PFD report

Leslie Harris · Prevention of Future Deaths report

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Issued 9 Dec 2020•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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
2

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. Failure to provide clear and consistent guidance on movement of patients to wards where other patients are in isolation from Covid
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.2

  1. Action

    Update and clarify infection-control guidance on isolating or cohorting exposed inpatients and using COVID-19 risk pathways.

    Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 6 January 2021.
  2. Action

    Further review the guidance to tighten wording and prevent misinterpretation of the advice.

    Stated by Public Health EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Published guidance already contained clear segregation advice and had been updated to address COVID-19 transmission risks.

    Stated by Public Health EnglandDisputes 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 to provide clear and consistent guidance on movement of patients to wards where other patients are in isolation from Covid

Wider context from the report

“The inquest heard that he was moved to a ward where other patients were in isolation from Covid due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way the trust have changed their policy and such movement no longer takes place. However, the guidance from PHE has not been amended and it was unknown how other trusts were choosing to interpret the guidance and as such putting potentially vulnerable patients at risk of developing Covid 19 whilst an in-patient. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Update and clarify infection-control guidance on isolating or cohorting exposed inpatients and using COVID-19 risk pathways.

Verbatim wording from the response

“National Infection, Prevention and Control guidance is issued jointly by the four nations. PHE publishes this guidance. Guidance at the time contained information on infection control precautions, including cohorting of patients. This guidance was updated after the sad passing of Mr Harris. Updated versions of the guidance, with most recent updates on 20th August 2020 and 21st January 2021, provide advice on reducing the risk of COVID-19 transmission through use of high, medium and low risk COVID-19 risk pathways determined by risk assessment of individuals based on information including test status.”

Source location

2020-0280-Response-from-Public-Health-England-Redacted
Page 2 · response
Published 6 January 2021

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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

Further review the guidance to tighten wording and prevent misinterpretation of the advice.

Verbatim wording from the response

“PHE will be further reviewing this guidance to ensure that wording is tightened to prevent any misinterpretation of the advice.”

Source location

2020-0280-Response-from-Public-Health-England-Redacted
Page 2 · response
Published 6 January 2021

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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

Published guidance already contained clear segregation advice and had been updated to address COVID-19 transmission risks.

Verbatim wording from the response

“This report states that Mr Harris died of COVID-19 pneumonia acquired whilst an inpatient at Stepping Hill Hospital, contributed to by the complications of an accidental fall. It outlines that the inquest heard that he was moved to a ward where other patients were in isolation from COVID-19 due to the interpretation of Public Health England guidance about management in these circumstances. As a result of reflection and concerns about interpreting the guidance in this way, the trust has changed their policy and such movement no longer takes place. It also states that the Public Health England guidance has not been amended and it was unknown how other trusts were choosing to interpret the guidance as such putting potentially vulnerable patients at risk of developing COVID-19 whilst an in-patient.”

Source location

2020-0280-Response-from-Public-Health-England-Redacted
Page 1 · response
Published 6 January 2021

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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

Implementation of national infection-control guidance and related risk assessments is assigned to healthcare providers at local level.

Verbatim wording from the response

“The principles in the guidance apply to all health and care settings. Its implementation should be underpinned at provider level by risk assessments that take into consideration the patient, environment, procedure and task being undertaken by any member of health care staff, and through safe systems of working: administrative, environmental and engineering measures/controls that need to be adopted to reduce the risk of transmission, including: personal protective equipment, hand hygiene, social distancing, cleanliness/decontamination of the environment and equipment, ventilation and separation and segregation of patient and staff within the high, medium and low risk pathways.”

Source location

2020-0280-Response-from-NHS-England-and-NHS-Improvement-Redacted
Page 2 · response
Published 6 January 2021

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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