PFD report

Kenneth Goodwin · Prevention of Future Deaths report

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Issued 14 Oct 2022•Manchester South

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
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. Lack of specific written confirmation of falls-risk handovers between wards
    Part of recurring concern: Unreliable clinical handover processesPart of recurring concern: Unreliable healthcare patient transfer processes
  2. Inconsistent use of bed signs to identify falls risk to staff
    Part of recurring concern: Inadequate control of falls risks
  3. Delays in completing falls-risk assessments after transfer to a new ward
    Part of recurring concern: Inadequate control of falls risks
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.6

  1. Action

    Audit use of the correct patient handover document through the senior nursing team’s ward audit programme.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.
  2. Action

    Use the patient handover document in a Chief Nurse-led senior nurse walkround to reinforce communication of risks during transfers.

    Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.
  3. Action

    Remove all unauthorised patient handover documents from use.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.

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

  1. Position

    The six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.

    Stated by Stockport 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

Lack of specific written confirmation of falls-risk handovers between wards

Wider context from the report

“(1) The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes; Unreliable healthcare patient transfer 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

Inconsistent use of bed signs to identify falls risk to staff

Wider context from the report

“(3) The Inquest heard that the use of signs on beds to visually identify falls risk to the staff is not consistently used. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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

Delays in completing falls-risk assessments after transfer to a new ward

Wider context from the report

“(2) The falls risk assessment on the new ward was not completed for just over 4.5 hours. The Inquest heard that the target time for this assessment is within 6 hours, a length of time which is of concern for patients transferred at night, displaying signs of confusion, and already identified as a fall risk. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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

Audit use of the correct patient handover document through the senior nursing team’s ward audit programme.

Verbatim wording from the response

“Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

Source location

Response from Stockport NHS Foundation Trust
Page 1 · response
Published 14 October 2022

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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

Use the patient handover document in a Chief Nurse-led senior nurse walkround to reinforce communication of risks during transfers.

Verbatim wording from the response

“Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

Source location

Response from Stockport NHS Foundation Trust
Page 1 · response
Published 14 October 2022

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

Remove all unauthorised patient handover documents from use.

Verbatim wording from the response

“Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

Source location

Response from Stockport NHS Foundation Trust
Page 1 · response
Published 14 October 2022

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

Relaunch the formal patient handover document across the Trust through weekly bulletin and targeted governance-team emails.

Verbatim wording from the response

“Action – The Trust’s formal patient handover document was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. Alongside this all unauthorised handover documents have been removed from use. The use of the handover document will be audited by the senior nursing team during their ward audit programme to ensure that the correct handover document is reliably utilised. The patient handover document will also be a focus of a senior nurse walkround led by the Chief Nurse to highlight the importance of communication upon transfer of all appropriate risks.”

Source location

Response from Stockport NHS Foundation Trust
Page 1 · response
Published 14 October 2022

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

Relaunch the maple leaf sign requirement across the Trust through weekly bulletin and targeted governance-team emails.

Verbatim wording from the response

“Action – The requirement for the use of the maple leaf sign, identifying patients at risk of falls, was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. The requirement for the use of the maple leaf sign will also be added on all agency staff induction check lists to ensure that their use is explained to staff who are new to the organisation. Completion of the checklists is already included within the audit programme.”

Source location

Response from Stockport NHS Foundation Trust
Page 2 · response
Published 14 October 2022

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 maple leaf sign use to agency staff induction checklists.

Verbatim wording from the response

“Action – The requirement for the use of the maple leaf sign, identifying patients at risk of falls, was re-launched across the Trust on 15 November 2022, via the Trust’s ‘Risky Business’ weekly bulletin and also via targeted e-mails from the divisions governance teams. The requirement for the use of the maple leaf sign will also be added on all agency staff induction check lists to ensure that their use is explained to staff who are new to the organisation. Completion of the checklists is already included within the audit programme.”

Source location

Response from Stockport NHS Foundation Trust
Page 2 · response
Published 14 October 2022

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 six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.

Verbatim wording from the response

“The Trust can confirm that there is a six hour standard for risk assessments to be completed following transfer of a patient to a ward. This window allows the receiving team to admit the patient into their care, undertake”

Source location

Response from Stockport NHS Foundation Trust
Page 1 · response
Published 14 October 2022

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’s formal handover document records falls risk for all transferred patients, contrary to the concern that no specific written confirmation is required.

Verbatim wording from the response

“The Inquest heard that the transfer process between wards for patients at risk of falls does not require a specific written confirmation that a handover in relation to that risk has taken place.”

Source location

Response from Stockport NHS Foundation Trust
Page 1 · response
Published 14 October 2022

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