PFD report

Wilfrid Pearson · Prevention of Future Deaths report

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Issued 24 Feb 2016•Manchester South

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
8

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
16

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 raised8

  1. Failure to maintain an up-to-date Status Epilepticus protocol
    Part of recurring concern: Unsafe updating of clinical policies and guidance
  2. Failure to promulgate the Status Epilepticus protocol to all relevant medical staff
    Part of recurring concern: Unreliable dissemination of safety-critical clinical guidance and learning
  3. Failure to establish lawful authority for detaining an agitated patient
    Part of recurring concern: Unreliable lawful decision-making for mental health patient detention and return
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.14

  1. Action

    Promote Deprivation of Liberty Safeguards principles through executive bulletins and Trust-wide posters.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 February 2016.
  2. Action

    Monitor Deprivation of Liberty Safeguards compliance and timescales through weekly reports to the Director of Quality and Governance.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 February 2016.
  3. Action

    Employ a Lead Nurse to advise staff and monitor compliance with Deprivation of Liberty Safeguards processes.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 February 2016.

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

  1. Position

    The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical condition.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustRedirects 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 maintain an up-to-date Status Epilepticus protocol

Wider context from the report

“1. The protocol for the observation, diagnosis and treatment of Status Epilepticus was written by the Consultant Neurologist who gave evidence to me. There was some doubt as to whether the document had been properly updated and whether and how it was promulgated to all relevant medical staff including locum doctors. ”

Is this part of a recurring concern?

Yes — Unsafe updating of clinical policies and guidance.

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 promulgate the Status Epilepticus protocol to all relevant medical staff

Wider context from the report

“1. The protocol for the observation, diagnosis and treatment of Status Epilepticus was written by the Consultant Neurologist who gave evidence to me. There was some doubt as to whether the document had been properly updated and whether and how it was promulgated to all relevant medical staff including locum doctors. ”

Is this part of a recurring concern?

Yes — Unreliable dissemination of safety-critical clinical guidance and learning.

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 establish lawful authority for detaining an agitated patient

Wider context from the report

“5. The deceased “absconded” from the ward and was described as agitated and confrontational. He was “brought back to the ward by Security”. I was told that no D.O.L.S. order was made or even contemplated, and he was not subject to compulsory detention under the Mental Health Act, therefore one has to ask where they derived the legal authority to detain the patient? ”

Is this part of a recurring concern?

Yes — Unreliable lawful decision-making for mental health patient detention and return.

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 by ITU doctors to prioritise brain protection

Wider context from the report

“3. There was no understanding of the need for, and method of, escalation of the care to the HDU or ITU and indeed according to the expert witness instructed by the Trust the impression is that the ITU doctors did not consider that brain protection was a high priority in Mr Pearson’s case”. ”

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 the need for and method of escalating care to HDU or ITU

Wider context from the report

“3. There was no understanding of the need for, and method of, escalation of the care to the HDU or ITU and indeed according to the expert witness instructed by the Trust the impression is that the ITU doctors did not consider that brain protection was a high priority in Mr Pearson’s case”. ”

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 of ITU registrar attendance at the ward when required

Wider context from the report

“4. There appears to have been a huge stress on the junior medical staff and I was told that “the ITU Registrar refused to attend the ward, but it is not normal for the ITU registrar to refuse to attend” and one of the junior doctors said “we were short staffed and overstretched”. This seems to have added to the omissions of care which were apparent. ”

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

Inadequate clarity, accuracy and completeness of medical and nursing notes

Wider context from the report

“2. The medical and nursing notes for Mr Pearson left much to be desired in terms of their clarity, accuracy and completeness. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Insufficient junior medical staffing capacity

Wider context from the report

“4. There appears to have been a huge stress on the junior medical staff and I was told that “the ITU Registrar refused to attend the ward, but it is not normal for the ITU registrar to refuse to attend” and one of the junior doctors said “we were short staffed and overstretched”. This seems to have added to the omissions of care which were apparent. ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

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

Promote Deprivation of Liberty Safeguards principles through executive bulletins and Trust-wide posters.

Verbatim wording from the response

“In addition Weightmans LLP have provided four sessions of Mental Capacity Training in September and October of 2015 for medical staff and Consultants. The Trust has another session scheduled for May 2016. To further promote the principles of DOLS and ensure staff are aware of these the trust has promotes this through the Trusts communication including my Chief Executive Bulletins ‘Catch up with Karen’ and posters have been distributed and displayed across the Trust. The Quality and Governance Team monitor DOLS and the timescales and a report is produced weekly which provides an update to the Director of Quality and Governance on the status of DOLS. Since the admission of Mr Pearson the Trust has undergone two CQC visits during which we have been challenged and scrutinised against the Trusts processes in place for Safeguarding Adults and Mental Capacity.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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

Monitor Deprivation of Liberty Safeguards compliance and timescales through weekly reports to the Director of Quality and Governance.

Verbatim wording from the response

“In addition Weightmans LLP have provided four sessions of Mental Capacity Training in September and October of 2015 for medical staff and Consultants. The Trust has another session scheduled for May 2016. To further promote the principles of DOLS and ensure staff are aware of these the trust has promotes this through the Trusts communication including my Chief Executive Bulletins ‘Catch up with Karen’ and posters have been distributed and displayed across the Trust. The Quality and Governance Team monitor DOLS and the timescales and a report is produced weekly which provides an update to the Director of Quality and Governance on the status of DOLS. Since the admission of Mr Pearson the Trust has undergone two CQC visits during which we have been challenged and scrutinised against the Trusts processes in place for Safeguarding Adults and Mental Capacity.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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

Employ a Lead Nurse to advise staff and monitor compliance with Deprivation of Liberty Safeguards processes.

Verbatim wording from the response

“Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered. The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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

Include the Status Epilepticus Policy in the mandatory Junior Doctor Grand Round.

Verbatim wording from the response

“The Trust’s Education Department have confirmed that Status Epilepticus Policy will now be included as part of the Junior Doctor Grand Round (this is the training programme that all Junior Doctors must complete). The Trust’s intranet has a search facility for documents which directs staff seeking guidance to documents including the Status Epilepticus Standards. The search also directs staff to the NICE Guidance Quality Standards for Epilepsies.”

Source location

W-Pearson-Response
Page 2 · response
Published 24 February 2016

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 medical staffing rotas to maximise senior cover and monitor staffing levels.

Verbatim wording from the response

“Since the time of Mr Pearson’s admission the rotas for medical staffing have been reviewed to maximise appropriate levels of senior cover and to monitor the levels of medical staffing.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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

Disseminate the Status Epilepticus Policy through junior doctor training, medical team discussions and the Trust intranet.

Verbatim wording from the response

“As well as making improvements to the Trust’s local policy, steps have been taken to ensure all clinicians at the Trust have awareness of the policy. It has been included as part of the training of Junior Doctors, and has been discussed with the Trust’s medical teams. The policy is also easily available for clinicians on the Trust’s intranet.”

Source location

W-Pearson-Response
Page 1 · response
Published 24 February 2016

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 nursing documentation and reinforce Ward Manager and Matron monitoring of documentation quality.

Verbatim wording from the response

“I am disappointed that HM Coroner found the medical and nursing records left much to be desired and I am sorry that you found this to be the case. HM Coroner will be aware that individual nursing and medical clinicians are responsible for their own professional standards. The Trust has a standard for medical record keeping and expects records to be timed and reflect an actual chronology. The Clinicians carrying out the assessment should document the time the assessment was carried out as well as the time of the medical entry. This is our Trust standard and the Trust encourage and promote this. The Trust has, since Mr Pearson’s admission, revised some of the nursing documentation and reinforced the role of Ward Managers and Matrons in monitoring the quality of documentation completed by staff.”

Source location

W-Pearson-Response
Page 2 · response
Published 24 February 2016

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

Work with local-authority Deprivation of Liberty Safeguards leads and Mental Capacity Advocates on safeguarding processes.

Verbatim wording from the response

“Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered. The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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

Deliver continuing Mental Capacity and Deprivation of Liberty Safeguards training for Trust staff, including the scheduled May 2016 session.

Verbatim wording from the response

“Again I am disappointed and concerned that HM Coroner found that it was unclear where the Trust derived that Legal Authority to detain the patient. I would like to take this opportunity to reassure HM Coroner that the Trust has undertaken a significant amount of work in relation to Safeguarding Adults and DOLS since 2014, and in particular promotion of when a DOLS is to be considered. The Trust employed a Lead Nurse who provides support and advice on DOLS for staff in May 2014 and who also monitors that processes are followed. The Trust works closely with the local Authority DOLS leads and Mental Capacity Advocates. Regular MCA/DOLS training sessions have been held in the Trust provided by an external expert in Mental Capacity and DOLS; this is open to all staff in the Trust.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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 recruiting medical staff and collaborate with Health Education North West and junior doctors to improve training experience and long-term attraction.

Verbatim wording from the response

“These take into account the mix in relation to substantive staff and locum staff. The Trust maintains an ongoing recruitment programme and has been working with Health Education North West and junior doctors to improve the experience of junior doctors in training and to attract medical staff long term.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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

Change and review the Critical Care Unit processes and care pathway.

Verbatim wording from the response

“The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical picture at a point in time. The Trust has a standard for the admission and discharge for Critical Care which provides guidance for clinical staff on the process for admission/escalation and this was revised in May 2014 to include further detail in relation to the National Early Warning Score and escalation and reviewed again in May 2015. This is available to all staff on the Trust’s intranet. The Critical Care Unit and the processes and pathway for Critical Care have been subject to extensive change since April 2014 and have been subject to independent third party review and inspection. They have been reviewed by the CQC as an independent third party in April 2015.”

Source location

W-Pearson-Response
Page 2 · response
Published 24 February 2016

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 and publish Critical Care admission, discharge and escalation standards, including National Early Warning Score guidance.

Verbatim wording from the response

“The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical picture at a point in time. The Trust has a standard for the admission and discharge for Critical Care which provides guidance for clinical staff on the process for admission/escalation and this was revised in May 2014 to include further detail in relation to the National Early Warning Score and escalation and reviewed again in May 2015. This is available to all staff on the Trust’s intranet. The Critical Care Unit and the processes and pathway for Critical Care have been subject to extensive change since April 2014 and have been subject to independent third party review and inspection. They have been reviewed by the CQC as an independent third party in April 2015.”

Source location

W-Pearson-Response
Page 2 · response
Published 24 February 2016

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 Trust’s Status Epilepticus Policy using current clinical guidance.

Verbatim wording from the response

“I am informed that since Mr Pearson’s admission in April 2014 nearly two years ago, Dr Douglass has revised the Trust’s Status Epilepticus Policy on two occasions, firstly in direct response to the admission of Mr Pearson and additionally at the time of review in 2015. The policy has been revised to assist clinicians in being able to more easily review and understand the appropriate steps to take when a patient presents with Status Epilepticus. The revisions were made by direct reference to recent guidance on Status Epilepticus published in the Lancet Medical Journal. Please find enclosed a copy of our current policy.”

Source location

W-Pearson-Response
Page 1 · response
Published 24 February 2016

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 key aspects of medical clinical documentation through the Trust’s Clinical Audit programme.

Verbatim wording from the response

“The Trust’s Clinical Audit programme, the Trust’s Clinical Lead for Clinical Audit has been working with doctors in training and audits have been undertaken which include key aspects of medical clinical documentation.”

Source location

W-Pearson-Response
Page 2 · response
Published 24 February 2016

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 decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical condition.

Verbatim wording from the response

“The decision to escalate a patient to critical care is ultimately a clinical decision made by clinicians based on the patient’s clinical picture at a point in time. The Trust has a standard for the admission and discharge for Critical Care which provides guidance for clinical staff on the process for admission/escalation and this was revised in May 2014 to include further detail in relation to the National Early Warning Score and escalation and reviewed again in May 2015. This is available to all staff on the Trust’s intranet. The Critical Care Unit and the processes and pathway for Critical Care have been subject to extensive change since April 2014 and have been subject to independent third party review and inspection. They have been reviewed by the CQC as an independent third party in April 2015.”

Source location

W-Pearson-Response
Page 2 · response
Published 24 February 2016

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

    Review Junior Doctor support and engagement and Consultant cover through the Medical Director’s revalidation-related work.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 February 2016.
  2. 2

    Implement robust monitoring of study leave and sickness, including return-to-work support and keep-in-touch arrangements.

    Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 February 2016.

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 Junior Doctor support and engagement and Consultant cover through the Medical Director’s revalidation-related work.

Verbatim wording from the response

“Additionally the engagement and support provided to Junior Doctors and cover provided by Consultants has been actively reviewed by the Medical Director alongside other work which forms part of the process for the medical staff revalidation programme. The Trust has also implemented more robust monitoring of study leave and staff sickness; these include ‘keep in touch’ days, and ways in which staff who are on sick leave can be supported back to work even if they are not clinically active to provide advice and guidance to colleagues.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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 robust monitoring of study leave and sickness, including return-to-work support and keep-in-touch arrangements.

Verbatim wording from the response

“Additionally the engagement and support provided to Junior Doctors and cover provided by Consultants has been actively reviewed by the Medical Director alongside other work which forms part of the process for the medical staff revalidation programme. The Trust has also implemented more robust monitoring of study leave and staff sickness; these include ‘keep in touch’ days, and ways in which staff who are on sick leave can be supported back to work even if they are not clinically active to provide advice and guidance to colleagues.”

Source location

W-Pearson-Response
Page 3 · response
Published 24 February 2016

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