PFD report

Mavis May Lawrence · Prevention of Future Deaths report

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Issued 30 Sep 2020•Stoke-on-Trent and North Staffordshire

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
9

Raised in this report

Recipients
3

Named on the report

Responses found
1

Of 3 recipients

Stated actions
8

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 raised9

  1. Failure of district nurses to involve Tissue Viability Nurses
    Part of recurring concern: Inadequate district nursing wound carePart of recurring concern: Inadequate management of pressure ulcersPart of recurring concern: Unreliable referrals to tissue viability services
  2. Failure to record district nurse visits
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  3. Failure to provide pain relief
    Part of recurring concern: Failure to provide timely and adequate pain relief
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.5

  1. Action

    Provide additional wound-care documentation training and verify staff completion through training-register checks.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
  2. Action

    Audit whether the pain-assessment process is embedded in clinical practice.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
  3. Action

    Raise multidisciplinary-team awareness of involving GPs in ongoing patient care.

    Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 November 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Records show wound assessments occurred after 18 December 2018, consistent with the Trust’s fortnightly assessment guidance.

    Stated by Midlands Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 of district nurses to involve Tissue Viability Nurses

Wider context from the report

“(8) District nurses had not involved Tissue Viability Nurses. ”

Is this part of a recurring concern?

Yes — Inadequate district nursing wound care; Inadequate management of pressure ulcers; Unreliable referrals to tissue viability services.

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 record district nurse visits

Wider context from the report

“(5)No record of last visit by district nurses on the 27.1.19 ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 provide pain relief

Wider context from the report

“(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. . ”

Is this part of a recurring concern?

Yes — Failure to provide timely and adequate pain relief.

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

Insufficient GP involvement

Wider context from the report

“(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. . ”

Is this part of a recurring concern?

Yes — Failure to provide sufficient GP involvement in patient care.

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 of the band 4 nurse to escalate the seriousness of the situation

Wider context from the report

“(6)There was no evidence that band 4 nurse escalated the seriousness of the situation. ”

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

Lack of wound treatment assessment charts

Wider context from the report

“(2)No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas. ”

Is this part of a recurring concern?

Yes — Inadequate wound management for deteriorating wounds.

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 keep the pressure mattress switched on

Wider context from the report

“(4)The pressure mattress had been turned off on the 22.1.19 ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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 of nursing notes to clearly record positioning and changes to ulcers

Wider context from the report

“(3)Nursing notes in December 2018 did not portray a clear story of positioning and changes to the ulcers. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 check pressure areas

Wider context from the report

“(1)Nursing notes evidence that pressure areas (sacrum/ buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes. ”

Is this part of a recurring concern?

Yes — Inadequate management of pressure ulcers.

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

Provide additional wound-care documentation training and verify staff completion through training-register checks.

Verbatim wording from the response

“(1) Nursing notes evidence that pressure areas (sacrum/buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes. We have identified a number of actions aimed at improving completeness of our documentation; including the provision of additional training and a programme of audits, to ensure improvements are made. (Please see action plan below actions 1 & 2 & 4c).”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 1 · response
Published 26 November 2020

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

Audit whether the pain-assessment process is embedded in clinical practice.

Verbatim wording from the response

“(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. Records show that pain assessments were done at each wound assessment but they do not document pain management in a way that we would expect. It is expected practice that any deterioration in the patient’s condition would be addressed with the appropriate intervention by the relevant practitioner, for example, the General Practitioner. We have identified an action to improve our processes to ensure that GPs are sufficiently involved and in addition to strengthen documentation associated with pain management (Please see action plan below - actions 3 & 4a, 4b, 4c & 7.).”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 2 · response
Published 26 November 2020

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

Raise multidisciplinary-team awareness of involving GPs in ongoing patient care.

Verbatim wording from the response

“(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. Records show that pain assessments were done at each wound assessment but they do not document pain management in a way that we would expect. It is expected practice that any deterioration in the patient’s condition would be addressed with the appropriate intervention by the relevant practitioner, for example, the General Practitioner. We have identified an action to improve our processes to ensure that GPs are sufficiently involved and in addition to strengthen documentation associated with pain management (Please see action plan below - actions 3 & 4a, 4b, 4c & 7.).”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 2 · response
Published 26 November 2020

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, update and relaunch the pain-assessment tool for clinical staff.

Verbatim wording from the response

“(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. Records show that pain assessments were done at each wound assessment but they do not document pain management in a way that we would expect. It is expected practice that any deterioration in the patient’s condition would be addressed with the appropriate intervention by the relevant practitioner, for example, the General Practitioner. We have identified an action to improve our processes to ensure that GPs are sufficiently involved and in addition to strengthen documentation associated with pain management (Please see action plan below - actions 3 & 4a, 4b, 4c & 7.).”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 2 · response
Published 26 November 2020

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

Audit nursing documentation and pressure-ulcer management, using a developed audit tool and reporting findings to senior management.

Verbatim wording from the response

“(1) Nursing notes evidence that pressure areas (sacrum/buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes. We have identified a number of actions aimed at improving completeness of our documentation; including the provision of additional training and a programme of audits, to ensure improvements are made. (Please see action plan below actions 1 & 2 & 4c).”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 1 · response
Published 26 November 2020

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

Records show wound assessments occurred after 18 December 2018, consistent with the Trust’s fortnightly assessment guidance.

Verbatim wording from the response

“(2) No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas. There is evidence in the deceased’s records that wound assessments were undertaken after the 18.12.2018. Wound assessments were completed on the 01.01.2019 and on the 27.01.2019 clearly documenting the condition and anatomical location of the wounds. The MPFT guidance is that wound assessments need to be carried out and documented on a fortnightly basis. If the wounds deteriorate before the next fortnightly review, a wound assessment will be completed prior to that date. Records show that in between the regular wound assessments there were regular summaries of the condition of the wounds. Up until the date of admission to hospital the records”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 1 · response
Published 26 November 2020

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

District nurses are skilled in wound management and refer to tissue viability specialists when wounds deteriorate, consistent with Trust policy.

Verbatim wording from the response

“(8) District nurses had not involved Tissue Viability Nurses. The district nurses and assistant practitioner band 4 assistant practitioners are skilled in managing wounds; including pressure ulcers.”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 2 · response
Published 26 November 2020

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

Records show the band 4 nurse appropriately escalated the situation to the district nurse team and tissue viability team.

Verbatim wording from the response

“(6) There was no evidence that band 4 nurse escalated the seriousness of the situation. There is evidence in the records that the band 4 nurse escalated this appropriately and notified the nurse in charge of the district nurse team, as well as the tissue viability team, on Sunday 27th January 2019.”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 2 · response
Published 26 November 2020

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 residential home is responsible for ensuring the pressure mattress is used appropriately.

Verbatim wording from the response

“(4) The pressure mattress had been turned off on the 22.1.19 The Residential Home is responsible for ensuring appropriate use of the equipment. Our records show that during a routine visit on 22.1.19 the district nurse noticed that the pressure mattress had been turned off, and took immediate action and turned it back on.”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 2 · response
Published 26 November 2020

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

Residential home carers are expected to conduct regular skin checks and contact district nurses when concerns arise.

Verbatim wording from the response

“(5) No record of last visit by district nurses on the 27.1.19 When the patient is cared for in a residential home, the carers are expected to carry out regular skin checks as they are tending to the patient, on a regular basis. The process in place requires that the care staff raise concerns to the district nurses as and when required. There is evidence in the care records that MPFT staff did request the Residential Home staff contact MPFT district nursing staff if they had any concerns. There is evidence of a wound assessment table having been completed by the assistant practitioner (band 4 nurse from the district nursing team) on 27.1.19, in the My Care File when the assistant practitioner (band 4 nurse from the district nursing team) was requested by the Residential home care staff to complete an assessment.”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 2 · response
Published 26 November 2020

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

    Share pressure-ulcer incident learning and best practice across clinical teams through monthly newsletters and team-huddle discussions.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
  2. 2

    Share learning from the Regulation 28 report and monitor the identified actions until the action plan is fully completed.

    Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 November 2020.
  3. 3

    Use a new Community Nursing Assessment document to record holistic assessments and identify patients’ care needs.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.

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

Share pressure-ulcer incident learning and best practice across clinical teams through monthly newsletters and team-huddle discussions.

Verbatim wording from the response

“6. Multidisciplinary team to share best practice and learning from incidents across all clinical teams via a monthly newsletter following each Pressure Ulcer Review Group and Tissue Viability Steering Group meeting for discussion at team huddles | Tissue Viability Clinical Lead | 04.11.2020 | Multidisciplinary team sharing best practice and learning from incidents. Across all clinical teams. A monthly newsletter following each Pressure Ulcer Review Group and Tissue Viability Steering Group meeting | 04.11.2020”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 4 · response
Published 26 November 2020

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

Share learning from the Regulation 28 report and monitor the identified actions until the action plan is fully completed.

Verbatim wording from the response

“In line with our governance processes we will share the learning from the Regulation 28 and the actions identified will be monitored, to ensure the action plan is fully completed.”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 4 · response
Published 26 November 2020

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

Use a new Community Nursing Assessment document to record holistic assessments and identify patients’ care needs.

Verbatim wording from the response

“Point 1 & Point 7 5. A new Community Nursing Assessment document has been introduced to document a holistic assessment for patients referred into the District Nursing service to identify needs based on the activities of daily living model. | | | | Completed”

Source location

2020-0191-Response-from-Midlands-Partnership-NHS-Foundation-Trust.pdf
Page 4 · response
Published 26 November 2020

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