PFD report

Robert Alan JONES · Prevention of Future Deaths report

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Issued 21 Jan 2015•Exeter and Greater Devon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to communicate the patient's total number of falls to all visiting staff
    Part of recurring concern: Failure to reliably identify and communicate individual patient risk factorsPart of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable communication of patient-care information between clinical staff
  2. Failure to record neurological observations correctly and at the minimum recommended frequency
    Part of recurring concern: Failure to carry out required neurological observationsPart of recurring concern: Unreliable recording of required observations in care and custody
  3. Use of an out-of-date post-falls checklist lacking required neurological observation details
    Part of recurring concern: Failure to carry out required neurological observationsPart of recurring concern: Unreliable post-fall assessment and clinical response
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

    Deliver neurological-observation training to registered nurses and reduced-consciousness assessment training to non-registered support staff.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.
  2. Action

    Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.
  3. Action

    Require falls risk and falls information in bedside handovers and safety briefings, with observational audits, feedback, and re-audit of information-sharing gaps.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.

    Stated by DRS GIBB MURCH GILLARD BOWYER & GEARYExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to communicate the patient's total number of falls to all visiting staff

Wider context from the report

“(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”

Is this part of a recurring concern?

Yes — Failure to reliably identify and communicate individual patient risk factors; Inadequate control of falls risks; Unreliable communication of patient-care information between clinical staff.

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 neurological observations correctly and at the minimum recommended frequency

Wider context from the report

“(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations; Unreliable recording of required observations in care and custody.

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

Use of an out-of-date post-falls checklist lacking required neurological observation details

Wider context from the report

“(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations; Unreliable post-fall assessment and clinical response.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Deliver neurological-observation training to registered nurses and reduced-consciousness assessment training to non-registered support staff.

Verbatim wording from the response

“(3) Ensure delivery of targeted training on performing neurological observations for nursing staff at South Molton Community Hospital and as a general communication across the trust.”

Source location

2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 2 · response
Published 21 January 2015

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 the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.

Verbatim wording from the response

“(1) Revise the Trust’s falls policy to include the recommended frequency and duration of neurological observations based on NICE guidance for patients where head injury has occurred or cannot be ruled out, and inclusion of relevant history of falls in handovers of care.”

Source location

2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 1 · response
Published 21 January 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Require falls risk and falls information in bedside handovers and safety briefings, with observational audits, feedback, and re-audit of information-sharing gaps.

Verbatim wording from the response

“The Trust’s falls policy (enclosed) has been revised to include information relating to the frequency and duration of neurological observations (in line with the relevant NICE guidelines) and published on the Trust’s policy website. The Trust’s policy includes a post falls checklist (enclosed) which details how often and for how long neurological observations should be recorded. The Trust’s bedside handover and safety briefing standard operating procedure clearly identifies information relating to patient falls (including their risk of falls) is a key component in shift to shift communication, and must be included in handover. Bedside handovers are audited via observation and reports and actions provided to wards and teams where there are gaps in information being shared. Improvement is measured by re-audit.”

Source location

2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 1 · response
Published 21 January 2015

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

Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.

Verbatim wording from the response

“To support the actions detailed above, the Trust will issue a Patient Safety Alert, which will communicate the need for neurological observations when a head injury has occurred or cannot be ruled out, completion of the post falls checklist, to include the frequency and duration of observations, to ensure the post falls checklist is filed with the patient’s observation chart for ease of access for all Multi-Disciplinary Team members, and to ensure that information relating to falls risk or actual falls is included in safety briefings and bedside handover. Patient Safety Alerts are disseminated across the whole Trust to clinical and managerial leads.”

Source location

2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 2 · response
Published 21 January 2015

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 filing of post-falls checklists with physiological and neurological observation charts for daily multidisciplinary team review of patients’ multiple falls.

Verbatim wording from the response

“As per (1), this information is included in safety briefings, which are multi-disciplinary events. Additionally, the Trust’s post falls checklist allows staff to record multiple falls on the same document, ensuring that information relating to falls is held in a central place. The trust is implementing a system that requires the post falls checklist to be filed with the patient’s physiological observations / neurological observations chart, which is reviewed by the Multi Disciplinary Team on a daily basis.”

Source location

2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 2 · response
Published 21 January 2015

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 hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.

Verbatim wording from the response

“The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

Source location

2015-0068-Response-by-The-Health-Centre
Page 1 · response
Published 21 January 2015

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 recommended safety actions are primarily the responsibility of the hospital trust.

Verbatim wording from the response

“The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

Source location

2015-0068-Response-by-The-Health-Centre
Page 1 · response
Published 21 January 2015

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.3

  1. 1

    Link the falls policy with the Bedside Handover and Safety Briefing standard operating procedure.

    Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2015.
  2. 2

    Hold ongoing discussions with Community Hospital management to embed the Action Plan’s measures into practice.

    Stated by DRS GIBB MURCH GILLARD BOWYER & GEARYStated plannedThe respondent said that this action was planned when they made their response on 21 January 2015.
  3. 3

    Share the hospital Action Plan with all GP colleagues in the practice.

    Stated by DRS GIBB MURCH GILLARD BOWYER & GEARYStated plannedThe respondent said that this action was planned when they made their response on 21 January 2015.

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

Link the falls policy with the Bedside Handover and Safety Briefing standard operating procedure.

Verbatim wording from the response

“A link from the falls policy will be put in to the Bedside Handover of Safety Briefing Standard Operating Procedure & vice versa.”

Source location

2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
Page 1 · response
Published 21 January 2015

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

Hold ongoing discussions with Community Hospital management to embed the Action Plan’s measures into practice.

Verbatim wording from the response

“I will be sharing this Action Plan with all GP colleagues in my practice and will be having ongoing discussions with the Community Hospital management team to ensure that these actions become firmly embedded into practice.”

Source location

2015-0068-Response-by-The-Health-Centre
Page 1 · response
Published 21 January 2015

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share the hospital Action Plan with all GP colleagues in the practice.

Verbatim wording from the response

“I will be sharing this Action Plan with all GP colleagues in my practice and will be having ongoing discussions with the Community Hospital management team to ensure that these actions become firmly embedded into practice.”

Source location

2015-0068-Response-by-The-Health-Centre
Page 1 · response
Published 21 January 2015

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