PFD report

Sylvia May NASH · Prevention of Future Deaths report

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Issued 2 Jan 2024•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
2

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
7

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 to involve the care home in decisions about removal of observations
  2. Failure to understand and follow the correct inter-agency decision-making process
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.5

  1. Action

    Ensure visiting professionals consider the potential safety impact of removing 1:1 observations.

    Stated by Connaught HouseStated plannedThe respondent said that this action was planned when they made their response on 8 January 2024.
  2. Action

    Cascade the new 1:1 review process to staff and display it in each nursing station.

    Stated by Connaught HouseStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
  3. Action

    Develop procedures requiring multidisciplinary decisions before removing one-to-one support in P2 beds.

    Stated by Birmingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    Orchards Nursing Home was responsible for reviewing Sylvia’s needs and seeking authorisation for 1:1 care if required.

    Stated by Connaught HouseRedirects 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 involve the care home in decisions about removal of observations

Wider context from the report

“1. It was clear both from the evidence and subsequent correspondence that the correct process for making decisions, such as (but not exclusively), removal of 1:1 observations, is not understood adequately by all parties who should be involved in that decision making process. 2. Whilst the Council understood this to be a multi-disciplinary process involving any professional involved in the patient’s care, the care home, Connaught House, indicated that this decision rests solely with the Council. 3. This is concerning for two reasons. Firstly, the correct procedure is not understood and therefore has not been followed. Secondly, the fact that the care home, where the patient resides is of the view that they are not responsible for making decisions as to removal of observations ahead of transfer. They, in my view, should be pivotal in this decision as the organisation who have had the most contact with the patient and therefore in a position to provide important information as to risk and behaviour. 4. I am concerned that the communication and understanding of the correct process between agencies is insufficient. ”

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 understand and follow the correct inter-agency decision-making process

Wider context from the report

“1. It was clear both from the evidence and subsequent correspondence that the correct process for making decisions, such as (but not exclusively), removal of 1:1 observations, is not understood adequately by all parties who should be involved in that decision making process. 2. Whilst the Council understood this to be a multi-disciplinary process involving any professional involved in the patient’s care, the care home, Connaught House, indicated that this decision rests solely with the Council. 3. This is concerning for two reasons. Firstly, the correct procedure is not understood and therefore has not been followed. Secondly, the fact that the care home, where the patient resides is of the view that they are not responsible for making decisions as to removal of observations ahead of transfer. They, in my view, should be pivotal in this decision as the organisation who have had the most contact with the patient and therefore in a position to provide important information as to risk and behaviour. 4. I am concerned that the communication and understanding of the correct process between agencies is insufficient. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Ensure visiting professionals consider the potential safety impact of removing 1:1 observations.

Verbatim wording from the response

“We have ensured that this has been cascaded to our staff team and a poster has been placed in each nursing station to ensure that all involved in any 1:1 review are fully aware of this new process. We will also ensure that any visiting professional also fully considers the potential impact of the removal of 1:1 observations.”

Source location

Response from Connaught House 2
Page 2 · response
Published 8 January 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

Cascade the new 1:1 review process to staff and display it in each nursing station.

Verbatim wording from the response

“We have ensured that this has been cascaded to our staff team and a poster has been placed in each nursing station to ensure that all involved in any 1:1 review are fully aware of this new process. We will also ensure that any visiting professional also fully considers the potential impact of the removal of 1:1 observations.”

Source location

Response from Connaught House 2
Page 2 · response
Published 8 January 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

Develop procedures requiring multidisciplinary decisions before removing one-to-one support in P2 beds.

Verbatim wording from the response

“BCC has worked with colleagues in the Integrated Care Board (ICB) to develop procedures around 1 to 1 support. The P2 (assessment) beds that Sylvia stayed in at Connaught House are funded by the ICB, so the ICB are taking a lead on developing this and embedding the new procedures across P2 beds. The procedure now clearly states that 1 to 1 support can only be removed following an MDT decision involving the care home nurse, social worker, and the clinical need.”

Source location

Response from Birmingham City Council
Page 4 · response
Published 8 January 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

Introduce a template for recording multidisciplinary discussions, agreed actions and risk mitigations.

Verbatim wording from the response

“In Sylvia’s case, the care record does not evidence the multi-disciplinary input and decision-making process. To address this, there have been staff engagement sessions and discussions with the Social Work staff around evidencing the multi-disciplinary decision making. There is now a template that workers need to complete to record the discussion, any agreed actions, and any risk mitigations.”

Source location

Response from Birmingham City Council
Page 3 · response
Published 8 January 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

Continue advocating for residents’ assessed care needs, including required 1:1 support.

Verbatim wording from the response

“I do not believe that it is within our power to make any changes to the way that funding is assessed or agreed by the Council or the ICB and we will continue to provide 1:1 care where we have assessed that it is required and continue to advocate for the residents in our care.”

Source location

Response from Connaught House
Page 3 · response
Published 8 January 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

Orchards Nursing Home was responsible for reviewing Sylvia’s needs and seeking authorisation for 1:1 care if required.

Verbatim wording from the response

“Our clinical decision was that Sylvia required 1:1 observations whilst in our care. We continually reevaluated and this was reduced to 12 hours during the day as we utilised our assistive technology during the night. It was the clinical decision of the Orchards Nursing Home that they could meet her assessed needs without the need for 1:1 supervision. It is worth noting that Sylvia was a resident of the Orchards Nursing Home for slightly longer than she was at Connaught House and any clinical decision should be subject to constant review. If they felt at any stage that Sylvia required 1:1 care then it was their responsibility to seek authorisation.”

Source location

Response from Connaught House 2
Page 1 · response
Published 8 January 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 Integrated Care Board leads development and implementation of procedures for one-to-one support across P2 beds.

Verbatim wording from the response

“BCC has worked with colleagues in the Integrated Care Board (ICB) to develop procedures around 1 to 1 support. The P2 (assessment) beds that Sylvia stayed in at Connaught House are funded by the ICB, so the ICB are taking a lead on developing this and embedding the new procedures across P2 beds. The procedure now clearly states that 1 to 1 support can only be removed following an MDT decision involving the care home nurse, social worker, and the clinical need.”

Source location

Response from Birmingham City Council
Page 4 · response
Published 8 January 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

Removal of one-to-one support at Connaught House is an MDT decision, not the responsibility of Birmingham City Council’s P2 team.

Verbatim wording from the response

“BCC does not use Connaught House for P2 provision. However, the ICB when required does spot purchase beds at Connaught House, which the ICB then oversees. Discussions have taken place between Connaught House and the ICB to ensure Connaught House understands that responsibility for removing 1 to 1 support does not sit with the BCC P2 team but is an MDT decision, which should include the care home nurse, clinical lead, and the social worker.”

Source location

Response from Birmingham City Council
Page 4 · response
Published 8 January 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

Connaught House did not remove Sylvia’s 1:1 observations; enhanced care remained in place throughout her stay.

Verbatim wording from the response

“The Regulation 28 Order suggests that Connaught House could make some changes to its procedures with respect to the cessation of 1:1 care and we strongly disagree with this conclusion. At no stage did Connaught House remove the 1:1 care for Sylvia and we kept this in place despite not being paid for this expensive provision. The P2 team are fully and solely responsible for the review of the care needs of any individual they place in a P2 bed and for the funding levels available to the new care setting they choose to send the resident to. Connaught House can only provide the information but are not in any position to dictate this decision in any way, shape or form.”

Source location

Response from Connaught House
Page 1 · response
Published 8 January 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

Changing how care funding is assessed or agreed is outside the respondent’s power; it can advise but cannot compel Council or ICB funding.

Verbatim wording from the response

“I do not believe that it is within our power to make any changes to the way that funding is assessed or agreed by the Council or the ICB and we will continue to provide 1:1 care where we have assessed that it is required and continue to advocate for the residents in our care.”

Source location

Response from Connaught House
Page 3 · response
Published 8 January 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 P2 team is responsible for reviewing placed residents’ care needs and determining the appropriate long-term placement.

Verbatim wording from the response

“The Regulation 28 Order suggests that Connaught House could make some changes to its procedures with respect to the cessation of 1:1 care and we strongly disagree with this conclusion. At no stage did Connaught House remove the 1:1 care for Sylvia and we kept this in place despite not being paid for this expensive provision. The P2 team are fully and solely responsible for the review of the care needs of any individual they place in a P2 bed and for the funding levels available to the new care setting they choose to send the resident to. Connaught House can only provide the information but are not in any position to dictate this decision in any way, shape or form.”

Source location

Response from Connaught House
Page 1 · response
Published 8 January 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

There was no communication or understanding failure concerning Sylvia’s need for 1:1 observations or the information provided to other agencies.

Verbatim wording from the response

“4. There is no issue with our communication or understanding of the need for 1:1 observations and this again was ably demonstrated by the care we delivered to Sylvia and the information we provided to the wider multi-disciplinary team. I would be extremely interested in the changes the Council have undertaken to adopt in light of this Regulation 28 Order as I believe the issue was not around our provision of information but rather whether there was an acceptance that this level of care was required or whether the Council could find an alternative placement that was cheaper. Connaught House did not decide that Sylvia needed to leave its care and nor did we decide that these 1:1 observations were not required. This decision was taken by others.”

Source location

Response from Connaught House
Page 3 · response
Published 8 January 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.2

  1. 1

    Conduct staff engagement sessions and discussions to reinforce recording of multidisciplinary decision-making.

    Stated by Birmingham City CouncilStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
  2. 2

    Continue providing 1:1 care where residents are assessed as requiring it.

    Stated by Connaught House Care HomeStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The Council is responsible for deciding funding for enhanced care and placements in alternative care settings.

    Stated by Connaught House Care HomeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The receiving care home is responsible for assessing transferred residents’ needs and increasing care provision when necessary.

    Stated by Connaught House Care HomeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Conduct staff engagement sessions and discussions to reinforce recording of multidisciplinary decision-making.

Verbatim wording from the response

“In Sylvia’s case, the care record does not evidence the multi-disciplinary input and decision-making process. To address this, there have been staff engagement sessions and discussions with the Social Work staff around evidencing the multi-disciplinary decision making. There is now a template that workers need to complete to record the discussion, any agreed actions, and any risk mitigations.”

Source location

Response from Birmingham City Council
Page 3 · response
Published 8 January 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

Continue providing 1:1 care where residents are assessed as requiring it.

Verbatim wording from the response

“I do not believe that it is within our power to make any changes to the way that funding is assessed or agreed by the Council or the ICB and we will continue to provide 1:1 care where we have assessed that it is required and continue to advocate for the residents in our care.”

Source location

Response from Connaught House
Page 3 · response
Published 8 January 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 Council is responsible for deciding funding for enhanced care and placements in alternative care settings.

Verbatim wording from the response

“2. I am unsure as to why the Council is suggesting that Connaught House, or indeed any other care home, has the power to decide the funding of care delivered by a different provider as it is clear from our experience that although we can decide that 1:1 care is necessary whilst a resident is in our care this doesn’t mean that the Council agree to this level of funding or indeed pay the invoices. The decision making process is a multi-disciplinary process solely in the respect of the provision of information but the decision to fund enhanced care or to make a placement in another care setting lies solely with the Council. This has been the case for every single resident that has ever been placed in a P2 bed and I am astounded the Council have now suggested otherwise.”

Source location

Response from Connaught House
Page 2 · response
Published 8 January 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 receiving care home is responsible for assessing transferred residents’ needs and increasing care provision when necessary.

Verbatim wording from the response

“Similarly, The Orchards Nursing Home was responsible for assessing Sylvia’s needs and for their decision that despite Sylvia being in receipt of 1:1 care at Connaught House they decided that they could meet her needs without 1:1 enhanced observations.”

Source location

Response from Connaught House
Page 1 · response
Published 8 January 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