PFD report

Urmila Patel · Prevention of Future Deaths report

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Issued 26 Feb 2026•East London

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
15

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 to make decisive urgent CT head scan referrals
    Part of recurring concern: Unreliable CT scan request and escalation processes
  2. Failure to review preceding clinical records for relevant falls information
    Part of recurring concern: Failure to review relevant clinical records before care decisions
  3. Failure to undertake adequate falls risk assessments
    Part of recurring concern: Inadequate control of falls risks
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.11

  1. Action

    Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  2. Action

    Require ward rounds and multidisciplinary reviews to consider events from the preceding 24–72 hours, including weekends.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  3. Action

    Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.

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

  1. Position

    NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 make decisive urgent CT head scan referrals

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

Is this part of a recurring concern?

Yes — Unreliable CT scan request and escalation processes.

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 review preceding clinical records for relevant falls information

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

Is this part of a recurring concern?

Yes — Failure to review relevant clinical records before care decisions.

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 undertake adequate falls risk assessments

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 adequately assess the likelihood of traumatic intracranial bleeding after a fall

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

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

Failure to record falls

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Incomplete, inaccurate or unavailable clinical and care records; Unreliable documentation of falls and related clinical response.

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 monitor and supervise patients

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

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

Failure to produce meaningful mobility care plans

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes.

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 reassess falls risk after a fall

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable post-fall assessment and clinical response.

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 review warfarin prescriptions after a fall

Wider context from the report

“1. The failure of nurses on the ward to instigate an adequate falls risk assessment of Mrs Patel. 2. The failure of nursing staff on the ward to produce a meaningful care-plan for Mrs Patel’s mobility. 3. The failure of Trust staff to note a fall on 23rd June 2025 and reassess risk of falls. 4. The failure of nursing staff on the ward to monitor and supervise Mrs Patel on the afternoon of 29th June 2025. 5. The failure of Trust staff to adequately assess the likelihood of a traumatic intra-cranial bleed following the fall on 29th June 2025. 6. The failure of the duty doctor to act decisively and refer Mrs Patel for an urgent CT Head scan on 29th June 2025. 7. The failure of the duty doctor to review Mrs Patel’s warfarin prescription after the fall. 8. The failure of ward staff on the ward round on 30th June 2025 to read the clinical records from the previous day to alert them to Mrs Patel’s fall on 29th June 2025. ”

Is this part of a recurring concern?

Yes — Unreliable post-fall assessment and clinical response.

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

Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.

Verbatim wording from the response

“Targeted education has been delivered to nursing staff, focusing on the timely completion of falls risk assessments on admission, recognition of dynamic risk, and the importance of translating assessed risk into clear and practical care plans. This has been reinforced through ward-based teaching, safety huddles, and incorporation into local induction and refresher training.”

Source location

Response from Barts Health NHS Trust
Page 1 · response
Published 3 March 2026

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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 ward rounds and multidisciplinary reviews to consider events from the preceding 24–72 hours, including weekends.

Verbatim wording from the response

“Ward teams have been reminded that ward rounds and multidisciplinary reviews must include active consideration of events from the preceding 24–72 hours, including weekends.”

Source location

Response from Barts Health NHS Trust
Page 4 · response
Published 3 March 2026

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 a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.

Verbatim wording from the response

“Falls prevention has also been strengthened through a multidisciplinary quality improvement programme, recognising the contribution of nursing, medical, therapy, and pharmacy teams. This includes initiatives focused on appropriate footwear, structured medication review (including medicines associated with increased falls risk), and consistent post-fall multidisciplinary review. To support assurance, a ward-level falls audit programme commenced on 2 February 2026, with the most recent audit completed on 14 April 2026. Early findings demonstrate high compliance with falls risk assessment (97.2%), improved initiation of falls care plans (83.3%), improved completion of lying and standing blood pressure (78%), and timely medical review following falls. These findings are reviewed through ward and divisional governance processes to support sustained improvement.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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 a mandatory post-inpatient-fall medical review bundle and standardised proforma covering neurological assessment, imaging, anticoagulation, medication review and senior escalation.

Verbatim wording from the response

“A mandatory post-inpatient fall medical review care bundle has been implemented, supported by a standardised proforma. This provides a structured framework for clinical assessment and decision-making following a fall.”

Source location

Response from Barts Health NHS Trust
Page 3 · response
Published 3 March 2026

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

Introduce an out-of-hours falls review protocol requiring the Duty Matron or Site Manager to review inpatient falls within two hours.

Verbatim wording from the response

“Senior oversight has been enhanced through the introduction of an out-of-hours falls review protocol, requiring the Duty Matron or Site Manager to review all inpatient falls within two hours, providing assurance that appropriate actions and escalation have occurred.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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

Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.

Verbatim wording from the response

“A mandatory post-fall care bundle and checklist has been introduced for all inpatient falls. This ensures that each fall is managed as a clinical event requiring structured assessment and response, aligned to the Patient Safety Incident Response Framework.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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 case learning through medical and nursing governance forums and reinforce it through simulation training on deterioration, imaging and anticoagulation safety.

Verbatim wording from the response

“Learning from this case has been shared through medical and nursing governance forums and reinforced through simulation-based training focusing on deterioration, imaging decisions, and anticoagulation safety.”

Source location

Response from Barts Health NHS Trust
Page 3 · response
Published 3 March 2026

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 post-fall neurological observations through divisional governance and provide multidisciplinary simulation training on recognition, escalation and immediate management.

Verbatim wording from the response

“Monitoring reliability has been strengthened through regular audit of post-fall neurological observations, with findings reviewed through divisional governance structures. In addition, multidisciplinary simulation training has been introduced, using scenarios such as anticoagulated patients and neurological deterioration, to reinforce recognition of risk, escalation, and immediate management.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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

Introduce routine ward-level audits of falls assessments and care plans, with governance escalation, tracked actions and re-audit.

Verbatim wording from the response

“A programme of routine audit has been introduced to review both completion and quality of falls risk assessments and care plans. Findings are reviewed at ward level and escalated through Divisional Governance where required, with actions agreed, tracked, and re-audited.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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

Require ward managers and nurses in charge to review new admissions each shift for completed falls assessments and care plans.

Verbatim wording from the response

“Accountability has been strengthened through clearer expectations of ward leadership. Ward managers and nurses in charge are now required to review new admissions each shift to confirm that falls risk assessments and associated care plans have been completed, with prompt action taken where gaps are identified.”

Source location

Response from Barts Health NHS Trust
Page 1 · response
Published 3 March 2026

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

Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.

Verbatim wording from the response

“Actions taken The Trust has reinforced expectations that all inpatient falls and significant safety events are documented contemporaneously and clearly communicated during both nursing and medical handover.”

Source location

Response from Barts Health NHS Trust
Page 3 · response
Published 3 March 2026

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

NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.

Verbatim wording from the response

“Given the concerns you have raised I feel it is important that you receive a response directly from NHS England as it has oversight for the issues you raise. Therefore, my officials have contacted NHS England who have agreed to respond to you directly about the Prevention of Future Death report concerning Mrs Patel.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 3 March 2026

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

    Implement Martha’s Rule to enable families to request urgent clinical review when deterioration is suspected.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  2. 2

    Strengthen daily multidisciplinary board rounds through the MBRACE quality-improvement programme to review patient risk, including falls and frailty.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  3. 3

    Discuss falls risk and mobility status explicitly during shift handovers and safety huddles.

    Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 March 2026.
  4. 4

    Embed a Red Flag Escalation Standard Operating Procedure with defined escalation triggers, including concerns raised by patients, relatives and staff.

    Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2026.

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 Martha’s Rule to enable families to request urgent clinical review when deterioration is suspected.

Verbatim wording from the response

“To strengthen escalation, a Red Flag Escalation Standard Operating Procedure has been developed and is being embedded. This provides clear triggers for escalation to medical teams and explicitly includes concerns raised by patients, relatives, or staff. This is supported by the implementation of Martha’s Rule, enabling families to request urgent clinical review where deterioration is suspected.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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 daily multidisciplinary board rounds through the MBRACE quality-improvement programme to review patient risk, including falls and frailty.

Verbatim wording from the response

“Daily multidisciplinary board rounds have been strengthened through the MBRACE quality improvement programme, supporting structured review of patient risk, including falls and frailty, and improving shared situational awareness.”

Source location

Response from Barts Health NHS Trust
Page 4 · response
Published 3 March 2026

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

Discuss falls risk and mobility status explicitly during shift handovers and safety huddles.

Verbatim wording from the response

“Falls risk and mobility status are now explicitly discussed at shift handovers and safety huddles, supporting visibility across the multidisciplinary team and consistent application of preventative measures.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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

Embed a Red Flag Escalation Standard Operating Procedure with defined escalation triggers, including concerns raised by patients, relatives and staff.

Verbatim wording from the response

“To strengthen escalation, a Red Flag Escalation Standard Operating Procedure has been developed and is being embedded. This provides clear triggers for escalation to medical teams and explicitly includes concerns raised by patients, relatives, or staff. This is supported by the implementation of Martha’s Rule, enabling families to request urgent clinical review where deterioration is suspected.”

Source location

Response from Barts Health NHS Trust
Page 2 · response
Published 3 March 2026

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