced capacity, emergency-department crowding and delayed admission.

Verbatim wording from the response

“We have very carefully considered and discussed widely, the risks associated with hospital bed removal and taken the view that this would create an even greater risk to patients and staff. This is because insufficient in-patient bed capacity inevitably increases the numbers and duration of patients waiting for admission in ED, exposing both patients and staff to conditions of crowding, with the associated and significantly increased risk of CoVid transmission. Prolonged waits in ED are also known to increase the risk of in-hospital mortality.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Two-metre bed spacing is one recommended infection-control measure, not a mandated requirement, and cannot always be achieved in acute care.

Verbatim wording from the response

“Two metre distancing between hospital beds is one just one of a broad range of Public Health England (PHE) Infection Prevention and Control (IPC) recommended measures; it is not however a mandated requirement.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 1 · response
Published 12 March 2021

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 broad, continuously reviewed package of infection-control measures is considered sufficient instead of implementing bed spacing in isolation.

Verbatim wording from the response

“The global CoVid pandemic is devastating and our staff have worked extremely hard throughout to maintain services, mitigate risks, and care for our patients. NHS Trusts have to make very difficult decisions on a daily basis and it is entirely appropriate to take a balanced approach to the risks by incorporating all of the available guidance and recommendations available nationally and internationally, instead of implementing one recommendation such as bed spacing in isolation. Throughout the pandemic, we have responded with a range of carefully considered safety measures; we will continue to do so in the interests of patient and staff safety.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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.18

  1. 1

    Provide suitable facilities and staff training for safe PPE donning, doffing and disposal.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  2. 2

    Maintain accessible, safely stored, in-date PPE supplies for use according to manufacturer specifications.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  3. 3

    Monitor carbon dioxide continuously in the Barry Building.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  4. 4

    Limit hospital visiting to reduce infection risks.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  5. 5

    Conduct daily multidisciplinary meetings to assess patient safety, capacity, demand, patient flow and infection-control priorities.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  6. 6

    Screen in-patients for COVID-19 on admission and at specified follow-up intervals.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  7. 7

    Test all staff with lateral-flow tests twice weekly and confirm positive results by PCR within 24 hours.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  8. 8

    Provide regular Board Assurance Framework reporting on measures strengthening COVID-19 safety.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  9. 9

    Vaccinate staff and vulnerable in-patients against COVID-19 when indicated.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  10. 10

    Require staff to use appropriate PPE and maintain two-metre distancing except during close clinical or personal care.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  11. 11

    Audit staff compliance with standard hygiene requirements regularly.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  12. 12

    Improve ventilation by opening windows in clinical and non-clinical areas.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  13. 13

    Commission and complete an IPC peer review identifying good practice and areas for improvement.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  14. 14

    Require in-patients, outpatients and visitors to wear fluid-resistant surgical masks, subject to valid exceptions.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  15. 15

    Have senior clinical and professional experts review evolving Government and PHE guidance through the Clinical Advisory Group two or three times weekly.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  16. 16

    Deliver weekly staff briefings and departmental communications reinforcing COVID-19 safety measures.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  17. 17

    Hold weekly meetings with Sussex system partners for shared learning and professional challenge on COVID-19 safety.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.
  18. 18

    Increase cleaning of clinical and non-clinical areas and equipment.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 March 2021.

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

  1. 1

    Catherine James Ward has six beds and one side-room, not thirteen beds as stated in the report.

    Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 suitable facilities and staff training for safe PPE donning, doffing and disposal.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Maintain accessible, safely stored, in-date PPE supplies for use according to manufacturer specifications.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Monitor carbon dioxide continuously in the Barry Building.

Verbatim wording from the response

“9. Other essential IPC measures in place include opening windows within clinical and non-clinical areas across the Trust to improve ventilation; continuous CO₂ monitoring in the Barry Building; and increased cleaning of clinical/non-clinical areas and equipment.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Limit hospital visiting to reduce infection risks.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Conduct daily multidisciplinary meetings to assess patient safety, capacity, demand, patient flow and infection-control priorities.

Verbatim wording from the response

“Throughout the pandemic, we have adopted the NHS major incident management system and held daily multi-professional meetings led by Hospital Executives and senior clinical staff from all front line specialties; this process continuously assesses the patient safety and capacity/demand requirements on our sites as well as patient flow and infection control priorities 7 days per week.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Screen in-patients for COVID-19 on admission and at specified follow-up intervals.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Test all staff with lateral-flow tests twice weekly and confirm positive results by PCR within 24 hours.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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 regular Board Assurance Framework reporting on measures strengthening COVID-19 safety.

Verbatim wording from the response

“BSUH has a robust Board Assurance Framework, aligned to best practice, which ensures that our Board (as well as our regulators and the public) are sighted regularly on the measures taken by the trust to strengthen CoVid safety. We also have weekly meetings with our partners across the Sussex system, in the spirit of shared learning and professional challenge.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Vaccinate staff and vulnerable in-patients against COVID-19 when indicated.

Verbatim wording from the response

“RSCH was one of the first hospitals to start the CoVid vaccination programme; since then almost 95% of our staff (clinical and non-clinical) have received their first and more than 25% their second vaccine dose. We also vaccinate vulnerable in-patients whenever indicated.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Require staff to use appropriate PPE and maintain two-metre distancing except during close clinical or personal care.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Audit staff compliance with standard hygiene requirements regularly.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Improve ventilation by opening windows in clinical and non-clinical areas.

Verbatim wording from the response

“9. Other essential IPC measures in place include opening windows within clinical and non-clinical areas across the Trust to improve ventilation; continuous CO₂ monitoring in the Barry Building; and increased cleaning of clinical/non-clinical areas and equipment.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Commission and complete an IPC peer review identifying good practice and areas for improvement.

Verbatim wording from the response

“Finally, we requested an IPC peer review, which was recently undertaken by the NHSI South East Director for equality and the Regional IPC lead. This documented much good practice as well as some areas for suggested improvement.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Require in-patients, outpatients and visitors to wear fluid-resistant surgical masks, subject to valid exceptions.

Verbatim wording from the response

“We have implemented, a range of specific, evidence based, measures for reducing the risks that arise from CoVid 19, always in line with PHE guidance.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Have senior clinical and professional experts review evolving Government and PHE guidance through the Clinical Advisory Group two or three times weekly.

Verbatim wording from the response

“Senior clinical and professional experts meet 2-3 times weekly, to review evolving Government and PHE guidance and to ensure that all decisions are clinically informed and led via this Clinical Advisory Group.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 2 · response
Published 12 March 2021

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

Deliver weekly staff briefings and departmental communications reinforcing COVID-19 safety measures.

Verbatim wording from the response

“Weekly Microsoft Team briefings incorporating staff Q+A input take place - either by myself or ████████. These update staff and reinforce our CoVid safety measures, which are also highlighted in departmental team meetings and through all staff communications.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Hold weekly meetings with Sussex system partners for shared learning and professional challenge on COVID-19 safety.

Verbatim wording from the response

“BSUH has a robust Board Assurance Framework, aligned to best practice, which ensures that our Board (as well as our regulators and the public) are sighted regularly on the measures taken by the trust to strengthen CoVid safety. We also have weekly meetings with our partners across the Sussex system, in the spirit of shared learning and professional challenge.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Increase cleaning of clinical and non-clinical areas and equipment.

Verbatim wording from the response

“9. Other essential IPC measures in place include opening windows within clinical and non-clinical areas across the Trust to improve ventilation; continuous CO₂ monitoring in the Barry Building; and increased cleaning of clinical/non-clinical areas and equipment.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 3 · response
Published 12 March 2021

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

Catherine James Ward has six beds and one side-room, not thirteen beds as stated in the report.

Verbatim wording from the response

“Firstly and for clarity, there are 6 beds and one side-room on Catherine James Ward, not 13 beds as mentioned in your report. Thirteen is the total number of beds in the Acute Respiratory Unit of which Catherine James Ward is one part.”

Source location

2021-0069-Response-from-Royal-Sussex-County-Hospital-Redacted
Page 1 · response
Published 12 March 2021

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