PFD report

Brenda Elizabeth MORRIS · Prevention of Future Deaths report

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Issued 19 Feb 2016•Inner North London

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised4

  1. Lack of routine consideration of family feedback after weekend leave
  2. Failure to communicate the basis for weekend leave to the supervising partner
    Part of recurring concern: Unsafe management of inpatient leave and absence
  3. Substandard nursing-record documentation of risk assessments before weekend leave
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable documentation of safety risk assessmentsPart of recurring concern: Unsafe management of inpatient leave and absence
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.3

  1. Action

    Implement and roll out the inpatient leave checklist requiring risk assessment, family discussions, contingency plans, return feedback, and RIO documentation.

    Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2016.
  2. Action

    Implement and roll out the Informal patient leave agreement documenting doctor-approved leave, conditions, contingency plans, and signatures.

    Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2016.
  3. Action

    Conduct quarterly audits of leave forms and corresponding RIO entries from July 2016 through January 2017.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 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

Lack of routine consideration of family feedback after weekend leave

Wider context from the report

“2. The weekend before the weekend of her death, Ms Morris’s partner felt that she had not been well during the weekend leave. I appreciate that care must be taken not to override a patient’s autonomy, but it might be useful for staff routinely to consider whether they are able to obtain feedback from family members after such leave. ”

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 communicate the basis for weekend leave to the supervising partner

Wider context from the report

“1. Brenda Morris was allowed weekend leave on the basis that her partner was at home to keep an eye on her, but no member of staff told him this. This was not a situation where she needed 24 hour supervision. Nevertheless, it would have been helpful for him to know the basis for the leave, because he would then have modified his own behaviour accordingly. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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

Substandard nursing-record documentation of risk assessments before weekend leave

Wider context from the report

“4. Substandard documentation in the nursing records had already been identified before the inquest by your serious incident review. Without improvement in the records, it is not possible to determine whether and if so by whom a necessary risk assessment is undertaken, e.g. immediately before weekend leave is taken. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable documentation of safety risk assessments; Unsafe management of inpatient leave and absence.

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 routinely obtain required medical authorisation for unplanned leave of informal patients

Wider context from the report

“3. There appears to be confusion about whether a doctor is needed to authorise unplanned leave of an informal patient (not relevant in this case because the leave had already been authorised). Your serious incident review of this matter indicates that this is necessary, but I heard evidence that such medical authorisation is not routinely sought. ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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

Implement and roll out the inpatient leave checklist requiring risk assessment, family discussions, contingency plans, return feedback, and RIO documentation.

Verbatim wording from the response

“In addition to the above an ‘In-patient leave checklist for informal and detained patients’ has been developed. It is also a requirement for this checklist to be completed for all leave. The checklist requires staff to assess risk prior to any period of leave, discuss with family or friends issues of risk and provide relatives/carers with a copy of an individualised contingency care plan. On return from leave staff will need to confirm that they have obtained feedback from family on the patient’s return from leave. The detail of all assessments and discussions will be fully documented on RIO.”

Source location

2016-0065-Response-by-East-London-NHS-Trust
Page 2 · response
Published 19 February 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 and roll out the Informal patient leave agreement documenting doctor-approved leave, conditions, contingency plans, and signatures.

Verbatim wording from the response

“However, in light of the importance of this issue the Trust has taken the decision to implement the use of template documentation to ensure that any leave has been appropriately agreed by a doctor. A new ‘Informal patient leave agreement’ has been developed. This document details the agreement of leave following assessment by a doctor. The template includes a box detailing any leave conditions along with any expectations from staff, patients, relatives and carers. A separate box deals with contingency plans. The agreement is then signed by the doctor, the patient and the relative. This document is expected to be in place before a patient goes on leave.”

Source location

2016-0065-Response-by-East-London-NHS-Trust
Page 2 · response
Published 19 February 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 quarterly audits of leave forms and corresponding RIO entries from July 2016 through January 2017.

Verbatim wording from the response

“Both forms are currently being piloted on one of our Mental Health Care for Older Persons wards with the aim of full introduction across all of our Older Persons wards by the end of this month. Use of the forms and the corresponding RIO entries will be the subject to quarterly audits starting from the end of July 2016 until January 2017 and will be subject to further review thereafter if necessary.”

Source location

2016-0065-Response-by-East-London-NHS-Trust
Page 2 · response
Published 19 February 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