PFD report

RUTH PATRICIA WHITMORE · Prevention of Future Deaths report

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Issued 6 Feb 2019•Norfolk

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
5

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 raised5

  1. Failure to ensure staff designated as in charge understand their responsibilities
  2. Failure to ensure staff designated as in charge are competent for that role
  3. Failure to conduct robust and thorough incident investigations
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable formal safety-incident management 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 ensure staff designated as in charge understand their responsibilities

Wider context from the report

“(1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed to be in charge to tell them of this, without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff. ”

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 staff designated as in charge are competent for that role

Wider context from the report

“(1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed to be in charge to tell them of this, without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff. ”

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 conduct robust and thorough incident investigations

Wider context from the report

“(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient. No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events. It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable formal safety-incident management 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 ensure support is in place for staff designated as in charge

Wider context from the report

“(1) A substantive member of staff namely a grade 5 Nurse was deemed to be in charge of the ward and as a result responsible for ensuring an immediate investigation into events and a record being made in the Multi Disciplinary Record. Responsibility was not discussed at handover. At the inquest the Nurse remained unaware that she had been in charge on the night 6/7 January 2018 and had any such responsibilities. At the inquest it was felt this could be remedied by sending out emails to staff who are deemed to be in charge to tell them of this, without reference to ensuring such staff are competent to be in charge and to ensuring support is in place for such members of staff. ”

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 assure the adequacy and thoroughness of incident investigations

Wider context from the report

“(2) The initial investigation into the incident was not robust in that it only included an account of what happened from the patient. No attempts were made to ascertain who members of staff on duty were and interview them. There was no detailed analysis of events. It is not clear from the evidence whether the initial investigation was checked, reviewed and discussed and whether additional steps are in place to ensure all investigations are adequate and thorough. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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