PFD report

Florence Elizabeth Catherine STEWART · Prevention of Future Deaths report

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Issued 10 Oct 2024•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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

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. Failure of high-level intermittent observations to maintain patient safety
    Part of recurring concern: Unreliable patient observation arrangements
  2. Unavailability of oxygen from a resuscitation oxygen bottle
    Part of recurring concern: Unsafe provision of oxygen therapy
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.9

  1. Action

    Discuss the inquest themes and the importance of observation-policy adherence with staff through supervision, group sessions and ward meetings.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.
  2. Action

    Embed oversight of staff training uptake for observations and therapeutic engagements.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.
  3. Action

    Embed and optimise the Brigid app for real-time observation recording, rationale and frequency documentation, and random-check prompts.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The Campbell Centre always has an ample, accessible oxygen supply, disputing that the resuscitation oxygen bottle ran out.

    Stated by Central and North West London 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 high-level intermittent observations to maintain patient safety

Wider context from the report

“Firstly that the system of high level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. Secondly, that the Oxygen bottle used during resuscitation ran out of oxygen. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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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

Unavailability of oxygen from a resuscitation oxygen bottle

Wider context from the report

“Firstly that the system of high level intermittent observations failed to prevent Florence's suicide and needs a fundamental review. Secondly, that the Oxygen bottle used during resuscitation ran out of oxygen. ”

Is this part of a recurring concern?

Yes — Unsafe provision of oxygen therapy.

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

Discuss the inquest themes and the importance of observation-policy adherence with staff through supervision, group sessions and ward meetings.

Verbatim wording from the response

“The Divisional Directors have provided assurance that the Campbell Centre management team has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement and have introduced measures to monitor understanding, training, and compliance. They have advised that there have been meetings with all staff to emphasise the importance of adherence to the Policy.”

Source location

Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024

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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

Embed oversight of staff training uptake for observations and therapeutic engagements.

Verbatim wording from the response

“The specific themes from Ms Stewart’s inquest have been discussed in group supervision, individual supervision and ward meetings. The Campbell Centre management team has strengthened how temporary and new staff members are inducted to ensure that they can better identify their patients' needs. They have also embedded a system to oversee staff uptake of training in the use of observations and therapeutic engagements.”

Source location

Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024

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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

Embed and optimise the Brigid app for real-time observation recording, rationale and frequency documentation, and random-check prompts.

Verbatim wording from the response

“The Trust has fully embedded the use of the Brigid app, a hand-held device that allows staff to remain with the patient and enter real-time updates of observation records, automatically updating the Trust's clinical record system. This has been optimised since the inquest and enables staff to document the rationale and frequency of observations, including prompts for random checks.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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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 trained nurses to conduct daily oxygen-supply checks and induct temporary and new staff on oxygen availability before care begins.

Verbatim wording from the response

“The Divisional Directors have confirmed that there is always an ample supply of oxygen across the Campbell Centre, which is easily accessible to trained staff. They have checked that all of our nurses are trained to conduct daily checks of the supplies and that temporary, or new staff members, receive an induction on oxygen availability before they start providing care.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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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

Participate in a Trust-wide quality-improvement project to improve patient observation quality through May 2026.

Verbatim wording from the response

“The Campbell Centre is part of a Trust-wide Quality improvement project looking to improve patient observation quality. The project commenced in November 2024 and is due to continue until May 2026.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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

Realign the Nurse in Charge role to prioritise high-level observations, ensure seamless handovers and enable faster escalation when patients cannot be located.

Verbatim wording from the response

“The Nurse in Charge role has been realigned to ensure that the observation system is delivered to prioritise patients requiring high-level intermittent observations and oversee a seamless handover of care when alternating staff members. This includes faster escalation”

Source location

Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024

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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

Strengthen observation governance through shift-level checks, daily multidisciplinary reviews of highest-risk patients and allocated senior nursing support.

Verbatim wording from the response

“The Campbell Centre management team has refined its governance processes to ensure that changes have been embedded. This includes several checks carried out during each shift by a duty senior nurse to ensure that observations are completed on time, a daily review by the MDT on those patients at most risk of harm, and senior nursing input allocated to support this.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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

Revise the observation audit schedule to monitor weekly improvement under senior practice development nurse leadership.

Verbatim wording from the response

“A system of audit schedules has been revised to check for weekly improvement, this is led by a senior practice development nurse.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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

Implement systems and processes supporting adherence to the observation and therapeutic engagement policy, with monitoring of staff understanding, training and compliance.

Verbatim wording from the response

“The Divisional Directors have provided assurance that the Campbell Centre management team has implemented new systems and processes to support staff in applying the Trust Policy on Observation and Therapeutic engagement and have introduced measures to monitor understanding, training, and compliance. They have advised that there have been meetings with all staff to emphasise the importance of adherence to the Policy.”

Source location

Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024

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 Campbell Centre always has an ample, accessible oxygen supply, disputing that the resuscitation oxygen bottle ran out.

Verbatim wording from the response

“The Divisional Directors have confirmed that there is always an ample supply of oxygen across the Campbell Centre, which is easily accessible to trained staff. They have checked that all of our nurses are trained to conduct daily checks of the supplies and that temporary, or new staff members, receive an induction on oxygen availability before they start providing care.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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.4

  1. 1

    Attach a visual oxygen-switching aid to every oxygen cylinder.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.
  2. 2

    Issue written communication about the oxygen issue to all Trust staff.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.
  3. 3

    Strengthen induction for temporary and new staff so they can identify patients’ needs more effectively.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.
  4. 4

    Provide targeted oxygen-use training, including increased simulation exercises alongside mandatory emergency life-support training.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 October 2024.

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

Attach a visual oxygen-switching aid to every oxygen cylinder.

Verbatim wording from the response

“Since the inquest, the Trust Resuscitation Group have developed a visual aid that is attached to each oxygen cylinder that clearly explains how to switch on the oxygen. In addition, a written communication highlighting this issue has been sent out to all Trust staff.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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

Issue written communication about the oxygen issue to all Trust staff.

Verbatim wording from the response

“Since the inquest, the Trust Resuscitation Group have developed a visual aid that is attached to each oxygen cylinder that clearly explains how to switch on the oxygen. In addition, a written communication highlighting this issue has been sent out to all Trust staff.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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

Strengthen induction for temporary and new staff so they can identify patients’ needs more effectively.

Verbatim wording from the response

“The specific themes from Ms Stewart’s inquest have been discussed in group supervision, individual supervision and ward meetings. The Campbell Centre management team has strengthened how temporary and new staff members are inducted to ensure that they can better identify their patients' needs. They have also embedded a system to oversee staff uptake of training in the use of observations and therapeutic engagements.”

Source location

Response from Central and NW London NHS Trust
Page 1 · response
Published 11 October 2024

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 targeted oxygen-use training, including increased simulation exercises alongside mandatory emergency life-support training.

Verbatim wording from the response

“The Campbell Centre management team has provided targeted training, including increasing the use of simulation exercises to improve familiarity with oxygen use, in addition to regular mandatory training in emergency life support.”

Source location

Response from Central and NW London NHS Trust
Page 2 · response
Published 11 October 2024

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