PFD report

Ranjan Raman · Prevention of Future Deaths report

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Issued 4 Mar 2016•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
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 of nurses to read medical entries
    Part of recurring concern: Failure to review relevant clinical records before care decisions
  2. Failure of medical staff to read nursing notes
    Part of recurring concern: Failure to review relevant clinical records before care decisions
  3. Inadequate detail in incident reports
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

    Reissue the neurological-observations flowchart and direct ward leaders to apply its recording requirements after relevant unwitnessed falls.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 March 2016.
  2. Action

    Review falls documentation and align resulting improvements with patient-safety and National Falls Audit actions.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2016.
  3. Action

    Work with community partners, service users and agencies to improve falls-risk identification and pathway continuity.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2016.

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 evidence that neurological observation charts were lost from the records; that inference would be conjecture.

    Stated by Tameside and Glossop Integrated Care 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 of nurses to read medical entries

Wider context from the report

“3. There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes, and the nurses were similarly not looking at the medical entries. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions.

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 medical staff to read nursing notes

Wider context from the report

“3. There was clear evidence that the medical staff were not reading (or even looking at) the nursing notes, and the nurses were similarly not looking at the medical entries. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions.

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

Inadequate detail in incident reports

Wider context from the report

“5. Although an “Incident Report” was carried out in this case, the details available to the Coroners court were sketchy and inadequate. ”

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 retain shift hand-over sheets

Wider context from the report

“4. The hand-over sheets for each shift were being shredded by the nurses as soon as the shift was completed. Whilst it is appreciated that these cannot be placed on the record of an individual patient for reasons of confidentiality, there is no reason why they could not be filed on the wards and retained for say 14 days which would allow further reference to be made to them, should this be deemed necessary or helpful. ”

Is this part of a recurring concern?

Yes — Failure to reliably preserve handover records; Failure to retain safety-critical source records and evidence; Unreliable shift handover 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

Insufficient assessment of falls risk

Wider context from the report

“1. The evidence showed that there was no, or no sufficient, assessment of her Falls Risk. ”

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 complete or retain neurological observation charts

Wider context from the report

“2. The Neurological observation charts were either never completed or had been lost from the notes. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations; Unreliable access to relevant clinical records for safe 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

Reissue the neurological-observations flowchart and direct ward leaders to apply its recording requirements after relevant unwitnessed falls.

Verbatim wording from the response

“This indicates that the requirement for staff to undertake neurological observations as cited on the flowchart needs to be reinforced and practices monitored to ensure robust implementation of the policy standards.”

Source location

R-Mistry-Response
Page 2 · response
Published 4 March 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 falls documentation and align resulting improvements with patient-safety and National Falls Audit actions.

Verbatim wording from the response

“The records indicate that there was a falls assessment undertaken for Mrs Mistry. This was updated and reviewed several times during her admission. The Trust acknowledges the Coroner’s observations that the assessment was not sufficiently completed and the Falls assessment tool should have been updated and reviewed after Mrs Mistry was found to have been on the floor following unwitnessed events on the 14/09/15 and the 17/09/15. The Trust has initiated one to one training and support for the members of staff involved and is currently undertaking a review of the documentation as a result of the Coroner’s comments. This piece of work will also align to actions and improvement plans we have in”

Source location

R-Mistry-Response
Page 1 · response
Published 4 March 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

Work with community partners, service users and agencies to improve falls-risk identification and pathway continuity.

Verbatim wording from the response

“The Trust is also focusing on falls prevention and falls assessment in the wider context. Working with our community partners, service users and agencies to look at improving the quality and lifestyle of Tameside residents and identifying and assessing those patients who may be of particular risk in relation to falls, and agreeing how we ensure pathway continuity. This involves ensuring that information held by the GP and community services and other healthcare and social services provide an integrated view of the patient’s overall picture.”

Source location

R-Mistry-Response
Page 2 · response
Published 4 March 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

Assess wider falls-prevention measures, including osteoporosis diagnosis, injury-risk identification, reablement and exercise or mobility therapy.

Verbatim wording from the response

“We will also be looking at the wider picture in respect of earlier diagnosis of osteoporosis and identification of patients at higher risk of a bony injury from a fall, intervention and reablement and the benefit of exercise and mobility therapy meaning that people and their carers are less dependent on intensive services and less likely to need admission to hospital and to have to mobilise and be cared for in unfamiliar environments.”

Source location

R-Mistry-Response
Page 2 · response
Published 4 March 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

Provide one-to-one falls training and support to involved staff.

Verbatim wording from the response

“The records indicate that there was a falls assessment undertaken for Mrs Mistry. This was updated and reviewed several times during her admission. The Trust acknowledges the Coroner’s observations that the assessment was not sufficiently completed and the Falls assessment tool should have been updated and reviewed after Mrs Mistry was found to have been on the floor following unwitnessed events on the 14/09/15 and the 17/09/15. The Trust has initiated one to one training and support for the members of staff involved and is currently undertaking a review of the documentation as a result of the Coroner’s comments. This piece of work will also align to actions and improvement plans we have in”

Source location

R-Mistry-Response
Page 1 · response
Published 4 March 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

Consider introducing electronic archiving of ward and departmental handover sheets.

Verbatim wording from the response

“The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.”

Source location

R-Mistry-Response
Page 3 · response
Published 4 March 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 neurological observation charts were lost from the records; that inference would be conjecture.

Verbatim wording from the response

“The Trust has a Falls Policy in place which clearly includes a flowchart which relates to the requirement to assess the patient following a fall or suspected fall. The Falls Policy and flowchart indicates that neurological observations would only be appropriate where a head injury was indicated or suspected. The Trust acknowledges that in the unwitnessed event involving Mrs Mistry on the 17/02/2016 a head injury could not be ruled out. In this event the flowchart indicates the taking of neurological observations (Unwitnessed fall and was verbalising that she had banged her head). However staff did not commence the charts. There is no evidence to suggest that these charts had been lost from the records. Any inference to this would be conjecture.”

Source location

R-Mistry-Response
Page 2 · response
Published 4 March 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

Paper handover sheets are not archived because confidentiality and maintaining reliance on the current sheet create practical constraints, although electronic archiving may be introduced.

Verbatim wording from the response

“The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.”

Source location

R-Mistry-Response
Page 3 · response
Published 4 March 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

Incident investigations are proportionate to patient harm; an unwitnessed fall causing no harm requires only a concise local investigation.

Verbatim wording from the response

“The Trust has a standard in place which details the expectations regarding processes for reporting of and management of incidents within the Trust. The type, process for and level of incident investigation is proportionate to the impact and level of harm sustained by the patient. For an event where the patient is found on the floor following an unwitnessed event which was ascertained at the time to have resulted in no harm (as occurred in Mrs Mistry’s case) the investigation is undertaken is concise and local and the important aspect of the interventions are to review the falls risk assessment and to try to reduce the risk of a fall occurring again to either that individual patient or to other patients within the hospital environment.”

Source location

R-Mistry-Response
Page 3 · response
Published 4 March 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

The decision to use particular patient records is a clinical decision for individual clinical staff.

Verbatim wording from the response

“The decision to use the records of a patient is a clinical decision for individual clinical staff on a continuous basis. The Trust is not unique in that nursing and medical staff record their observations or interactions separately in the patient’s medical records. This is a matter of practicality from the user’s viewpoint and allows the medical and nursing staff to access and update their records at the same time without hindering each other but also allows the staff to contemporaneous records and to access the most recent records which fall within their main area/discipline of practice without having to find entries amongst other disciplines entries.”

Source location

R-Mistry-Response
Page 2 · response
Published 4 March 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

    Provide an online guidance document for staff conducting concise local falls investigations.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 March 2016.
  2. 2

    Progress the move toward a paper-light medical-record system to improve accessibility and continuity of information.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2016.
  3. 3

    Introduce daily multidisciplinary Board rounds to coordinate patient management and supplement shift handovers.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 March 2016.

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

Provide an online guidance document for staff conducting concise local falls investigations.

Verbatim wording from the response

“The Trust has a standard in place which details the expectations regarding processes for reporting of and management of incidents within the Trust. The type, process for and level of incident investigation is proportionate to the impact and level of harm sustained by the patient. For an event where the patient is found on the floor following an unwitnessed event which was ascertained at the time to have resulted in no harm (as occurred in Mrs Mistry’s case) the investigation is undertaken is concise and local and the important aspect of the interventions are to review the falls risk assessment and to try to reduce the risk of a fall occurring again to either that individual patient or to other patients within the hospital environment.”

Source location

R-Mistry-Response
Page 3 · response
Published 4 March 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

Progress the move toward a paper-light medical-record system to improve accessibility and continuity of information.

Verbatim wording from the response

“The Trust also has an electronic patient system and information such as test results and letters, appointments and other information can be accessed by appropriate staff and is used alongside the handwritten notes. As is happening Nationally the Trust is moving towards a paper light system of medical records which should support a more accessible and seamless approach to medical records.”

Source location

R-Mistry-Response
Page 3 · response
Published 4 March 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

Introduce daily multidisciplinary Board rounds to coordinate patient management and supplement shift handovers.

Verbatim wording from the response

“To ensure that staff maintain an overview of the patient from a medical and nursing perspective the Trust has introduced Board rounds when multidisciplinary teams including discharge case managers meet to discuss and agree the approach to the management of the patient, these are held on the Wards daily and augment information provided at shift handover. Nursing staff attend Ward Rounds with medical staff to ensure that they are aware of the patient plan and that they can ensure that patients and relatives are updated. Additionally the multidisciplinary team will hold formal and informal MDT meetings where patient have complex needs.”

Source location

R-Mistry-Response
Page 3 · response
Published 4 March 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