PFD report

Henry James Holcombe · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 15 Jul 2021•Brighton and Hove

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to require staff compliance with therapeutic engagement and observation policy during night-time or presumed-sleeping observations
    Part of recurring concern: Unreliable patient observation arrangements
  2. Failure to produce effective action following Serious Incident reports
    Part of recurring concern: Failure of organisational governance to act on escalated patient-safety concerns
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.4

  1. Action

    Strengthen internal monitoring of Policy compliance through weekly Ward Manager and monthly Matron reviews.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 August 2021.
  2. Action

    Undertake a quality-improvement programme addressing observation competencies, individualised care, patient experience, and night-time observations including seclusion and physical observations.

    Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
  3. Action

    Enhance therapeutic-observation training and competency assessment, including for agency and bank staff.

    Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 August 2021.

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 staff compliance with therapeutic engagement and observation policy during night-time or presumed-sleeping observations

Wider context from the report

“(1) The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 – page 5). Since 27.12.2019 to 5.3.2021 there have been three occasions when patients described as asleep over a series of observations, have actually been found to have been dead for several hours. Serious Incident reports have promised action but nothing effective has been produced. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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 produce effective action following Serious Incident reports

Wider context from the report

“(1) The ongoing failure of SPFT to require their staff to comply with the Trusts therapeutic engagement and observation policy. Especially those sections which relate to night times or when patients are believed to be sleeping (see para 4.5.5, 4.5.7 and table 1 – page 5). Since 27.12.2019 to 5.3.2021 there have been three occasions when patients described as asleep over a series of observations, have actually been found to have been dead for several hours. Serious Incident reports have promised action but nothing effective has been produced. ”

Is this part of a recurring concern?

Yes — Failure of organisational governance to act on escalated patient-safety concerns.

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

Strengthen internal monitoring of Policy compliance through weekly Ward Manager and monthly Matron reviews.

Verbatim wording from the response

“Specifically, in response to the findings of our investigation into Mr Holcombe's death, we have strengthened our internal monitoring arrangements to ensure the”

Source location

2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 1 · response
Published 3 August 2021

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

Undertake a quality-improvement programme addressing observation competencies, individualised care, patient experience, and night-time observations including seclusion and physical observations.

Verbatim wording from the response

“Also, although Ms Hamilton-Deeley's concerns related particularly to safety at night, we have recognised that a systemic quality improvement approach is needed to ensure that therapeutic observations are of an appropriate standard. As a result, we are undertaking a robust programme of therapeutic observation Quality Improvement ('QI') work. The aim of this work is to improve the quality of therapeutic observations in terms of safety, effectiveness and experience; specifically, to ensure observations are therapeutic, individualised and skilled intervention that is responsive to a patient's needs, are least restrictive, and aimed at recovery. This QI work will give specific attention to:”

Source location

2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 2 · response
Published 3 August 2021

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

Enhance therapeutic-observation training and competency assessment, including for agency and bank staff.

Verbatim wording from the response

“The Trust's actions, to date, in relation to this issue, have focused on staff training, competency and understanding of our Policy. This stipulates that: ‘If a member of staff is not able to observe the patient move or breath they must ensure the patient is conscious which will require entering the bedroom’ and staff competency and understanding of the Policy is assessed through competency checks. However, it is clear that further, sustained action is required to ensure that this requirement is fully understood and adhered to by all clinical staff.”

Source location

2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 1 · response
Published 3 August 2021

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

Consider technological aids to support patient safety and enhanced physical observation, including remote monitoring of respiration, movement and heart rate.

Verbatim wording from the response

“Additionally, consideration is being given to the potential use of technological aids to support patient safety and enhanced physical observation, which includes an electronic system to remotely monitor a patient’s respiration, movement and heart rate and flags immediate changes to the patient’s physical presentation.”

Source location

2021-0257-Response-from-Sussex-Partnership-Foundation-NHS-Trust_Published
Page 2 · response
Published 3 August 2021

Open published response
Back to top

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