Rebecca Emily JONES · Prevention of Future Deaths report

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Issued 8 Oct 2015•Hertfordshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised0

    Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

    1. Department of Health and Social Care

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

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

      Bleep-holder training is primarily the responsibility of employers.

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

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

      Unable 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

    Open published response

    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

    Open published response

    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

    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