PFD report

Mr Barry Peter Joseph Davies · Prevention of Future Deaths report

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Issued 12 Jun 2026•Manchester North

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
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
14

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 raised1

  1. Neurological observations performed too infrequently or discontinued while a second CT scan is pending
    Part of recurring concern: Failure to carry out required neurological observations
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

    Deliver reflective learning with involved medical and nursing staff and share incident learning through team safety huddles.

    Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  2. Action

    Provide mandatory head-injury and trauma-care training, including neurological-observation requirements, to relevant nursing staff.

    Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  3. Action

    Complete final review and approval of the head-injury Neurological Observation Care Plan.

    Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.

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

Neurological observations performed too infrequently or discontinued while a second CT scan is pending

Wider context from the report

“(1) The Court heard Neurological observations were not carried out on Mr Davies as frequently as they should have been before his deterioration was noted. (2) The court heard evidence a Nurse had discontinued the Neurological observations on the evening of the 22nd October whilst Mr Davies was still waiting his second CT scan. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations.

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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

Deliver reflective learning with involved medical and nursing staff and share incident learning through team safety huddles.

Verbatim wording from the response

“9. In relation to the incident, reflective learning has been undertaken with the medical and nursing staff involved. Learning from the incident has been shared more widely through team safety huddles, including neurological observations, timely escalations and referral to haematology for patients presenting with head injury.”

Source location

Response from Northern Care Alliance
Page 3 · response
Published 21 August 2026

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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

Provide mandatory head-injury and trauma-care training, including neurological-observation requirements, to relevant nursing staff.

Verbatim wording from the response

“6. All registered nursing staff in the Emergency Departments across the NCA and Urgent Care Observation Unit at The Royal Oldham Hospital (the other sites do not have an observation unit) complete mandatory training in head injury and trauma care, including neurological observation requirements in line with NICE guidance. Current compliance is 100% for head injury training and 94% for Trauma Life Support training.”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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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

Complete final review and approval of the head-injury Neurological Observation Care Plan.

Verbatim wording from the response

“1. A Neurological Observation Care Plan for head injuries has been developed to ensure early recognition of deterioration, with clear guidance on increasing observation frequency and escalation. This is currently undergoing final review and approval. This will be linked to the Head Injury Policy on the Trust Policy Hub and will be disseminated across the Trust by 30th August 2026, this will be supported by a communication plan and followed by an audit programme (described in more detail at point 13).”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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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

Submit the amended Head Injury Policy and Neurological Observations Care Plan for approval and distribute them across the Trust.

Verbatim wording from the response

“2. The Head Injury Policy and Neurological Observations Care Plan has been further updated to reflect that the decision to cease neurological observations must be an MDT approach and clearly documented in the clinical notes. The amended policy will be submitted for approval and distribution across the Trust by 30th August 2026.”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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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

Display posters across clinical areas highlighting frequent neurological observations and documentation when observations cease.

Verbatim wording from the response

“7. A poster has been developed to highlight the requirement for frequent neurological observations in patients with a head injury. It also emphasises that any decision to cease these observations must be clearly documented in accordance with Trust policy. The poster is now displayed across all clinical areas.”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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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

Disseminate the approved head-injury Neurological Observation Care Plan across the Trust with supporting communications.

Verbatim wording from the response

“1. A Neurological Observation Care Plan for head injuries has been developed to ensure early recognition of deterioration, with clear guidance on increasing observation frequency and escalation. This is currently undergoing final review and approval. This will be linked to the Head Injury Policy on the Trust Policy Hub and will be disseminated across the Trust by 30th August 2026, this will be supported by a communication plan and followed by an audit programme (described in more detail at point 13).”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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 audits of neurological observations and care plans, sharing results and learning with staff for real-time feedback.

Verbatim wording from the response

“8. A programme of monthly audits has been introduced to monitor compliance with neurological observations and care plans, enabling early identification of any gaps and further training needs. There were 11 admissions from 1st June 2026 to 8th July 2026 for post head injury care. 3 sets of notes have been sent for scanning so could not be reviewed. Of the remaining 8 patients all had a head injury proforma and neurological care plan completed and 98% of neurological observations were completed on time. None of the 11 patients required escalation. Audit results and identified learning is being shared with the team at time of audit, for real time feedback and support.”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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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

Implement the single NCA observation policy with additional neurological-observation guidance and include it in standard nursing training.

Verbatim wording from the response

“5. A single NCA NEWS policy (NCAUECCC002 – “Observation policy for Patients 16 years and over”) was launched on 10th June 2026 replacing the previous versions applicable to Salford Royal NHS Foundation Trust and Pennine Acute Hospitals NHS Trust. The new policy includes additional guidance added to Neurological Observations – section 5.3 and will be included in the standard neurological observation training for nursing staff.”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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.6

  1. 1

    Share the case through regular departmental Learning from Datix sessions.

    Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  2. 2

    Implement the Head Injury Admission Proforma covering physiological assessment, neurological assessment, neurosurgical planning, imaging advice and medication risks.

    Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  3. 3

    Continue discussions, review and stakeholder engagement on potential digital recording solutions for neurological observations in Patientrack.

    Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.
  4. 4

    Approve and circulate the UCOU Head Injury Admission SOP for adult head-injury admissions at Oldham Hospital.

    Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.
  5. 5

    Work with radiology to improve prioritisation of urgent CT scans using head-injury safety prompts.

    Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.
  6. 6

    Implement Martha’s Rule with staff training, escalation policies and routine patient questions about deterioration.

    Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.

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 case through regular departmental Learning from Datix sessions.

Verbatim wording from the response

“10. Regular “Learning from Datix” sessions are held within the department, where serious incidents are discussed openly to support continuous improvement. This case has shared within those sessions from June 2026 onwards.”

Source location

Response from Northern Care Alliance
Page 3 · response
Published 21 August 2026

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 the Head Injury Admission Proforma covering physiological assessment, neurological assessment, neurosurgical planning, imaging advice and medication risks.

Verbatim wording from the response

“3. A Head Injury Admission Proforma has been developed which supports an initial admission assessment of the patient’s physiological observations and Glasgow Coma Scale, the neurosurgical plan including CT head findings and advice received from the neurosurgical team and a medication review including the use of anticoagulants and Haemostatics.”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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 discussions, review and stakeholder engagement on potential digital recording solutions for neurological observations in Patientrack.

Verbatim wording from the response

“13. Discussions are ongoing regarding the future development of Patientrack, the electronic patient observation and monitoring system used across Bury, Rochdale and Oldham hospitals. This includes exploring potential solutions for the digital recording of neurological observations. Further review and stakeholder engagement will take place as this work progresses.”

Source location

Response from Northern Care Alliance
Page 3 · response
Published 21 August 2026

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

Approve and circulate the UCOU Head Injury Admission SOP for adult head-injury admissions at Oldham Hospital.

Verbatim wording from the response

“4. Local Standard Operating Procedure (SOP) - Urgent Care Observation Ward (“UCOU”) Head Injury Admission has been drafted which will provide local guidance for the Oldham Hospital Emergency Department and UCOU, for adult patients (age >16) who have a head injury that requires admission from the emergency department to the UCOU. This will be approved via the Clinical Service Unit Assurance Meeting and then circulated to staff by 30th August 2026.”

Source location

Response from Northern Care Alliance
Page 2 · response
Published 21 August 2026

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 radiology to improve prioritisation of urgent CT scans using head-injury safety prompts.

Verbatim wording from the response

“12. We are working closely with the radiology service to improve prioritisation of urgent CT scans, supported by the new head injury proforma that includes key safety prompts such as anticoagulation status.”

Source location

Response from Northern Care Alliance
Page 3 · response
Published 21 August 2026

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 Martha’s Rule with staff training, escalation policies and routine patient questions about deterioration.

Verbatim wording from the response

“11. Martha’s Rule was introduced in March 2026, supported by bespoke staff training and clear escalation policies. This ensures that patients and their families can raise concerns and request a further clinical review if they feel their condition is deteriorating or not being recognised. Patients on the ward are now routinely asked about changes in how they feel, with structured processes such the new NEWS policy in place to respond promptly to deterioration.”

Source location

Response from Northern Care Alliance
Page 3 · response
Published 21 August 2026

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