PFD report

Mr Brian James SHILLINGLAW · Prevention of Future Deaths report

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Issued 6 Nov 2015•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
7

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised7

  1. Failure to implement the Observation Policy as part of risk assessment and management
    Part of recurring concern: Unreliable patient observation arrangements
  2. Failure to recognise, document and communicate Deprivation of Liberty Safeguarding Order status across care settings
    Part of recurring concern: Inadequate deprivation of liberty safeguarding for people lacking capacity
  3. Failure to amend and dynamically update care plans and risk assessment documentation
    Part of recurring concern: Unreliable care-planning processes
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 implement the Observation Policy as part of risk assessment and management

Wider context from the report

“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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 recognise, document and communicate Deprivation of Liberty Safeguarding Order status across care settings

Wider context from the report

“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

Is this part of a recurring concern?

Yes — Inadequate deprivation of liberty safeguarding for people lacking capacity.

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 amend and dynamically update care plans and risk assessment documentation

Wider context from the report

“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning 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 understand and comply with risk assessment and management policies

Wider context from the report

“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

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 ensure ongoing communication between members of the multi-disciplinary team

Wider context from the report

“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

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 create care plans, risk assessments and other admission documentation

Wider context from the report

“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes; Unreliable completion of admission documentation.

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 recognise patient status and record it correctly in all paperwork

Wider context from the report

“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
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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