PFD report

Maureen Veronica Martin · Prevention of Future Deaths report

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Issued 26 Aug 2019•Staffordshire 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
1

Named on the report

Responses found
1

Of 1 recipient

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 maintain best possible visibility from Nurses’ Stations
    Part of recurring concern: Failure to maintain adequate visibility for patient monitoring
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

    Remove the Ward 5 nursing station desk and provide staff with a mobile desk to improve patient visibility.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.
  2. Action

    Review all nursing station desks at Queen’s Hospital Burton to confirm correct positioning and visibility.

    Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 September 2019.

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 maintain best possible visibility from Nurses’ Stations

Wider context from the report

“Her son pointed out that at the time of her fall, the desk for the Nurses’ Station on the ward was facing the wrong way. Possibly this was linked to some temporary decoration works. When Mrs Martin’s son mentioned this, the desk was repositioned appropriately. I would be grateful if you could check that the desks at Nurses’ Stations in Queens Hospital are properly positioned and, if they do temporarily have to be moved, that the best possible visibility is maintained. ”

Is this part of a recurring concern?

Yes — Failure to maintain adequate visibility for patient monitoring.

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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

Remove the Ward 5 nursing station desk and provide staff with a mobile desk to improve patient visibility.

Verbatim wording from the response

“1. Mrs Martin’s fall on Ward 5 was the subject of an internal investigation which concluded that the nursing station was indeed moved and it was found not to promote visibility of the patients as the nurse, if sat at the station, was facing the incorrect way. The action that arose out of this investigation was to remove the nursing station desk on that Ward and provide the staff with a “desk on wheels” so that this can be wheeled with the staff as they walk around the Bays.”

Source location

2019-0220-Response-by-University-Hospitals-of-Derby-and-Burton-NHS-Trust
Page 1 · response
Published 13 September 2019

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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

Review all nursing station desks at Queen’s Hospital Burton to confirm correct positioning and visibility.

Verbatim wording from the response

“2. A walkaround review has also been undertaken of all of the nursing stations/desks at Queen’s Hospital Burton to see if they are positioned in the correct places. I would like to assure you that they are all in the correct places and are facing the correct way. Indeed, most of the nursing desks are on wheels to allow nurses to complete their paperwork whilst they are in the Bays caring for patients; this encourages more visibility of the nursing staff and allows more time for the nurses to be with patients.”

Source location

2019-0220-Response-by-University-Hospitals-of-Derby-and-Burton-NHS-Trust
Page 2 · response
Published 13 September 2019

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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