PFD report

Norma Winifred BRUTON · Prevention of Future Deaths report

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Issued 19 May 2023•Birmingham and Solihull

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 of the falls risk assessment document to prompt consideration or documentation of attachments
    Part of recurring concern: Incomplete consideration of relevant factors in falls risk assessmentsPart of recurring concern: Unreliable objective criteria for safety risk assessment
  2. Failure of documentation on other forms to prompt reconsideration of the falls risk assessment
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Incomplete consideration of relevant factors in falls risk assessments
  3. Failure of the falls risk assessment document to prompt assessment of attachment relevance
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Incomplete consideration of relevant factors in falls risk assessmentsPart of recurring concern: Unreliable falls risk assessment tools
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.2

  1. Action

    Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 May 2023.
  2. Action

    Review the falls risk assessment and identify required improvements to capture equipment-related mobility risks.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2023.

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

  1. Position

    Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.

    Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 falls risk assessment document to prompt consideration or documentation of attachments

Wider context from the report

“1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions. 2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls. 3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment. ”

Is this part of a recurring concern?

Yes — Incomplete consideration of relevant factors in falls risk assessments; Unreliable objective criteria for safety risk assessment.

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 documentation on other forms to prompt reconsideration of the falls risk assessment

Wider context from the report

“1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions. 2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls. 3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Incomplete consideration of relevant factors in falls risk assessments.

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 falls risk assessment document to prompt assessment of attachment relevance

Wider context from the report

“1. The Birmingham Heartlands Hospital falls risk assessment document does not prompt staff to consider or document the presence of attachments such as chest drains or intravenous infusions. 2. The document does not prompt staff to comment on the relevance or otherwise of such attachments when assessing the risk of falls. 3. Where attachments are documented on other forms (for example, the manual handling assessment form), this does not prompt the staff to reconsider the falls risk assessment. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Incomplete consideration of relevant factors in falls risk assessments; Unreliable falls risk assessment tools.

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

Add a PICS falls-assessment dropdown for equipment such as drains and record the selected information in the Patient Handling Assessment Form.

Verbatim wording from the response

“Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023

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 the falls risk assessment and identify required improvements to capture equipment-related mobility risks.

Verbatim wording from the response

“Updates to falls risk assessment document We have considered the concerns you have raised within your report to prevent future deaths and we are taking steps to add in a drop down menu, within the falls risk assessment, which will allow staff to select an appropriate option if a patient has any equipment, such as drains, in place. This will then also be recorded in the PHAF (Patient Handling Assessment Form) therefore attachments will be reflected in both risk assessments. This will further increase staff awareness of falls risk factors.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023

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

Manual handling and falls assessments need not automatically feed into each other because staff are expected to consider them together with other records.

Verbatim wording from the response

“The information recorded in the manual handling assessment has not been designed to automatically feed into the falls risk assessment as this was considered to be a duplication of the information in the patient record. The recommendation is that these assessments are looked at in combination not isolation.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023

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.2

  1. 1

    Disseminate the importance of recording and considering patient attachments in manual-handling needs through nursing governance groups.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2023.
  2. 2

    Update the Trust Inpatient Falls Procedure to emphasise recording and considering patient attachments in manual-handling needs.

    Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2023.

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

Disseminate the importance of recording and considering patient attachments in manual-handling needs through nursing governance groups.

Verbatim wording from the response

“There is a lead in time for the changes to be made to our PICS system, and we can confirm that this change is expected to take place on the 15th August 2023. In the meantime whilst waiting for the programming work to be completed, the Lead Nurse for Falls Prevention has attended and highlighted at Divisional Preventing Harm Groups, which are attended by ward managers, Matrons and Deputy Directors of Nursing, the importance of ensuring that attachments are recorded and considered as part of a person’s manual handling needs. This has also been discussed at the Operational Care Quality Group chaired by the Director of Nursing Quality, Safety and Innovation, and attended by all of the Divisional Deputy Directors of Nursing and Nursing Leads for patient harm groups. We have also updated our Trust Inpatient Falls Procedure so that this is further emphasised.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023

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

Update the Trust Inpatient Falls Procedure to emphasise recording and considering patient attachments in manual-handling needs.

Verbatim wording from the response

“There is a lead in time for the changes to be made to our PICS system, and we can confirm that this change is expected to take place on the 15th August 2023. In the meantime whilst waiting for the programming work to be completed, the Lead Nurse for Falls Prevention has attended and highlighted at Divisional Preventing Harm Groups, which are attended by ward managers, Matrons and Deputy Directors of Nursing, the importance of ensuring that attachments are recorded and considered as part of a person’s manual handling needs. This has also been discussed at the Operational Care Quality Group chaired by the Director of Nursing Quality, Safety and Innovation, and attended by all of the Divisional Deputy Directors of Nursing and Nursing Leads for patient harm groups. We have also updated our Trust Inpatient Falls Procedure so that this is further emphasised.”

Source location

Response from University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 19 May 2023

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