PFD report

Anthony Thomas McManus · Prevention of Future Deaths report

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Issued 31 Oct 2016•Milton Keynes

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised3

  1. Failure to record observations contemporaneously
    Part of recurring concern: Unreliable recording of required observations in care and custody
  2. Failure to carry out required observations
    Part of recurring concern: Failure to carry out required overnight checksPart of recurring concern: Unreliable patient observation arrangements
  3. Failure to conduct observations at varied times
    Part of recurring concern: Unreliable patient observation arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 observations contemporaneously

Wider context from the report

“(1) The system of observations carried out within the unit, particularly at night is in need of reform. (2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly. (3) Some observations were not carried out and the observation chart completed at the end of the shift. ”

Is this part of a recurring concern?

Yes — Unreliable recording of required observations in care and custody.

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 carry out required observations

Wider context from the report

“(1) The system of observations carried out within the unit, particularly at night is in need of reform. (2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly. (3) Some observations were not carried out and the observation chart completed at the end of the shift. ”

Is this part of a recurring concern?

Yes — Failure to carry out required overnight checks; 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 conduct observations at varied times

Wider context from the report

“(1) The system of observations carried out within the unit, particularly at night is in need of reform. (2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly. (3) Some observations were not carried out and the observation chart completed at the end of the shift. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

Open source report
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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