PFD report

Christopher Harold Brand · Prevention of Future Deaths report

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Issued 21 Apr 2016•Berkshire

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
11

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 carry out hospital observation checks correctly and ensure patient safety
    Part of recurring concern: Unreliable patient observation arrangements
  2. Delays in commencing CPR for unresponsive patients
    Part of recurring concern: Unreliable emergency response to patient collapsePart of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
  3. Failure to check that patients are alive and well when room doors are unlocked
    Part of recurring concern: Failure to conduct required welfare checks on people in distress
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.8

  1. Action

    Redesign basic life support and automated defibrillator training around realistic ward-based emergencies and required resuscitation procedures.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.
  2. Action

    Maintain ward-level knowledge and skills assessments for staff undertaking enhanced engagement and observations, with annual auditing.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.
  3. Action

    Participate in a cross-hospital CQUIN programme on best practice in managing risk through supportive observations.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.

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 carry out hospital observation checks correctly and ensure patient safety

Wider context from the report

“(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”

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

Delays in commencing CPR for unresponsive patients

Wider context from the report

“(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response to patient collapse; Unreliable resuscitation preparedness and response during cardiac arrest.

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 check that patients are alive and well when room doors are unlocked

Wider context from the report

“(1) There were periods during the observation of Mr Brand by nursing staff where the hospital observation policy was not followed correctly. In particular, one nurse gave evidence that he saw no movement from Mr Brand after 06.50 hours for some 40-50 minutes. His view of Mr Brand was obscured by poor lighting in the room, scratches to the observation window through which he was observing Mr Brand and by the position in which Mr Brand was lying under heavy bedding. He made no effort to ensure that Mr Brand was safe and well, in line with the policy. (2) When the door to Mr Brand’s room was unlocked at 07.15 on 1st July 2015, no attempt was made to check that he was alive and well in breach of the policy at the time. At least a further 10 minutes passed before it was realised that Mr Brand had not moved and checks revealed him to be unresponsive. (3) Having found Mr Brand to be unresponsive, nursing staff did not immediately begin CPR. The evidence shows that it was only the 4th member of staff attending Mr Brand who commenced CPR and there was a delay while the first staff on the scene called for more senior assistance. (4) While the failure to follow hospital policy may not have directly impacted upon the circumstances of Mr Brand’s death, the nature of the breaches are so fundamental that they could be the difference between life and death of a patient on future occasions. ”

Is this part of a recurring concern?

Yes — Failure to conduct required welfare checks on people in distress.

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

Redesign basic life support and automated defibrillator training around realistic ward-based emergencies and required resuscitation procedures.

Verbatim wording from the response

“Following Mr Brand’s death, the basic life support and automated defibrillator training course was redesigned. It now takes place on ward environments where emergencies are recreated to mimic realistic ward situations, enabling staff to better transfer their skills. It incorporates the in-hospital resuscitation procedures designed by the Resuscitation Council (UK), which in turn is accredited by NICE. Each attendee has the opportunity to perform all stages of the sequences of action required to support the collapsed patient. In keeping with the inquest findings (and recommendations of the Resuscitation Council) the requirement for immediate action and subsequent medical and managerial leadership of the resuscitation process is emphasised. Positive feedback has been obtained from course attendees. For staff expected to complete this course, there is currently 87% compliance.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 3 · response
Published 21 April 2016

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 ward-level knowledge and skills assessments for staff undertaking enhanced engagement and observations, with annual auditing.

Verbatim wording from the response

“In 2014, we introduced a Knowledge Skills Assessment (KSA) record on each ward, relating to enhanced engagement and observations. The ward managers and team leaders complete KSA records for all ward staff likely to undertake enhanced engagement and observations in their areas. Staff are expected to read the policy relating to enhanced engagement and observations, to discuss this with the ward manager or team leader and sign to say they have done so and also the ward manager/team leader has to confirm that they are happy for the member of staff to carry out observations. A yearly audit is completed and the next due in June 2016.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 2 · response
Published 21 April 2016

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

Participate in a cross-hospital CQUIN programme on best practice in managing risk through supportive observations.

Verbatim wording from the response

“We have undertaken workshops with the theme of observations, both locally and nationally and from 2014 to 2016 the hospital was involved in a CQUIN regarding the best practice in managing risk using supportive observations. This was in conjunction with the other two high secure hospitals in England.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 2 · response
Published 21 April 2016

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

Conduct unannounced out-of-hours audits of observation practice.

Verbatim wording from the response

“A number of initiatives have been undertaken focussing on observations. Following the death and the identified problems with observations, our Practice Development Nurse introduced unannounced out of normal business hours audits of observation practice. We have completed eight such audits since August 2013, the last being in April 2016. If we have identified any concerns with practice during the audits, ward managers have been asked to address these issues with the staff concerned.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 2 · response
Published 21 April 2016

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

Implement standard operating procedures requiring the nurse in charge to attend each post-confinement door opening and confirm each patient’s presence and wellbeing.

Verbatim wording from the response

“There has been no evidence of this practice being more widespread, but we introduced standard operating procedures for all nurses in charge of wards, which detail, clearly, expectations and responsibilities. One of these is that they will be present when each door is opened following the conclusion of night time confinement and the nurse in charge must see and speak to each patient. A verbal response must be received (or a deliberate conscious movement, such as a hand wave). This is to ensure the patient’s presence and check their general wellbeing.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 2 · response
Published 21 April 2016

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

Deliver mandatory clinical risk training on engagement and supportive observations to clinical staff every three years.

Verbatim wording from the response

“In September 2014, the hospital introduced a specific module within our mandatory clinical risk training regarding engagement and supportive observations. This course must be undertaken every three years by all clinical staff and currently 92% of staff are compliant with this training.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 2 · response
Published 21 April 2016

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

Deliver local and national workshops focused on observation practice.

Verbatim wording from the response

“We have undertaken workshops with the theme of observations, both locally and nationally and from 2014 to 2016 the hospital was involved in a CQUIN regarding the best practice in managing risk using supportive observations. This was in conjunction with the other two high secure hospitals in England.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 2 · response
Published 21 April 2016

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

Conduct monthly checks of observation windows on every ward and record and escalate damage.

Verbatim wording from the response

“With regards to the fabric of the ward, the hospital introduced a monthly check of the observation windows of all the rooms on each ward. These are on-going. We have documentary records of these checks and also records of when damage has been identified and reported to our Estates and Facilities. These reports are completed by staff on the ward and are reviewed by the ward manager.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 1 · response
Published 21 April 2016

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.3

  1. 1

    Commission Immediate Life Support courses for medical and nursing staff to recognise and treat rapidly deteriorating patients.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.
  2. 2

    Review all emergency admissions to general hospitals to identify conditions leading to transfer and opportunities for safer decision-making.

    Stated by West London NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 April 2016.
  3. 3

    Incorporate the National Early Warning Score into Broadmoor Hospital’s clinical policy to identify deterioration before cardiac arrest.

    Stated by West London NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    There is no evidence that noncompliance with the night-time confinement policy was more widespread than the identified incident.

    Stated by West London NHS 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

Commission Immediate Life Support courses for medical and nursing staff to recognise and treat rapidly deteriorating patients.

Verbatim wording from the response

“Further action taken by the Trust includes commissioning the Resuscitation Councils Immediate Life Support Courses at Frimley Park Hospital. This is a knowledge and skills based course where medical and nursing staff are taught to recognise and treat the rapidly deteriorating patient. Accordingly the Trusts objective is to act before a cardiorespiratory arrest situation as encountered with Mr Bland.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 3 · response
Published 21 April 2016

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

Review all emergency admissions to general hospitals to identify conditions leading to transfer and opportunities for safer decision-making.

Verbatim wording from the response

“Finally the hospital is currently undertaking a review of all its emergency admissions to General Hospitals (usually Frimley Park Hospital). Historically the Trust has and continues to undertake reviews of any serious incident. It is expected that by analysing all admissions this will further inform us of the clinical conditions that lead to emergency transfer, areas of good practice and areas of practice where the hospital may need to take action to improve safer decision making.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 3 · response
Published 21 April 2016

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

Incorporate the National Early Warning Score into Broadmoor Hospital’s clinical policy to identify deterioration before cardiac arrest.

Verbatim wording from the response

“In May 2015 the Royal College of Physicians published a working party report recommending the implantation of a National Early Warning Score (NEWS). It recommends its use as a surveillance system for all patients in hospitals for tracking their clinical condition, alerting the clinical team to any medical deterioration and triggering a timely clinical response. This is now incorporated into clinical policy at Broadmoor Hospital, the objective of which is again to identify the rapidly deteriorating patient prior to cardiorespiratory arrest.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 3 · response
Published 21 April 2016

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 evidence that noncompliance with the night-time confinement policy was more widespread than the identified incident.

Verbatim wording from the response

“The staff on the ward did not comply with the policy with respect to the conclusion of night time confinement. The nurse in charge was responsible for unlocking Mr Brand’s room door at 07.15 and did not happen. The staff involved have clearly shown candour and remorse for not complying with this policy and have been made fully aware of their responsibilities.”

Source location

2016-0154-Response-by-West-London-Mental-Health-NHS-Trust
Page 2 · response
Published 21 April 2016

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