PFD report

Theresa Maria BUTTON · Prevention of Future Deaths report

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Issued 3 Oct 2018•West 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.

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Concerns
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised6

  1. Failure to provide prescribed hoisting and mealtime encouragement for immobile patients
  2. Failure to maintain contemporaneous nursing records of food and fluid intake
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needsPart of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to fully and effectively implement clinicians' treatment plans
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.7

  1. Action

    Update the Trust-wide shortfall response document to reflect National Quality Board safe-staffing guidance.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 March 2019.
  2. Action

    Review nursing acuity, dependency and skill mix twice yearly and review roster templates against agreed staffing plans.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 March 2019.
  3. Action

    Complete Healthcheck auditing of ward J83 nutrition and hydration documentation and care standards.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 March 2019.

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

  1. Position

    Records show regular hoisting and eating encouragement; missed hoisting often followed the patient’s refusal.

    Stated by Leeds Teaching Hospitals NHS 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 provide prescribed hoisting and mealtime encouragement for immobile patients

Wider context from the report

“2. Evidence taken at the Inquest revealed concerns that treatment plans instituted by clinicians were not always fully or effectively implemented as the staff were often too busy, particularly at night. Example included not hoisting an immobile lady out of bed onto a chair before mealtimes' and then having time to encourage her to eat. ”

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 maintain contemporaneous nursing records of food and fluid intake

Wider context from the report

“5. Contemporaneous nursing records were not always maintained; for example relating to food and fluid intake (even though nutrition was a matter of concern to the treating clinicians). ”

Is this part of a recurring concern?

Yes — Inadequate management of patients' nutrition and hydration needs; 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 fully and effectively implement clinicians' treatment plans

Wider context from the report

“2. Evidence taken at the Inquest revealed concerns that treatment plans instituted by clinicians were not always fully or effectively implemented as the staff were often too busy, particularly at night. Example included not hoisting an immobile lady out of bed onto a chair before mealtimes' and then having time to encourage her to eat. ”

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

Insufficient time for clinicians and nursing staff to explain treatment decisions to family members

Wider context from the report

“4. Insufficient time was available for the nursing staff and clinicians to explain treatment decisions to family members. An example given at the Inquest related to a decision to prescribe anti-depressant medication without the family being informed of any psychiatric involvement. ”

Is this part of a recurring concern?

Yes — Insufficient clinical workload capacity for completing important patient-care tasks.

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 ensure patients can access food in an appropriate position

Wider context from the report

“3. In this case the deceased was frail and losing weight due to not eating. A family member witnessed her food being left on her tray whilst she was laid flat and hence unable to access it with the result that it went cold and she did not eat, despite the concern relating to her nutritional condition. ”

Is this part of a recurring concern?

Yes — Inadequate provision of food for care residents.

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

Insufficient nursing staffing levels for patients with complex needs

Wider context from the report

“1. The staffing levels on Ward J83 should be reviewed, notwithstanding that they currently meet the minimum levels prescribed. The ward handles a challenging cohort of patients with liver disease who have complex needs which merit close nursing attention. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

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

Update the Trust-wide shortfall response document to reflect National Quality Board safe-staffing guidance.

Verbatim wording from the response

“This is supported by a Trust-wide document - Actions to be taken when the numbers of Nurses and Midwives per shift falls Short of the Agreed Roster Template. This document was updated earlier in 2018 to reflect and meet the National Quality Board Guidance issued in February 2018. A copy of this is attached for your information.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 3 · response
Published 1 March 2019

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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

Review nursing acuity, dependency and skill mix twice yearly and review roster templates against agreed staffing plans.

Verbatim wording from the response

“A twice yearly ward staffing review of nursing acuity and dependency levels is undertaken, which informs changes to skill-mix required and the annual updates to the roster system. Following the July 2018 establishment and skill mix review, 102 roster templates have been reviewed to ensure they align to the current staffing level plan agreed for each ward.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 1 March 2019

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

Complete Healthcheck auditing of ward J83 nutrition and hydration documentation and care standards.

Verbatim wording from the response

“The Trust has in place an audit process referred to as the ward/department Healthcheck. This provides a systematic overview of performance across a range of key areas that influence or reflect the standards of care, patient outcomes and experience of care delivered in the Trust. The data can be viewed at organisational, CSU and ward level, providing both a local and strategic picture. A copy of the completed Healthcheck for ward J83 over a 12 months period in relation to nutrition and hydration has been included with this letter. You will note that the ward results demonstrate a very high level of compliance across the key areas identified.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 5 · response
Published 1 March 2019

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

Address inconsistent nutrition and hydration record-keeping with the ward team and discuss it subsequently.

Verbatim wording from the response

“Prior to, and during the course of the inquest ████████ apologised that record keeping in relation to nutrition and hydration was not to a consistently high standard. This was addressed with the ward team at the time and has been discussed subsequently.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 4 · response
Published 1 March 2019

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 daily RAG-rated nurse staffing status reporting with escalation of unmitigated ward staffing concerns.

Verbatim wording from the response

“The Trust has in place a comprehensive escalation process to support CSUs in the event of staffing shortfalls and concerns. Further to a pilot in surgical services a RAG rated nurse staffing status report has been introduced for daily reporting. This daily oversight is provided by the Deputy Chief Nurse/Director of Nursing (Operations) with any unmitigated concerns regarding individual ward areas being escalated to the Chief Nurse. A weekly Red, Amber, Green (RAG) status report is provided to the quality meeting and the Executive Director meeting.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 3 · response
Published 1 March 2019

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

Agree three staffing levels and update ward rosters to reflect current staffing plans.

Verbatim wording from the response

“By way of background, following discussions with senior nursing staff, three levels of staffing for their areas has been agreed and staffing rosters have been submitted to reflect the current staffing level. The three levels are:”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 1 March 2019

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

Continue recruiting registered nurses, midwives and operating department practitioners to increase staffing capacity.

Verbatim wording from the response

“The Trust continues to recruit band 5 registered nurses, midwives and operating department practitioners with 304 external registered and 5 staff starting in post since April 2018. 262 of the 304 new starters commenced in post in September and October 2018, in line with university out turns. Corresponding to our recruitment figures is a reduction in both registered and unregistered nursing and midwifery vacancies across the organisation. Registered Nurse vacancies have reduced from 14% in September 2018 to 11% in October 2018, with unregistered vacancies reducing from 6% in September to 4% in October 2018.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 3 · response
Published 1 March 2019

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

Records show regular hoisting and eating encouragement; missed hoisting often followed the patient’s refusal.

Verbatim wording from the response

“Mrs Button’s nursing needs, clinical treatment and support requirements were reviewed on a daily basis. Enhanced care and intentional rounding were utilised to support Mrs Button.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 3 · response
Published 1 March 2019

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

Daily staffing reviews, safe-staffing systems and escalation processes are considered sufficient to manage staffing levels and patient-specific needs.

Verbatim wording from the response

“Staffing levels on all of our ward areas including ward J83 are reviewed daily in accordance with safe staffing requirements together with the numbers and individual needs of our patients.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 1 · response
Published 1 March 2019

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.1

  1. 1

    Share the Regulation 28 concerns with relevant staff to inform the response and safety work.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 March 2019.

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

Share the Regulation 28 concerns with relevant staff to inform the response and safety work.

Verbatim wording from the response

“I can confirm that the contents of your Regulation 28 Report have been shared with the relevant staff to enable us to provide you with a comprehensive response.”

Source location

2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 1 · response
Published 1 March 2019

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