PFD report

Victor Jackson HUTCHENS · Prevention of Future Deaths report

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Issued 7 Aug 2025•County Durham and Darlington

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
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 raised1

  1. Failure to prevent erroneous reductions in the frequency of care rounds
    Part of recurring concern: Unreliable patient observation arrangements
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

    Deliver education to the ward team distinguishing care rounding from observation frequency and reinforcing required clinical justification and oversight.

    Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
  2. Action

    Conduct organisation-wide audits to identify incorrect care-rounding practices and regularly monitor that correct practices remain embedded.

    Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
  3. Action

    Provide remedial education to teams where similar care-rounding practices are identified.

    Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.

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 prevent erroneous reductions in the frequency of care rounds

Wider context from the report

“On 20 February 2025, a week before the deceased's death, the frequency of care rounds was reduced, in error, from hourly to four-hourly. The member of staff responsible for the error is unaware of how the error occurred. That being the case, there is a concern that the error could occur again and could cause or contribute to a future death. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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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 education to the ward team distinguishing care rounding from observation frequency and reinforcing required clinical justification and oversight.

Verbatim wording from the response

“In response, we have undertaken a comprehensive education programme with the ward team to clarify the distinct purposes of care rounding and observation frequency, and to reinforce that neither should be reduced without appropriate clinical justification and oversight.”

Source location

Response from County Durham and Darlington NHS Foundation Trust
Page 1 · response
Published 13 August 2025

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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

Conduct organisation-wide audits to identify incorrect care-rounding practices and regularly monitor that correct practices remain embedded.

Verbatim wording from the response

“We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas.”

Source location

Response from County Durham and Darlington NHS Foundation Trust
Page 1 · response
Published 13 August 2025

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

Provide remedial education to teams where similar care-rounding practices are identified.

Verbatim wording from the response

“We have also conducted an organisation-wide audit to ensure this issue is not occurring elsewhere. Where similar practices have been identified, remedial education has been undertaken with the relevant teams. We continue to audit regularly to ensure that correct practices are maintained and embedded across all areas.”

Source location

Response from County Durham and Darlington NHS Foundation Trust
Page 1 · response
Published 13 August 2025

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