PFD report

Walter Colin HORTON · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 10 Sep 2025•South Yorkshire (Eastern)

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
4

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.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to keep adequate records of falls care
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable documentation of falls and related clinical response
  2. Failure to maintain adequate discharge handover information
    Part of recurring concern: Unreliable handover of care information and responsibilityPart of recurring concern: Unreliable hospital discharge processes
  3. Failure to keep adequate wound management records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.2

  1. Action

    Operate a Trust-wide action group to improve discharge processes and report to the Patient Safety Review Group.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
  2. Action

    Operate a Trust-wide action group to drive discharge-process quality improvement and report to the Patient Safety Review Group.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    There is no record or evidence that the patient experienced a fall during admission.

    Stated by Doncaster and Bassetlaw Teaching Hospitals 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 keep adequate records of falls care

Wider context from the report

“(1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable documentation of falls and related clinical response.

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 maintain adequate discharge handover information

Wider context from the report

“(1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ”

Is this part of a recurring concern?

Yes — Unreliable handover of care information and responsibility; 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 keep adequate wound management records

Wider context from the report

“(1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 use aseptic techniques and maintain cleanliness during wound management

Wider context from the report

“(1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ”

Is this part of a recurring concern?

Yes — Failure to control infection risks during care.

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

Operate a Trust-wide action group to improve discharge processes and report to the Patient Safety Review Group.

Verbatim wording from the response

“• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 2 · response
Published 19 September 2025

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

Operate a Trust-wide action group to drive discharge-process quality improvement and report to the Patient Safety Review Group.

Verbatim wording from the response

“• A Trust-wide action group is in place to drive quality improvement in discharge processes, reporting to the Patient Safety Review Group.”

Source location

Response from Doncaster & Bassetlaw NHS Foundation Trust
Page 2 · response
Published 19 September 2025

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

There is no record or evidence that the patient experienced a fall during admission.

Verbatim wording from the response

“• There is no record or evidence of Mr Horton experiencing a fall during his admission.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 1 · response
Published 19 September 2025

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

There was no evidence of an aseptic technique breach during wound care.

Verbatim wording from the response

“• A detailed review found no evidence of breach in aseptic technique during wound care.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 2 · response
Published 19 September 2025

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 disputes that wound care involved a breach of aseptic technique, stating that review found no evidence of one.

Verbatim wording from the response

“4. Aseptic Technique and Wound Cleanliness”

Source location

Response from Doncaster & Bassetlaw NHS Foundation Trust
Page 2 · response
Published 19 September 2025

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 disputes that Mr Horton experienced a fall during admission, stating that no record or evidence of a fall exists.

Verbatim wording from the response

“1. Record Keeping - Falls”

Source location

Response from Doncaster & Bassetlaw NHS Foundation Trust
Page 1 · response
Published 19 September 2025

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.4

  1. 1

    Maintain the comprehensive skin integrity improvement plan, including regular audit, education and training.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
  2. 2

    Maintain and monitor the Trust-wide falls prevention action plan through established governance processes.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
  3. 3

    Maintain the comprehensive skin integrity improvement plan, including regular audit, education, and training.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
  4. 4

    Monitor the Trust-wide falls prevention action plan through established governance processes.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.5

  1. 1

    Responsibility for the deferred hoist assessment was assigned to community services, with the care home continuing nursing in bed.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    There was no indication that wound management contributed to sepsis, and no infection or inflammation was present at discharge.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. 3

    The pressure ulcer was pre-existing and confirmed by photographic evidence, rather than acquired during admission.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  4. 4

    Responsibility for completing the deferred hoist assessment was assigned to community services, while the care home agreed to continue nursing in bed.

    Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  5. 5

    The Trust disputes that wound management caused or contributed to sepsis, citing an existing pressure ulcer and no infection or inflammation at discharge.

    Stated by Doncaster and Bassetlaw Teaching Hospitals 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

Maintain the comprehensive skin integrity improvement plan, including regular audit, education and training.

Verbatim wording from the response

“• The Trust maintains a comprehensive skin integrity improvement plan, including regular audit, education, and training.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 2 · response
Published 19 September 2025

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 and monitor the Trust-wide falls prevention action plan through established governance processes.

Verbatim wording from the response

“• Falls prevention remains a Trust-wide safety priority, with an action plan monitored through established governance processes.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 1 · response
Published 19 September 2025

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 the comprehensive skin integrity improvement plan, including regular audit, education, and training.

Verbatim wording from the response

“• The Trust maintains a comprehensive skin integrity improvement plan, including regular audit, education, and training.”

Source location

Response from Doncaster & Bassetlaw NHS Foundation Trust
Page 2 · response
Published 19 September 2025

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 the Trust-wide falls prevention action plan through established governance processes.

Verbatim wording from the response

“• Falls prevention remains a Trust-wide safety priority, with an action plan monitored through established governance processes.”

Source location

Response from Doncaster & Bassetlaw NHS Foundation Trust
Page 1 · response
Published 19 September 2025

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

Responsibility for the deferred hoist assessment was assigned to community services, with the care home continuing nursing in bed.

Verbatim wording from the response

“• A mobility assessment was conducted; a hoist assessment was deferred to community services, with the care home agreeing to continue nursing in bed.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 1 · response
Published 19 September 2025

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

There was no indication that wound management contributed to sepsis, and no infection or inflammation was present at discharge.

Verbatim wording from the response

“• At discharge, there were no signs of infection or inflammation that could have contributed to sepsis.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 2 · response
Published 19 September 2025

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 pressure ulcer was pre-existing and confirmed by photographic evidence, rather than acquired during admission.

Verbatim wording from the response

“• Mr Horton was admitted with a pre-existing category 3 pressure ulcer, confirmed by photographic evidence.”

Source location

Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Page 1 · response
Published 19 September 2025

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

Responsibility for completing the deferred hoist assessment was assigned to community services, while the care home agreed to continue nursing in bed.

Verbatim wording from the response

“• A mobility assessment was conducted; a hoist assessment was deferred to community services, with the care home agreeing to continue nursing in bed.”

Source location

Response from Doncaster & Bassetlaw NHS Foundation Trust
Page 1 · response
Published 19 September 2025

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 disputes that wound management caused or contributed to sepsis, citing an existing pressure ulcer and no infection or inflammation at discharge.

Verbatim wording from the response

“• Mr Horton was admitted with a pre-existing category 3 pressure ulcer, confirmed by photographic evidence.”

Source location

Response from Doncaster & Bassetlaw NHS Foundation Trust
Page 1 · response
Published 19 September 2025

Open published response
Back to top

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