PFD report

FRED MALCOLM REYNOLDS (Ted) · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 15 Jul 2021•Mid Kent and Medway

Report record

Published report and response evidence

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

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Failure to document the reason for discontinuing neurological observations
    Part of recurring concern: Failure to carry out required neurological observations
  2. Failure to continue neurological observations following head injury
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuriesPart of recurring concern: Failure to carry out required neurological observations
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.8

  1. Action

    Include clinically indicated neurological observations in shift handovers and patient status boards, with ongoing quality assurance audits.

    Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
  2. Action

    Train staff in electronic observations and neurological-observation competencies, with ongoing training for newly appointed nursing and medical staff.

    Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
  3. Action

    Maintain a NICE-compliant Falls Policy specifying neurological-observation frequency and continuation until medical review.

    Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.

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 document the reason for discontinuing neurological observations

Wider context from the report

“Specialist neurology advice was given to conduct neurological observations every two hours for 48 hours following head injury. These observations were commenced but not continued. It was not possible to understand why these observations has been discontinued and there was no entry made in the medical records. ”

Is this part of a recurring concern?

Yes — Failure to carry out required neurological observations.

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 continue neurological observations following head injury

Wider context from the report

“Specialist neurology advice was given to conduct neurological observations every two hours for 48 hours following head injury. These observations were commenced but not continued. It was not possible to understand why these observations has been discontinued and there was no entry made in the medical records. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries; Failure to carry out required neurological observations.

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

Include clinically indicated neurological observations in shift handovers and patient status boards, with ongoing quality assurance audits.

Verbatim wording from the response

“2. Neurological observations are part of every handover if clinically indicated, as set out in the Inpatient Handover Protocol which was introduced in protocol in December 2018, and on the patient status board/at a glance board. Shift handover processes are regularly reviewed, and are subject to quality checks through our programme of CLIQ Quality assurance audits, in order to ensure ongoing quality improvement.”

Source location

2021-0241-Response-from-KMPT_Published
Page 2 · response
Published 15 July 2021

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

Train staff in electronic observations and neurological-observation competencies, with ongoing training for newly appointed nursing and medical staff.

Verbatim wording from the response

“As part of the roll out of this new system, training was provided and completed by all members of staff, and there is ongoing training offered to new nursing and medical staff. Their competencies are assessed and signed off as part of this training, further demonstrating the steps we have taken to improve staff knowledge, skills, and confidence with undertaking neuro observations.”

Source location

2021-0241-Response-from-KMPT_Published
Page 2 · response
Published 15 July 2021

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 a NICE-compliant Falls Policy specifying neurological-observation frequency and continuation until medical review.

Verbatim wording from the response

“1. Our Falls Policy, which is NICE compliant, provides guidance regarding neurological observations. It clearly sets out that neurological observations should be completed every thirty minutes for two hours. Only when it is confirmed that no abnormalities have been detected, this becomes hourly observation for the next four hours, and then two-hourly after that, until medical review has occurred. Staff are sufficiently trained and compliant with this quality standard is monitored through our Falls Care Pathway and incident reporting. We have a well-established system for sharing lessons learnt through our quality governance meetings, and Mr Reynolds’s story has been presented there.”

Source location

2021-0241-Response-from-KMPT_Published
Page 2 · response
Published 15 July 2021

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 compliance with neurological-observation standards through the Falls Care Pathway, incident reporting and quality governance reviews.

Verbatim wording from the response

“1. Our Falls Policy, which is NICE compliant, provides guidance regarding neurological observations. It clearly sets out that neurological observations should be completed every thirty minutes for two hours. Only when it is confirmed that no abnormalities have been detected, this becomes hourly observation for the next four hours, and then two-hourly after that, until medical review has occurred. Staff are sufficiently trained and compliant with this quality standard is monitored through our Falls Care Pathway and incident reporting. We have a well-established system for sharing lessons learnt through our quality governance meetings, and Mr Reynolds’s story has been presented there.”

Source location

2021-0241-Response-from-KMPT_Published
Page 2 · response
Published 15 July 2021

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

Use electronic NEWS2 observations to identify consciousness changes, trigger neurological observations when indicated, issue missed-observation alerts and support remote clinical review.

Verbatim wording from the response

“3. All patients on our wards have a set of vital signs recorded via NEWS2, i.e. the National Early Warning Score 2 since an electronic observation project was rolled out across 2019. This is a system designed to standardise the assessment and response to acute illness. Any patient returning from a visit to A&E, or the general hospital, have their vital signs recorded on eObs, an electronic recording system, that will calculate National Early Warning Score (NEWS2). This encompasses a consciousness level assessment, and will identify the need for Glasgow Comma Scale (GCS) to be completed. Neurological observations utilising GCS are implemented when clinically indicated, or following a reduced consciousness score from NEWS2.”

Source location

2021-0241-Response-from-KMPT_Published
Page 2 · response
Published 15 July 2021

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop and disseminate a learning bulletin reminding staff to complete Glasgow Coma Scale observations after incidents, possible strokes, head injuries and medical emergencies.

Verbatim wording from the response

“8. Following Mr Reynolds’s death, the Older Adults Care Group developed and disseminated a learning bulletin to all staff, reiterating the need for neurological observations to be completed for any seen or unseen incident where a patient is presenting with a head injury, possible stroke symptoms or any medical emergency. It clearly reminded staff that observations should be completed using the Glasgow Coma Scale.”

Source location

2021-0241-Response-from-KMPT_Published
Page 3 · response
Published 15 July 2021

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 Trust-wide train-the-trainer education on neurological observations and the Glasgow Coma Scale to physical health nurses, with refresher sessions and online access.

Verbatim wording from the response

“7. Our resuscitation service has further developed a Trust-wide “Train the Trainer” course for neurological observations and the Glasgow Coma Scale, and has delivered this to all physical health nurses. Since March 2021, all the physical health nurses across the Trust have been trained, and we now offer a short refresher training session for each team, and will continue to facilitate these sessions as required. This training is also available via eLearn (virtual learning platform) for all staff to access as needed.”

Source location

2021-0241-Response-from-KMPT_Published
Page 3 · response
Published 15 July 2021

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 specialist Physical Health Nurse on each ward to teach, support and supervise physical healthcare.

Verbatim wording from the response

“6. In addition to staff training, the use of digital technology, and the improved quality governance and assurance systems in place, we have also employed specialist Physical Health Nurses on each ward as part of our nursing skill mix. This ensures that we have staff with relevant technical expertise to teach, support and supervise provision of high-quality physical health care to our patients. This was not in place at the time of Mr Reynolds’s treatment.”

Source location

2021-0241-Response-from-KMPT_Published
Page 3 · response
Published 15 July 2021

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.1

  1. 1

    Share learning from incidents through quality governance meetings, including presenting Mr Reynolds’s case.

    Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.

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 learning from incidents through quality governance meetings, including presenting Mr Reynolds’s case.

Verbatim wording from the response

“1. Our Falls Policy, which is NICE compliant, provides guidance regarding neurological observations. It clearly sets out that neurological observations should be completed every thirty minutes for two hours. Only when it is confirmed that no abnormalities have been detected, this becomes hourly observation for the next four hours, and then two-hourly after that, until medical review has occurred. Staff are sufficiently trained and compliant with this quality standard is monitored through our Falls Care Pathway and incident reporting. We have a well-established system for sharing lessons learnt through our quality governance meetings, and Mr Reynolds’s story has been presented there.”

Source location

2021-0241-Response-from-KMPT_Published
Page 2 · response
Published 15 July 2021

Open published response
Back to top

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