Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 36
East London NHS Foundation Trust
Use escalation protocols to guide staff when resources are insufficient to meet care needs.
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East London NHS Foundation Trust
Continue using Safety Huddles and document discussions on the handover template.
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East London NHS Foundation Trust
Deliver face-to-face Honesty in Documentation training across inpatient services.
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East London NHS Foundation Trust
Increase staffing on each shift by one unregistered Band 3 member and add a weekday Band 4 Life Skills Recovery Worker.
View source
East London NHS Foundation Trust
Recruit to eliminate registered vacancies, review unregistered workforce skills, and maintain safer staffing rota approval and monitoring.
View source
East London NHS Foundation Trust
Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
View source
East London NHS Foundation Trust
Offer carers and significant others follow-up support calls and use an escalation process to improve communication.
View source
East London NHS Foundation Trust
Pilot Trust-wide clinical induction and provide bank staff protected study time to achieve equivalent competencies.
View source
East London NHS Foundation Trust
Review night-shift culture, design night-practice standards and develop assurance for unsupervised night visits.
View source
East London NHS Foundation Trust
Introduce observation relay boards to reduce missed observations and improve clinical-information handover.
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East London NHS Foundation Trust
Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
View source
East London NHS Foundation Trust
Develop a learning system linking internal incident and improvement learning with national observation-practice work.
View source
East London NHS Foundation Trust
Improve governance for temporary and bank nursing staff, including training-compliance oversight, supervision and reflective practice.
View source
East London NHS Foundation Trust
Deliver monthly Tower Hamlets training on Dialog+ care planning, safety plans and risk formulations using group scenarios.
View source
East London NHS Foundation Trust
Pilot the Microsoft PowerApps observation-documentation application on four wards and plan wider inpatient rollout.
View source
East London NHS Foundation Trust
Review findings from the service-user qualitative observations audit tool.
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East London NHS Foundation Trust
Facilitate weekly safety discussions for inpatient staff to review observation data, reflect on practice gaps and disseminate learning.
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East London NHS Foundation Trust
Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
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East London NHS Foundation Trust
Develop a second Trust-wide quality-improvement phase with the multidisciplinary team to identify alternatives to daytime observations.
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East London NHS Foundation Trust
Maintain participation in the Cavendish Square community of practice to develop approaches and adopt learning.
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East London NHS Foundation Trust
Run Trust-wide learning seminars on incident learning, improvement work and good practice.
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East London NHS Foundation Trust
Review and relaunch the Standard Observation Measurement tool and its outputs to influence practice.
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East London NHS Foundation Trust
Complete the external human-factors analysis of inpatient observation practice and conduct senior leadership review of its findings and suggested improvements.
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East London NHS Foundation Trust
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
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East London NHS Foundation Trust
Establish an Executive-led improvement board to monitor actions and agreed plans.
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East London NHS Foundation Trust
Adjust observation spot-check data to focus specifically on observation quality and begin collecting it.
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East London NHS Foundation Trust
Provide twilight shifts and zonal observation approaches to increase therapeutic engagement and monitor patients and ward dynamics.
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East London NHS Foundation Trust
Use Power BI to capture current missed-observation data consistently and accessibly.
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East London NHS Foundation Trust
Cover the administrators’ office during handover and allocate the patient/carer phone to a named, logged staff member.
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East London NHS Foundation Trust
Design internal governance for reviewing missed-observation cases and reporting resulting learning to safety and quality committees.
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East London NHS Foundation Trust
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
View source
East London NHS Foundation Trust
Operate annual inpatient safety-culture assessments, share team reports and discuss findings with staff.
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East London NHS Foundation Trust
Introduce the Loop App so only staff with required competencies can book bank shifts.
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East London NHS Foundation Trust
Develop and roll out a standardised 24-hour handover template with daily and quarterly audits.
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East London NHS Foundation Trust
Continue reviewing escalation protocols to support task prioritisation, rapid resource deployment and reporting of compromised care.
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East London NHS Foundation Trust
Continue work promoting honesty in documentation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to conduct an adequate risk assessment before ending a safety plan
Wider context from the report “Concern 5
A safety plan had been agreed with Anna and put in place in the afternoon of 24 November 2021. This worked well and was a good example of staff thinking about Anna’s safety and the best strategy in the context of least restrictive practice. However, during the night shift, that safety plan was ended without a formal (or any adequate) risk assessment taking place . In accordance with the Trust’s policy, safe and supportive observation levels cannot be decreased without the input of a doctor. I remain unclear whether the same applies to other measures contained in safety plans and the PFD witness was unable to confirm the position.
” 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 complete safe and supportive observation charts to the required standard
Wider context from the report “Concern 2
The Trust’s policy is very clear on what should be recorded on the safe and supportive observation charts. In addition, all of the witnesses could explain in evidence, the expectation and what good practice looks like. However, only one staff member’s entries met this expectation . All of the other entries that I was taken to simply recorded Anna’s location at the time of the observation . I heard evidence that observation records are audited for quality and entries raised with staff if they do not meet expectations. However, this process of auditing was in place at the time of Anna’s death and the observation entries of the senior nurses responsible for that auditing were of the same poor quality.
” 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 and pass on safety-relevant information
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on ; an entry relating to a different patient was recorded in Anna’s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information.
” 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 written handover records to capture vital information
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in Anna’s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information .
” 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 audit staff to produce adequate observation records
Wider context from the report “Concern 2
The Trust’s policy is very clear on what should be recorded on the safe and supportive observation charts. In addition, all of the witnesses could explain in evidence, the expectation and what good practice looks like. However, only one staff member’s entries met this expectation. All of the other entries that I was taken to simply recorded Anna’s location at the time of the observation. I heard evidence that observation records are audited for quality and entries raised with staff if they do not meet expectations. However, this process of auditing was in place at the time of Anna’s death and the observation entries of the senior nurses responsible for that auditing were of the same poor quality .
” 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 complete safe and supportive observations
Wider context from the report “Concern 3
In Anna’s case, safe ad supportive observations were missed . This is, at least, in part due to high acuity on the unit as a whole on the night of Anna’s death, a support worker undertaking those observations being called away to an emergency and her colleagues reporting being unaware that she had left the ward . I heard evidence about steps that have been put in place to prevent observations being missed but the data provided by the Trust appeared to show that missed observations are rising and not decreasing. However, the data provided was out of date and the PFD witness was unable to interpret what was provided. I heard evidence about a strong focus on safety, openness and honesty following Anna’s death. I am therefore unclear whether the data reflects a true rise in missed observations or whether it is the result of more honest reporting of missed observations by staff on the ground.
” Is this part of a recurring concern? Yes — Unreliable patient observation arrangements .
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 spot checks to identify and address falsified observation records
Wider context from the report “Concern 4
In Anna’s case, observation records were backfilled despite the observations not having been conducted. All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done”. As the spot checks described to me only look at the quality and timings of the written observations , I am not reassured that records are not still being falsified or about how this is being identified and addressed .
” 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 Falsification of safe and supportive observation records
Wider context from the report “Concern 4
In Anna’s case, observation records were backfilled despite the observations not having been conducted . All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done ”. As the spot checks described to me only look at the quality and timings of the written observations, I am not reassured that records are not still being falsified or about how this is being identified and addressed.
” 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 keep patient records accurate and correctly attributed
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in Anna’s records ; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information.
” 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 maintain secure individual account access
Wider context from the report “Concern 1
There were issues with record keeping across the board. Including, a telephone call from Anna’s mother reporting concerning messages was not recorded or passed on; an entry relating to a different patient was recorded in Anna’s records; staff were sharing log on details or not logging off from their account (also raising data protection concerns); and the written handover document was inadequate, failing to record vital information.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report
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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 Use escalation protocols to guide staff when resources are insufficient to meet care needs.
Verbatim wording from the response “Escalation protocols have been developed for use to guide staff when there are not sufficient resources in place to meet care needs.”
Source location Response from ELFT Page 4 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue using Safety Huddles and document discussions on the handover template.
Verbatim wording from the response “14. In addition, the Trust will continue to use Safety Huddles as a way of discussion and decision making during a shift. Safety Huddle discussions will be documented on the handover template. This will ensure vital information during a shift is captured in the handover documentation.”
Source location Response from ELFT Page 3 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver face-to-face Honesty in Documentation training across inpatient services.
Verbatim wording from the response “Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.”
Source location Response from ELFT Page 5 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase staffing on each shift by one unregistered Band 3 member and add a weekday Band 4 Life Skills Recovery Worker.
Verbatim wording from the response “Staffing/ resource availability | Staff establishment reviews were undertaken in 22/23 and 23/24. Correct and agreed investments have gone into teams, increasing staff on each shift by one unregistered Band 3. Additional investment has been made for a Band 4 Life Skills Recovery Worker on Mondays to Fridays 9am to 5pm to increase the delivery of activities and opportunities for meaningful engagement.”
Source location Response from ELFT Page 4 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit to eliminate registered vacancies, review unregistered workforce skills, and maintain safer staffing rota approval and monitoring.
Verbatim wording from the response “A proactive recruitment campaign has been ongoing with services moving to zero registered vacancies and a review of the unregistered workforce (correct band and skill). Staffing rotas for the wards have been reviewed and updated to reflect safer staffing requirements; senior approval of rotas is required six weeks in advance of the current period and quarterly rota monitoring meetings are in place.”
Source location Response from ELFT Page 4 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
Verbatim wording from the response “The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.”
Source location Response from ELFT Page 5 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Offer carers and significant others follow-up support calls and use an escalation process to improve communication.
Verbatim wording from the response “7. In addition, HTT staff will be offering carers and significant others a check-in/follow up call for support as needed. An escalation process has been put in place to improve communication within and outside of the team.”
Source location Response from ELFT Page 2 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot Trust-wide clinical induction and provide bank staff protected study time to achieve equivalent competencies.
Verbatim wording from the response “A pilot of Trust-wide clinical induction started in August 2024. Prior to this, comprehensive clinical inductions were being done in directorates. This Trust-wide approach supports consistency of material and ensures core learning on commencement of clinical roles. Non substantive staff (bank staff) are booked to attend and have access to protected study time to achieve the same competencies as substantive staff.”
Source location Response from ELFT Page 5 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review night-shift culture, design night-practice standards and develop assurance for unsupervised night visits.
Verbatim wording from the response “A review of night-shift culture engaging staff and service users and observing work as done. Design standards for night shift practice and a mechanism for assessing unsupervised night visits.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce observation relay boards to reduce missed observations and improve clinical-information handover.
Verbatim wording from the response “A Trust-wide Quality Improvement programme which involved all inpatient teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”
Source location Response from ELFT Page 6 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
Verbatim wording from the response “Communication
To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a learning system linking internal incident and improvement learning with national observation-practice work.
Verbatim wording from the response “Learning system
To develop a learning system that includes learning from incidents and improvement work internally, but that also links in with national work in relation to observations practice.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve governance for temporary and bank nursing staff, including training-compliance oversight, supervision and reflective practice.
Verbatim wording from the response “Staff knowledge and capability
To improve the robustness and governance of systems for the temporary/bank nursing workforce. This would include better oversight of training compliance and support offered (supervision and reflective practice).”
Source location Response from ELFT Page 7 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver monthly Tower Hamlets training on Dialog+ care planning, safety plans and risk formulations using group scenarios.
Verbatim wording from the response “25. In Tower Hamlets the Trust has introduced Dialog+ Plus and Safety Planning training facilitated by Trust Matrons. We have a monthly schedule where inpatient staff in Tower Hamlets must attend Training covering Dialog+ care planning, safety plans and risk formulations. Staff have an opportunity to practice using scenarios in groups.”
Source location Response from ELFT Page 9 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Pilot the Microsoft PowerApps observation-documentation application on four wards and plan wider inpatient rollout.
Verbatim wording from the response “A digital application to document observations (using Microsoft PowerApps) has been developed and is in the testing phase. It is planned that this will be piloted from October 2024 on four wards and then scaled across all inpatient units.”
Source location Response from ELFT Page 6 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review findings from the service-user qualitative observations audit tool.
Verbatim wording from the response “A review of findings from the service user experience of observations qualitative audit tool. The introduction of the Loop App will ensure that only staff with the required competencies for each clinical area are able to book onto bank shifts.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Facilitate weekly safety discussions for inpatient staff to review observation data, reflect on practice gaps and disseminate learning.
Verbatim wording from the response “Safety discussion sessions are facilitated weekly in directorates for all inpatient staff to review observation data, reflect on gaps in practice and disseminate learning.”
Source location Response from ELFT Page 5 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
Verbatim wording from the response “Standardised processes
To develop a consistent approach to supporting staff to learn from their observations practice through reflection, personal accountability and if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.”
Source location Response from ELFT Page 9 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a second Trust-wide quality-improvement phase with the multidisciplinary team to identify alternatives to daytime observations.
Verbatim wording from the response “Developing the second phase of quality improvement work to include collaborative work with the whole MDT to identify alternatives to observations during working hours. This would require a significant cultural shift away from observations, which will require a significant project to be undertaken Trust-wide.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain participation in the Cavendish Square community of practice to develop approaches and adopt learning.
Verbatim wording from the response “Observation practice
To maintain involvement in the Cavendish Square community of practice attended by Chief Nurses to develop new approaches and adopt learning.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run Trust-wide learning seminars on incident learning, improvement work and good practice.
Verbatim wording from the response “Trust-wide learning lessons seminars open to all staff focus on areas of learning and improvement from incidents or identified areas of good practice.”
Source location Response from ELFT Page 5 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and relaunch the Standard Observation Measurement tool and its outputs to influence practice.
Verbatim wording from the response “Review and relaunch use of SOM tool and outputs to impact on practice.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete the external human-factors analysis of inpatient observation practice and conduct senior leadership review of its findings and suggested improvements.
Verbatim wording from the response “Building on the Quality Improvement work around therapeutic engagement and observations, in June 2024 ELFT commissioned an external Human Factors and Patient Safety Consultant to undertake an analysis of observations practice on our mental health In-Patient Wards to better understand observations practice from a human factors/systems approach, and to provide redesign ideas to address any gaps, pain points and workarounds that exist. Once the work has been completed, senior leadership review of the findings and suggested improvements of the Human Factors Analysis work.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Verbatim wording from the response “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an Executive-led improvement board to monitor actions and agreed plans.
Verbatim wording from the response “An Executive-led improvement board will monitor actions and agreed plans.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adjust observation spot-check data to focus specifically on observation quality and begin collecting it.
Verbatim wording from the response “17. The Directorate has now adjusted spot check data to be specific around quality of observations. It will begin collecting data from September 2024.”
Source location Response from ELFT Page 3 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide twilight shifts and zonal observation approaches to increase therapeutic engagement and monitor patients and ward dynamics.
Verbatim wording from the response “A Trust-wide Quality Improvement programme which involved all inpatient teams and service users across the Trust, and ran over a period of 18 months, was undertaken from September 2022 and led to three agreed interventions. The aim was to improve consistency of completed observations and shift the culture of observation practice. The three change ideas agreed to move into standard practice were:”
Source location Response from ELFT Page 6 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Power BI to capture current missed-observation data consistently and accessibly.
Verbatim wording from the response “20. I apologise that the most up to date data was not provided during the inquest hearing in relation to missed observations. It has come to my attention that the data from an old presentation was used. Going forward we are using power BI (a Microsoft data application) to capture up-to-date information in a consistent and easily accessible fashion.”
Source location Response from ELFT Page 4 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Cover the administrators’ office during handover and allocate the patient/carer phone to a named, logged staff member.
Verbatim wording from the response “6. Steps are now in place to ensure calls are not missed: the administrators’ office will now be covered with admin staff during the team handover from 14:00 to 16:00 to ensure calls are not missed.”
Source location Response from ELFT Page 2 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Design internal governance for reviewing missed-observation cases and reporting resulting learning to safety and quality committees.
Verbatim wording from the response “To design an internal governance process for the review of reported cases of missed observations and learning that arises from this, that will report into the Patient Safety and Quality Assurance committees.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Verbatim wording from the response “19. The Trust is currently developing a new E-observations (e-obs) platform which has in-built prompts to ensure staff capture the location of a patient, what they observe and their interactions with a patient. Daily spot checks will be undertaken by the clinical nurse manager or the most senior nurse on shift out of hours. It is hoped that this will be in place in the coming six months.”
Source location Response from ELFT Page 3 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate annual inpatient safety-culture assessments, share team reports and discuss findings with staff.
Verbatim wording from the response “Since 2023 a new safety culture self-assessment process has been incorporated into the Quality Assurance annual review process for each in-patient team across ELFT. Annually, staff complete an anonymous survey based on each component safety culture element. A bespoke team report on the safety culture results is then shared back to directorates and teams (where enough responses are received) with advice/signposting to where steps can be taken to strengthen safety culture. The survey tool results are then discussed in team away-days and meetings with teams, enabling local leaders to focus on areas where improvements need to be made.”
Source location Response from ELFT Page 7 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Loop App so only staff with required competencies can book bank shifts.
Verbatim wording from the response “A review of findings from the service user experience of observations qualitative audit tool. The introduction of the Loop App will ensure that only staff with the required competencies for each clinical area are able to book onto bank shifts.”
Source location Response from ELFT Page 8 · response Published 31 July 2024
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and roll out a standardised 24-hour handover template with daily and quarterly audits.
Verbatim wording from the response “13. Tower Hamlets is currently working on creating a standardised handover template. This project is being led by the Deputy Borough Lead Nurse. The aim is to have a running document over a 24-hour period. The handover template has been tested on some of the wards and is currently being rolled out to the remaining wards. Roll out should be completed by the end of September 2024. The Matron responsible for ward will be responsible for the initial audit daily, this will be audited by the Lead Nurses quarterly.”
Source location Response from ELFT Page 3 · response Published 31 July 2024
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing escalation protocols to support task prioritisation, rapid resource deployment and reporting of compromised care.
Verbatim wording from the response “Staffing/resource availability
Continue to review escalation protocols to senior staff on site in response to changes in acuity or demand or if there are staff shortages on a shift. This is to include:”
Source location Response from ELFT Page 7 · response Published 31 July 2024
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue work promoting honesty in documentation.
Verbatim wording from the response “Continued work on honesty in documentation.”
Source location Response from ELFT Page 7 · response Published 31 July 2024
Open published response