PFD report

Rebecca Emily JONES · Prevention of Future Deaths report

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Issued 8 Oct 2015•Hertfordshire

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
0

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

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Concerns and recipient responses

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No concerns are currently included for this report.

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Implementation of observation guidelines is a matter for each local NHS Trust.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Bleep-holder training is primarily the responsibility of employers.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. 3

    Health Education England cannot impose specific continuing professional development activities on employers or the workforce.

    Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implementation of observation guidelines is a matter for each local NHS Trust.

Verbatim wording from the response

“Although such observation guidelines exist, their implementation is a matter for each local NHS Trust. However, I would expect all hospitals to have clear written policies on the use of observation. This should include requirements to record when observations are carried out and the findings.”

Source location

2015-0504-Response-by-Department-of-Health
Page 3 · response
Published 8 October 2015

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Bleep-holder training is primarily the responsibility of employers.

Verbatim wording from the response

““Bleep holder” training is part of Continuing Professional Development (CPD) and such training is primarily the responsibility of employers. However, Health Education England (HEE) spends approximately £215million per year on activities which together are termed as ‘workforce development’. HEE is undertaking a root and branch review of its workforce development spend, in response to its mandated commitment to ensuring professional and personal development beyond the end of formal training.”

Source location

2015-0504-Response-by-Department-of-Health
Page 3 · response
Published 8 October 2015

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Health Education England cannot impose specific continuing professional development activities on employers or the workforce.

Verbatim wording from the response

“The Health and Social Care Act places a duty on the health system to promote autonomy for providers of healthcare or those that provide services that assist that purpose. Although HEE cannot impose specific CPD activities on employers or the workforce, it endorses the policy of Hertfordshire Partnership University NHS Foundation Trust in providing more training for bleep holders adopted in the wake of Ms. Jones’ death.”

Source location

2015-0504-Response-by-Department-of-Health
Page 3 · response
Published 8 October 2015

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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