PFD report

John Lowe · Prevention of Future Deaths report

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Issued 1 Apr 2015•Nottinghamshire

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
1

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

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Concerns raised1

  1. Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unsafe provision of one-to-one care
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

Inaccurate nursing staff belief that 1:1 nursing care is unavailable for falls risk or physical care needs

Wider context from the report

“1. That there was a belief amongst members of the Trust’s nursing staff that they were unable as a matter of policy to provide 1:1 nursing care for a patient in respect of that patient’s falls risk assessment alone, no matter what that assessment might be. 2. That there was a belief amongst members of the Trust’s nursing staff that 1:1 nursing could only be provided on the basis of a patient’s particular mental health needs, and not in respect of his or her physical care needs. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unsafe provision of one-to-one care.

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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