PFD report

Derek Crowther · Prevention of Future Deaths report

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Issued 9 Oct 2025•Manchester 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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 raised2

  1. Lack of contemporaneous digital recording of observations on wards
  2. Failure to ensure that clinical staff are up to date with required Life Support training before undertaking shifts
    Part of recurring concern: Failure to ensure mandatory safety training is completed before safety-critical workPart of recurring concern: Inadequate staff competence to provide first aid
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.8

  1. Action

    Work with Greater Manchester Mental Health colleagues to share learning and progress and inform development of the Trust’s electronic-observations system.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2025.
  2. Action

    Escalate non-attendance at booked ILS courses to Ward Managers and Network Quality Leads to address attendance barriers and improve compliance.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2025.
  3. Action

    Require and daily-monitor at least one ILS-trained nursing staff member on every inpatient ward shift, escalating staffing gaps.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The Trust cannot rely on the existing GMMH eObservations app because its lack of offline capability may compromise data integrity during Wi-Fi outages.

    Stated by Pennine Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Lack of contemporaneous digital recording of observations on wards

Wider context from the report

“2. Whilst the Court heard evidence as to relevant changes made to the Trust’s Observations Policy since Mr Crowther’s death, I am concerned that despite having an Electronic Patient Records system, there is currently no mechanism in use on the wards for contemporaneous digital recording of observations. I am concerned that an ongoing risk of future deaths arises from this position, in the view of the potential for such systems to accurately record timings of observations, facilitate trend analysis (particularly in the context of a deteriorating patient), and reduce the potential for errors, either arising from incorrect / unclear manual recording of observations ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 ensure that clinical staff are up to date with required Life Support training before undertaking shifts

Wider context from the report

“1. The Court heard evidence that a registered nurse working on the Unit at the time of Mr Crowther’s death was not up to date with Intermediate Life Support (‘ILS’) training, despite this being termed ‘mandatory’. Having heard evidence from the Trust’s Clinical Excellence Lead for Older Peoples’ Services, I am concerned that instances continue to arise across the Trust whereby clinical staff are undertaking shifts despite not being up to date with the required level of Life Support training. ”

Is this part of a recurring concern?

Yes — Failure to ensure mandatory safety training is completed before safety-critical work; Inadequate staff competence to provide first aid.

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

Work with Greater Manchester Mental Health colleagues to share learning and progress and inform development of the Trust’s electronic-observations system.

Verbatim wording from the response

“integrity would be maintained. We are working closely with colleagues at GMMH, sharing learning and progress to inform our project and ensure we are able to implement an effective system at PCFT.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 4 · response
Published 14 October 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

Escalate non-attendance at booked ILS courses to Ward Managers and Network Quality Leads to address attendance barriers and improve compliance.

Verbatim wording from the response

“Increased training capacity has been created by ensuring additional ILS training sessions have been made available. This has increased capacity and reduced waiting times for staff who need to book onto available training. Timetabling of training has been adjusted to improve access for ward-based staff. The Trust is also addressing non-attendance on ILS training, which is recognised to impact on compliance rates. Non-attendance on a booked course is escalated to Ward Managers and Network Quality Leads to support awareness but also understanding of the underlying causes or reasons why staff could not attend as planned.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 14 October 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

Require and daily-monitor at least one ILS-trained nursing staff member on every inpatient ward shift, escalating staffing gaps.

Verbatim wording from the response

“Each ward is required to have at least one ILS trained member of nursing staff on every shift, including nights and weekends. Compliance with this requirement is monitored daily through Safer Staffing meetings, with escalation where gaps arise to ensure an ILS trained staff member is available for all shifts on every inpatient ward across the Trust.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 14 October 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

Develop, configure, test and pilot an electronic observations app incorporating offline capability for reliable observation recording.

Verbatim wording from the response

“The Trust also established an Enhanced Therapeutic Observations of Care (ETOC) Task and Finish Group in March 2025. One of the workstreams within that group is the development of an electronic observations (eObs) app. This response will provide additional information pertaining to that workstream in addition to the information provided previously regarding the broader work of the group around, policy, training, culture and improvement. The development of an eobs app is just one element of that workplan. The build and configuration work has began on the app. This will be ready for testing by March 2026 and pilot of the app commenced in April 2026. At this stage we are unable to give a full implementation go live date Trust wide but can update you in our progress as the pilot progresses and concludes.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 14 October 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

Incorporate ILS compliance into ward rota planning to release staff for refresher training while maintaining appropriate staffing.

Verbatim wording from the response

“ILS compliance is being incorporated into ward rota planning to ensure wards are appropriately staffed whilst simultaneously releasing those staff who require refresher training, which will in turn lead to an increase in compliance. The Trust is extending ILS training to additional clinical staff groups such as Bank staff and trainee doctors to increase resilience and the number of ILS trained staff present on the ward on a shift.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 14 October 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 additional ILS training sessions and adjust timetables to increase capacity, improve ward-staff access and reduce booking delays.

Verbatim wording from the response

“Increased training capacity has been created by ensuring additional ILS training sessions have been made available. This has increased capacity and reduced waiting times for staff who need to book onto available training. Timetabling of training has been adjusted to improve access for ward-based staff. The Trust is also addressing non-attendance on ILS training, which is recognised to impact on compliance rates. Non-attendance on a booked course is escalated to Ward Managers and Network Quality Leads to support awareness but also understanding of the underlying causes or reasons why staff could not attend as planned.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 14 October 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

Increase the Trust-wide ILS compliance target to 85% and monitor compliance through mandatory-training dashboards and governance reporting.

Verbatim wording from the response

“compliance and availability of training, which is overseen within our Resuscitation Committee but also reported as part of our management structures and governance meetings.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 14 October 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

Extend ILS training to Bank staff and trainee doctors to increase the number of trained staff available on ward shifts.

Verbatim wording from the response

“ILS compliance is being incorporated into ward rota planning to ensure wards are appropriately staffed whilst simultaneously releasing those staff who require refresher training, which will in turn lead to an increase in compliance. The Trust is extending ILS training to additional clinical staff groups such as Bank staff and trainee doctors to increase resilience and the number of ILS trained staff present on the ward on a shift.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 2 · response
Published 14 October 2025

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

The Trust cannot rely on the existing GMMH eObservations app because its lack of offline capability may compromise data integrity during Wi-Fi outages.

Verbatim wording from the response

“We understand a question was asked in relation to the eObs app in place at Greater Manchester Mental Health NHS Foundation Trust (GMMH) and the ability for the Trust to adopt this. Whilst GMMH has been able to implement therapeutic observations on some of their wards, which had Wi-Fi upgrades, there are challenges still with their coverage. GMMH are currently not utilising 'offline' capability, which has been identified as key requirement for our e-Obs solution, given feedback to date and the lessons that have been learnt at GMMH. Without 'offline' capability we cannot guarantee that should there be a drop in Wi-Fi connection; data”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 14 October 2025

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

A Trust-wide eObservations implementation date cannot yet be provided while pilot testing and evaluation remain ongoing.

Verbatim wording from the response

“The Trust also established an Enhanced Therapeutic Observations of Care (ETOC) Task and Finish Group in March 2025. One of the workstreams within that group is the development of an electronic observations (eObs) app. This response will provide additional information pertaining to that workstream in addition to the information provided previously regarding the broader work of the group around, policy, training, culture and improvement. The development of an eobs app is just one element of that workplan. The build and configuration work has began on the app. This will be ready for testing by March 2026 and pilot of the app commenced in April 2026. At this stage we are unable to give a full implementation go live date Trust wide but can update you in our progress as the pilot progresses and concludes.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 14 October 2025

Open published response

Other statements in published responses

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

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Implement therapeutic-observation improvements through a policy, targeted training course and implementation plan across individual care areas.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
  2. 2

    Communicate electronic-observations development directly to relevant clinical leadership.

    Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
  3. 3

    Review how electronic-observations progress can be shared more broadly with staff before testing.

    Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2025.

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

Implement therapeutic-observation improvements through a policy, targeted training course and implementation plan across individual care areas.

Verbatim wording from the response

“The Trust has undertaken some focused improvement work on therapeutic observations of care, from December 2024 into the spring of 2025. This was led by our Deputy Director of Nursing, Quality and AHP’s and informed by nationally indicated best practice and published guidance. This included the creation of a policy, and the development of a targeted training course which was supported by an implementation plan for staff to deliver this at scale and pace, within the individual care areas.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 14 October 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

Communicate electronic-observations development directly to relevant clinical leadership.

Verbatim wording from the response

“I was sorry to learn that the Clinical Excellence Lead attending Mr Crowther’s inquest was not aware of these developments whilst he gave evidence, as this may have provided you with the assurance of action that you were seeking. I understand that steps have been taken to ensure this is communicated effectively to them directly, but also reviewing the ways in which this progress can be shared with staff more broadly as we approach the testing phase of this process. We are working with our digital team we have set April ’26 as a realistic date that we can deliver a pilot on eObs.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 14 October 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

Review how electronic-observations progress can be shared more broadly with staff before testing.

Verbatim wording from the response

“I was sorry to learn that the Clinical Excellence Lead attending Mr Crowther’s inquest was not aware of these developments whilst he gave evidence, as this may have provided you with the assurance of action that you were seeking. I understand that steps have been taken to ensure this is communicated effectively to them directly, but also reviewing the ways in which this progress can be shared with staff more broadly as we approach the testing phase of this process. We are working with our digital team we have set April ’26 as a realistic date that we can deliver a pilot on eObs.”

Source location

Response from Pennine Care NHS Foundation Trust
Page 3 · response
Published 14 October 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