PFD report

Roger Southwick · Prevention of Future Deaths report

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Issued 16 May 2023•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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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 complete Falls Risk Assessments accurately
    Part of recurring concern: Inadequate control of falls risks
  2. Failure of investigation reports to identify and address falls-risk assessment deficiencies
  3. Failure to reassess falls risk following information about compromised mobility and unsteadiness
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

    Amend the falls-prevention policy to assess changes from a patient’s baseline mobility and support holistic patient and relative or carer assessment.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  2. Action

    Recirculate the falls proforma within the Acute Medical Unit and implement monthly ward-link-nurse audits of assessment accuracy.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  3. Action

    Create a Safer Care Assurance Panel to review moderate-harm falls incidents, root-cause analyses, missed opportunities and learning to prevent future harm.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.

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 Falls Risk Assessments accurately

Wider context from the report

“(1) There was a failure to complete the Falls Risk Assessment accurately; ”

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

Failure of investigation reports to identify and address falls-risk assessment deficiencies

Wider context from the report

“(3) The Investigation Report prepared by the Trust failed to identify and therefore did not address issues 1 and 2 above. ”

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 reassess falls risk following information about compromised mobility and unsteadiness

Wider context from the report

“(2) There was a failure to reassess the risk of falls when staff were informed by members of the deceased’s family of his significantly compromised mobility and unsteadiness on his feet; ”

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

Amend the falls-prevention policy to assess changes from a patient’s baseline mobility and support holistic patient and relative or carer assessment.

Verbatim wording from the response

“The Trust have reviewed the Falls prevention policy and have identified further improvement to the policy which will now include the assessment of the patient to include changes from their ‘baseline’ mobility, this will facilitate a holistic patient and relative/carer approach to assessing mobility and any acute changes.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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

Recirculate the falls proforma within the Acute Medical Unit and implement monthly ward-link-nurse audits of assessment accuracy.

Verbatim wording from the response

“The requirement of when and how complete a falls risk assessment is clearly described in the Trust’s Slips, and Falls Policy, which is accessible to all staff in the Trust (attached for your information). There has been a focused piece of work undertaken on the Acute Medical Unit in relation to falls risk assessment and the accuracy of this. During the inquest of Mr Southwick, the falls proforma was not completed in line with Trust policy following a fall. This proforma has been recirculated within the Acute Medical Unit team with emphasis on the importance of the accuracy of this document. As such a monthly audit has been implemented and is completed by the ward link nurse for falls. This focused piece of work has been discussed at a number of forums including:”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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

Create a Safer Care Assurance Panel to review moderate-harm falls incidents, root-cause analyses, missed opportunities and learning to prevent future harm.

Verbatim wording from the response

“• Safer Care Assurance Panel has been created to review falls and pressures ulcer incidents, which caused moderate harm. Chaired by a Deputy Director of Nursing or Head of Nursing, this forum reviews Root Causes Analyses (RCAs) to identify areas of good practice and any missed opportunities or lapses in care to ensure learning can be gained and future harms prevented.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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 twice-weekly Incident Review Group to review falls and other incidents, support timely reviews, and share immediate learning.

Verbatim wording from the response

“To provide additional oversight and learning of falls incidents the Trust now also operate a scrutiny process which comprises of the following:”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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 the Safer Care Group to develop, implement and monitor falls-prevention work, including training, audit, performance gaps and improvement plans.

Verbatim wording from the response

“• Safer Care Group –The Safer Care Group was created to lead the development, implementation and monitoring of work within the Safer Care portfolio which includes falls. The Group is chaired by one of the trusts Deputy Chief Nurses and the patient safety clinical lead. This group reports into Service Quality and Governance (SQAG) via the Patient Safety Programme Board. The group monitors performance, training and audit in relation to harm prevention across the Integrated Care Foundation Trust. It measures compliance against key targets taking responsibility for identification of gaps and develops improvement plans to address and action these. Oversight of divisional work is monitored via this group, with key update reports including a summary of training compliance, audit results, action plan updates, learning from incidents and any quality improvement work being delivered.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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 the Serious Incident Review Group with executive oversight to determine investigations, review serious harm incidents and support organisational learning.

Verbatim wording from the response

“• Serious Incident Review Group (SIRG). The Serious Incident Review Group is held on a weekly basis and supports robust governance systems relating to the declaration, investigation, completion and learning from serious incident investigations declared in line with the Serious Incident Framework (2015). SIRG has replaced the current Executive Scrutiny Panel and reports into the Service, Quality Assurance and Governance Group (SQAG). SIRG has Executive oversight and receives and reviews all incidents where a patient(s) is suspected to have come to significant harm, or where a never event is suspected; determine the agreed level/type of investigation to be completed and where relevant, to agree external reporting to commissioning and regulatory bodies.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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

    Develop a Trust-wide falls-prevention action plan informed by the Falls Risk Summit and monitor its progress through governance arrangements.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  2. 2

    Establish Focus on Falls Week as an annual falls-prevention event.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  3. 3

    Create a Trust-wide Learning Forum to share falls learning with nursing and ward leadership and deliver education to prevent future harm.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  4. 4

    Introduce a standard operating procedure and checklist for consistent care following an inpatient fall, with daily safety-huddle oversight.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.

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 Trust-wide falls-prevention action plan informed by the Falls Risk Summit and monitor its progress through governance arrangements.

Verbatim wording from the response

“In 2022 the Trust held a “Falls Risk Summit” chaired by the Executive Director of Nursing, which brought together members of the multidisciplinary team from across the organisation. The summit enabled a focused review of falls data, themes, learning and each Clinical Division supported the development of a Trust wide action plan to improve the processes, education and resources for falls prevention. Progress on this action plan is monitored via the Safer Care Group. The learning and actions taken in response to this Regulation 28 Notice will also be monitored via the Safer Care Group. The safer care Group feeds into the Patient safety Board and ultimately into the Trust Service, Quality, Assurance and Governance Group.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 1 · response
Published 17 May 2023

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

Establish Focus on Falls Week as an annual falls-prevention event.

Verbatim wording from the response

“The Trust are continually improving the falls prevention work. The Trust held a ‘Focus on Falls Week’ in September 2022 and this is now an annual event. The Trust strive to improve the experience and outcomes for patients by avoidance, where possible, of patients falling and/or reducing the number of falls occurring whilst in our care.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 4 · response
Published 17 May 2023

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

Create a Trust-wide Learning Forum to share falls learning with nursing and ward leadership and deliver education to prevent future harm.

Verbatim wording from the response

“The above scrutiny process ensures the Trust to have oversight of incidents, particularly those relating to falls, on a regular basis where learning can be shared. This also feeds into the Trust Wide Learning Forum which has been created to share learning from the panel and deliver education to prevent future harm(s) occurring. All Heads of Nursing, Matrons and Ward Managers are invited to attend. Areas focussed on to date in relation to falls prevention include:”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 3 · response
Published 17 May 2023

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

Introduce a standard operating procedure and checklist for consistent care following an inpatient fall, with daily safety-huddle oversight.

Verbatim wording from the response

“To share the learning further the Trust has introduced a separate Standard Operating Procedure (SOP) to ensure a consistent approach to care following an inpatient fall. I have attached the checklist and SOP for your information. The process will have daily oversight at the Trust Safety Huddle and will be overseen by the Divisional Heads of Nursing.”

Source location

Response from Tameside and Glossop Integrated Care NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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