PFD report

His Honour Bruce Caulfield · Prevention of Future Deaths report

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Issued 5 Feb 2026•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.

View original report
Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised4

  1. Delays between family concerns and medical review
  2. Failure of intentional rounding and nursing practices to ensure adequate hydration and nutrition for vulnerable ward patients
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needsPart of recurring concern: Unreliable intentional-rounding systems
  3. Failure to ensure prominent documentation of agreed sitting-out recommendations across the Trust
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.7

  1. Action

    Formalise Ward Manager and Matron walkarounds to increase assurance of mealtime preparedness and real-time patient feedback.

    Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
  2. Action

    Increase the volume and frequency of peer dining audits from March 2026, reporting results through senior nursing and nutrition governance.

    Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 February 2026.
  3. Action

    Continue enhanced auditing of appropriate food-chart commencement for three months to assure consistent nutrition monitoring across WTWA hospitals.

    Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.

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

  1. Position

    The Trust considers its comprehensive care approach, including nutrition and hydration support for vulnerable patients, sufficient to address the concern.

    Stated by Manchester University NHS Foundation TrustExisting 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

Delays between family concerns and medical review

Wider context from the report

“1. In relation to events leading up to His Honour’s death at Trafford General Hospital on 19th August 2025, I am concerned as to how long transpired between a family member expressing concerns about a significant change in his condition and requesting a review by a doctor, and any medical review actually taking place; ”

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 intentional rounding and nursing practices to ensure adequate hydration and nutrition for vulnerable ward patients

Wider context from the report

“2. Having considered all of the evidence before the inquest with the utmost care, I am concerned that the approach to intentional rounding at Wythenshawe hospital in conjunction with other relevant nursing practices is insufficient to ensure vulnerable patients (such as those with cognitive impairment or the inability to eat or drink without assistance) receive adequate hydration and nutrition whilst on the wards; ”

Is this part of a recurring concern?

Yes — Inadequate management of patients' nutrition and hydration needs; Unreliable intentional-rounding systems.

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 ensure prominent documentation of agreed sitting-out recommendations across the Trust

Wider context from the report

“3. Whilst the Ward Manager’s local investigation in relation to the circumstances of a fall His Honour sustained on Doyle Ward, Wythenshawe hospital on 30th July 2025 has resulted in an important change in practice as regards to communication between physiotherapy and nursing professionals as to agreed sitting-out recommendations and prominent documentation of these, I am concerned that comparable measures may not be in place across the Trust as a whole. ”

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 ensure communication of agreed sitting-out recommendations between physiotherapy and nursing professionals across the Trust

Wider context from the report

“3. Whilst the Ward Manager’s local investigation in relation to the circumstances of a fall His Honour sustained on Doyle Ward, Wythenshawe hospital on 30th July 2025 has resulted in an important change in practice as regards to communication between physiotherapy and nursing professionals as to agreed sitting-out recommendations and prominent documentation of these, I am concerned that comparable measures may not be in place across the Trust as a whole. ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff; Unreliable documentation and communication of shared clinical decisions.

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

Formalise Ward Manager and Matron walkarounds to increase assurance of mealtime preparedness and real-time patient feedback.

Verbatim wording from the response

“• Ward Manager and Matron walk arounds are in place and are now being formalised as part of increased assurance mechanisms to focus on mealtime preparedness and patient feedback in real time.”

Source location

Response from Manchester University NHS Foundation Trust
Page 8 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Increase the volume and frequency of peer dining audits from March 2026, reporting results through senior nursing and nutrition governance.

Verbatim wording from the response

“• Increased volume and frequency of peer audits from March 2026 reporting into the weekly Senior Nurse Huddle chaired by ████████ and oversight into the WTWA Nutrition and Hydration Group.”

Source location

Response from Manchester University NHS Foundation Trust
Page 8 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Continue enhanced auditing of appropriate food-chart commencement for three months to assure consistent nutrition monitoring across WTWA hospitals.

Verbatim wording from the response

“Following His Honour’s admission to Doyle Ward on 23 July 2025, he was placed on food charts on 24 July 2025. This measure allowed staff to track his nutrition status closely and respond promptly to any emerging concerns. An audit of 49 patient records at Wythenshawe Hospital, completed in February 2026, found that 89% of relevant patients had food charts commenced appropriately. This enhanced audit will continue for the next three months to provide further assurance of consistent practice across WTWA hospitals. As part of His Honour’s nutrition and hydration management, he was placed on the ‘red tray system’ on 24 July 2025. The red tray is a visible prompt for staff, indicating that the patient is at high risk of malnutrition and requires assistance with eating or drinking. During his admission, His Honour required encouragement and support with both eating and drinking.”

Source location

Response from Manchester University NHS Foundation Trust
Page 4 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Extend the Wythenshawe audit of physiotherapy assessments and nursing review processes across the Trust and report findings through hospital quality and safety groups.

Verbatim wording from the response

“For patients sitting out for the first time, or where fatigue risk is identified, AHP staff undertake structured assessments including medical history, baseline function, muscle strength, sitting balance and cognition. Recommendations regarding transfer method and seating are documented in HIVE and verbally handed over to nursing colleagues. Nursing staff implement these recommendations in conjunction with moving and handling risk assessments and ongoing observation.”

Source location

Response from Manchester University NHS Foundation Trust
Page 9 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide additional nutrition and hydration monitoring through quality and safety walk rounds led by nursing directors, with real-time feedback.

Verbatim wording from the response

“• Additional monitoring is being provided through quality and safety walk rounds led by the Director or Deputy Director of Nursing with feedback provided in real time.”

Source location

Response from Manchester University NHS Foundation Trust
Page 8 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Roll out Martha’s Rule through an Oak Ward pilot enabling patients and families to request urgent clinical review and a second opinion.

Verbatim wording from the response

“The Trust is rolling out Martha’s Rule, a national NHS patient safety initiative that empowers patients and families to request an urgent review and second opinion should they have concerns regarding the clinical condition of the patient. Oak Ward at Trafford Hospital has been identified as a pilot ward within the adult services roll-out. The pilot will commence in April 2026 and will be overseen by a Trust led oversight group and hospital site Quality and Patient Safety Groups.”

Source location

Response from Manchester University NHS Foundation Trust
Page 3 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Maintain consistent Trust-wide use of seating charts and documentation of allied health professional recommendations in HIVE for communication and care planning.

Verbatim wording from the response

“I would like to offer our sincere apologies if the evidence presented at the inquest gave the impression that the improvements implemented on Doyle Ward were isolated to that ward alone; this is not the case. Across all inpatient areas a seating chart is used consistently, whether as laminated bedside signage or integrated into therapy timetables. AHP recommendations are documented within HIVE, which is accessible to all clinical professionals across the Trust, ensuring a unified approach to communication and care planning.”

Source location

Response from Manchester University NHS Foundation Trust
Page 9 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Trust considers its comprehensive care approach, including nutrition and hydration support for vulnerable patients, sufficient to address the concern.

Verbatim wording from the response

“As you may be aware, ‘intentional rounding’ is a term used to describe a practice in care delivery to patients during their hospital admission; it is a structured proactive nursing process where staff check on patients at regular intervals to address any key needs such as pain, communication and placement of items such as a call bell. Although the terminology ‘intentional rounding’ was used with regards to care provided on Doyle Ward, it is not a term that is widely used across WTWA Hospitals to describe what is a more comprehensive approach to care delivery, which includes assessment and implementation of care. This approach is provided to all patients, including those patients who require support with nutrition and hydration, and those patients with a cognitive impairment.”

Source location

Response from Manchester University NHS Foundation Trust
Page 3 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Trust disputes that communication and documentation measures for sitting-out recommendations were isolated to Doyle Ward, stating they apply consistently across all inpatient areas.

Verbatim wording from the response

“I would like to offer our sincere apologies if the evidence presented at the inquest gave the impression that the improvements implemented on Doyle Ward were isolated to that ward alone; this is not the case. Across all inpatient areas a seating chart is used consistently, whether as laminated bedside signage or integrated into therapy timetables. AHP recommendations are documented within HIVE, which is accessible to all clinical professionals across the Trust, ensuring a unified approach to communication and care planning.”

Source location

Response from Manchester University NHS Foundation Trust
Page 9 · response
Published 10 February 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. 1

    Progress appropriate patient and carer representation on the WTWA Patient Experience Group.

    Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
  2. 2

    Require all ward areas to re-read the Early Warning Score policy, including recognition and escalation of neurological change and increased drowsiness.

    Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 February 2026.
  3. 3

    Cascade requirements to document and clinically recognise relatives’ concerns, reference deterioration concerns in safety huddles, and monitor dissemination across WTWA teams.

    Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.
  4. 4

    Operate the Trust-wide Active Hospitals programme across participating inpatient areas to promote daily physical activity and reduce avoidable hospital-acquired deconditioning.

    Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
  5. 5

    Implement a targeted action plan to improve completion of MUST screening, with trajectory plans aiming for full compliance by the end of March 2026.

    Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 February 2026.

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Progress appropriate patient and carer representation on the WTWA Patient Experience Group.

Verbatim wording from the response

“An area of focus is to ensure appropriate patient and carer representation on our Patient Experience Group, and this is being progressed by ████████. This will help us to ensure that programmes of work undertaken are meaningful and reflective of the patient’s voice.”

Source location

Response from Manchester University NHS Foundation Trust
Page 6 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Require all ward areas to re-read the Early Warning Score policy, including recognition and escalation of neurological change and increased drowsiness.

Verbatim wording from the response

“████████ will oversee an action for all ward areas to re-read the Trust’s EWS policy, with specific reference in the policy regarding recognition and escalation of neurological change, including new or increased drowsiness. This will be overseen through the WTWA Quality and Patient Safety Group also.”

Source location

Response from Manchester University NHS Foundation Trust
Page 3 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Cascade requirements to document and clinically recognise relatives’ concerns, reference deterioration concerns in safety huddles, and monitor dissemination across WTWA teams.

Verbatim wording from the response

“Discussions are taking place throughout March 2026 led by ████████ through team meetings and other forums, such as a team brief, to ensure that all ward teams, which include Medical, Nursing, and Allied Health Professional (AHP) colleagues, understand that any concerns raised by relatives must be documented in the patient’s clinical record and treated as clinically relevant information, irrespective of EWS score. Family concerns with regards to patient deterioration will be referenced within local ward level safety huddles and documented. To be assured this has been discussed and cascaded to all teams across WTWA Hospitals, this action will be monitored at the WTWA Quality and Patient Safety Group, which is chaired by ████████”

Source location

Response from Manchester University NHS Foundation Trust
Page 2 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Operate the Trust-wide Active Hospitals programme across participating inpatient areas to promote daily physical activity and reduce avoidable hospital-acquired deconditioning.

Verbatim wording from the response

“As a Trust we remain committed to developing and embedding a culture of physical activity across the Trust, as demonstrated through our ‘Active Hospitals’ programme which was formally launched in October 2025. This approach supports patients to remain active during their hospital stay and aims to prevent the avoidable harm associated with hospital-acquired deconditioning. Staff encourage patients to complete daily active actions aligned to their acuity and individual ability. Promoting physical movement supports recovery, maintains independence, and improves mental wellbeing. Progress of the Active Hospitals programme is monitored by a Trust-wide group, with senior leads identified for each hospital site. Ten inpatient areas across WTWA Hospitals including Doyle and Oak Ward are participating in this programme.”

Source location

Response from Manchester University NHS Foundation Trust
Page 10 · response
Published 10 February 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement a targeted action plan to improve completion of MUST screening, with trajectory plans aiming for full compliance by the end of March 2026.

Verbatim wording from the response

“Compliance with MUST screening is monitored monthly via the Integrated Performance Report. This is reviewed by the WTWA Nutrition and Hydration Group, with oversight at the WTWA Quality and Patient Safety Group and the Management Group. Compliance rates for completed MUST screens for patients admitted to WTWA were 91.7% in February 2026 and 92.4% in January 2026. Performance is monitored in real time through HIVE to support active learning. A targeted action plan, overseen by the WTWA Nutrition and Hydration Group and chaired by the WTWA Hospitals”

Source location

Response from Manchester University NHS Foundation Trust
Page 4 · response
Published 10 February 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026