PFD report

Sarah Anne Shepherd · Prevention of Future Deaths report

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Issued 16 Dec 2013•Surrey

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
6

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 raised6

  1. Unclear alignment of resuscitation training with current guidance
    Part of recurring concern: Failure to ensure staff competence in resuscitationPart of recurring concern: Inadequate staff competence to provide first aidPart of recurring concern: Unreliable emergency response to patient collapse
  2. Failure to initiate resuscitation when a patient is not breathing normally
    Part of recurring concern: Failure to ensure staff competence in resuscitationPart of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
  3. Failure to establish a clear referral process to the Psychiatric Intensive Care Unit
    Part of recurring concern: Unreliable mental health referral pathways
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

Unclear alignment of resuscitation training with current guidance

Wider context from the report

“(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in resuscitation; Inadequate staff competence to provide first aid; Unreliable emergency response to patient collapse.

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 initiate resuscitation when a patient is not breathing normally

Wider context from the report

“(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in resuscitation; Unreliable resuscitation preparedness and response during cardiac arrest.

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 establish a clear referral process to the Psychiatric Intensive Care Unit

Wider context from the report

“(1) It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient’s RIO (or other medical) notes. From the evidence heard, it does not seem that these concerns have yet been addressed or sufficiently addressed by amendment of the Operational Policy and consequential staff training. ”

Is this part of a recurring concern?

Yes — Unreliable mental health referral pathways.

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 include required observations and recording in resuscitation training

Wider context from the report

“(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in conducting and interpreting clinical observations.

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 require written and reasoned referral responses and their recording in patient notes

Wider context from the report

“(1) It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient’s RIO (or other medical) notes. From the evidence heard, it does not seem that these concerns have yet been addressed or sufficiently addressed by amendment of the Operational Policy and consequential staff training. ”

Is this part of a recurring concern?

Yes — Unreliable internal hospital referral processes; Unreliable mental health referral pathways.

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

Misleading resuscitation aide memoires in staff resuscitation bags

Wider context from the report

“(2) It was apparent from the evidence that the nursing staff who found the Deceased in an unresponsive state on the 12th September 2011 did not attempt to resuscitate her in accordance with the guidelines of the Resuscitation Council. They understood that resuscitation should be started if the patient was not “breathing” whereas the Council states that it should be started if the patient is not “breathing normally”. The evidence heard as to what training the nursing staff had been given concerning when resuscitation should be started was unclear and confusing. It remains unclear whether the resuscitation training now being given to clinical staff (a) is fully and clearly in accordance with the current guidance of the Resuscitation Council and (b) includes training as to what observations should be taken and recorded. Further, it was apparent from the evidence that the resuscitation bags used by staff contain a laminated aide memoire which is itself misleading as it refers to the use of resuscitation when the patient is not “breathing” rather than “breathing normally”. ”

Is this part of a recurring concern?

Yes — Failure to ensure staff competence in resuscitation; Unreliable resuscitation preparedness and response during cardiac arrest.

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