PFD report

Gerard Murray · Prevention of Future Deaths report

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Issued 4 Aug 2023•Nottinghamshire

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
16

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised4

  1. Extremely limited family and carer involvement in care planning and ward rounds
    Part of recurring concern: Failure to involve families and carers in safety-critical care decisions
  2. Limited staff awareness of the ligature risk reduction pathway
  3. Inadequate door board system for monitoring patient returns after unescorted leave
    Part of recurring concern: Unsafe management of inpatient leave and absence
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.15

  1. Action

    Procure Storm Skills Training for inpatient services and prepare for its planned rollout.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  2. Action

    Procure and pilot an electronic leave-alarm system, then consider wider rollout based on pilot feedback.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  3. Action

    Assign ward staff to verify leave parameters, record departures and expected returns, and manage associated safety and property checks.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.

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

Extremely limited family and carer involvement in care planning and ward rounds

Wider context from the report

“3. There was extremely limited family and carer involvement in Gerard’s care, with no involvement in the care plan, nor involvement in ward rounds on ward B2 now Beech ward ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in safety-critical care decisions.

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

Limited staff awareness of the ligature risk reduction pathway

Wider context from the report

“4. There was limited awareness of the ligature risk reduction pathway by staff on B2 now Beech ward ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

Inadequate door board system for monitoring patient returns after unescorted leave

Wider context from the report

“2. There was an inadequate door board system for monitoring the return of patients after unescorted leave on ward B2. The same arrangements remain currently, despite the ward move to Beech ward on new premises ”

Is this part of a recurring concern?

Yes — Unsafe management of inpatient leave and absence.

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

Limited risk assessment and risk management planning

Wider context from the report

“1. There was a limited risk assessment and risk management plan documented for Gerard on ward B2 now Beech ward ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Procure Storm Skills Training for inpatient services and prepare for its planned rollout.

Verbatim wording from the response

“The Trust has also identified Storm Skills Training as being applicable for our inpatient services, and we are in the process of procuring this training package, with an anticipated roll out through Quarter 4 of 2023/24. The Storm Skills Training is an evidenced skills-based training programme with a focus on suicide prevention and self-harm reduction. These training courses complement each other to support staff to make informed decisions regarding an individual risk of suicide or self-harm including, but not exclusively regarding the risk of ligatures. This will then inform the overall risk formulation and allow our clinicians to make individualised decisions regarding access to items that could be used to ligate.”

Source location

Response from Nottingham Heathcare
Page 5 · response
Published 30 October 2023

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

Procure and pilot an electronic leave-alarm system, then consider wider rollout based on pilot feedback.

Verbatim wording from the response

“The staff member maintains a running log of when patients leave the ward, and are due back, their clothing, and a brief description to aid searching if a patient chooses not to return. Given the frequent use of leave from patients across the site, the Care Group has sought ways to enhance this monitoring. As such, an electronic device is being procured which will allow multiple alarms to be set for each person’s leave, ensuring an audible alarm will sound when a patient is due back on the ward. This will be trialled and rolled out based on the feedback of this pilot. We will share with you the output of this in due course.”

Source location

Response from Nottingham Heathcare
Page 3 · response
Published 30 October 2023

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

Assign ward staff to verify leave parameters, record departures and expected returns, and manage associated safety and property checks.

Verbatim wording from the response

“Each ward has a dedicated member of staff responsible for assessing individual mental state, checking leave parameters, and reiterating these to the patient prior to leave, confirming legality and permission issues with the nurse in charge, and managing those possessions a patient may take on or return with from leave, IE Cigarette Lighters and items bought at the local shops etc.”

Source location

Response from Nottingham Heathcare
Page 3 · response
Published 30 October 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review service-wide risk assessment and care planning processes for therapeutic leave, including the boundaries between ground and community leave.

Verbatim wording from the response

“In addition to the changes made at Sherwood Oaks, there is currently a service wide review of the risk assessment and care planning processes linked to agreeing therapeutic leave, which will include the definitions of where leave in the grounds and leave in the community begin. This is being progressed via the AMH inpatient Rapid Improvement Group which is chaired by the Executive Director of Nursing and AHPs.”

Source location

Response from Nottingham Heathcare
Page 2 · response
Published 30 October 2023

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 updated suicide awareness and response training incorporating NICE guidance and embed the SAFE Tool in clinical systems for documentation and audit.

Verbatim wording from the response

“As an organisation we have been delivering updated suicide awareness and suicide response training using content developed by 4 Mental Health, since Dec 2022. This training includes updated NICE guidelines in relation to assessment, risk mitigation and safety planning for suicidality and provides a Suicide Assessment Framework E-Tool (SAFE Tool) which has been embedded in RIO and SystmOne for documentation and audit.”

Source location

Response from Nottingham Heathcare
Page 4 · response
Published 30 October 2023

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 multidisciplinary teams to decide ward leave during weekly ward rounds or daily board reviews and document the associated risk assessment and clinical rationale.

Verbatim wording from the response

“This has been discussed with the Multi-Disciplinary Team (MDT) across the unit and agreed that all leave from the ward areas, will only to be decided upon during weekly ward rounds, or the daily board review where the full MDT is present. To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.”

Source location

Response from Nottingham Heathcare
Page 2 · response
Published 30 October 2023

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 bespoke family-intervention training to the Beech Ward multidisciplinary team.

Verbatim wording from the response

“Finally, the family intervention team have devised a bespoke one-day training package which all of the Beech ward team including the MDT are booked on to attend. A copy of the training program is included below, and is scheduled to start in January 2023, with roll out through to June 2024.”

Source location

Response from Nottingham Heathcare
Page 4 · response
Published 30 October 2023

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

Conduct daily senior-nurse spot checks of door board compliance, staff understanding, and escalation of late returns.

Verbatim wording from the response

“To ensure there is consistent compliance with the door board system, a checking process has been incorporated in the Senior Nurse’s daily observation spot checks. This includes a band 6 nurse or above observing staff completing their observations rounds, and quality checking their understanding and performance within the role. The spot checks also test individual understanding of the door board process, their knowledge of who is on and off the ward, and discussions to ensure they understand clearly how to escalate concerns if a patient hasn’t returned.”

Source location

Response from Nottingham Heathcare
Page 3 · response
Published 30 October 2023

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

Strengthen adherence to the door board process across Beech Ward and the wider site.

Verbatim wording from the response

“Historically the system of monitoring who leaves and returns to the wards, (locally known as the Door Board) was poorly adhered to in some areas. Significant work has been completed with the team on Beech (and across the site) to strengthen their adherence to the process which has seen a significant improvement in practice.”

Source location

Response from Nottingham Heathcare
Page 3 · response
Published 30 October 2023

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

Introduce admission-based Carer Contact Plans recording patients’ preferences for family and carer involvement and information sharing.

Verbatim wording from the response

“To enhance the work of the Carer Peer Support Worker, it is planned that all patients will on admission complete a carer contact plan. This will include who the patient would like to be involved in their care and care discussions, and what level of information should be shared. The Carer Contact Plan is in the final stage of agreement and should be used through the in-patient wards by the end of December 2023. The use of the Carer Contact Plan will be reviewed in Quarter 4 of 2023/34.”

Source location

Response from Nottingham Heathcare
Page 4 · response
Published 30 October 2023

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

Add leave-related risk assessment and clinical rationale requirements to the Adult Mental Health Operational Policy.

Verbatim wording from the response

“This has been discussed with the Multi-Disciplinary Team (MDT) across the unit and agreed that all leave from the ward areas, will only to be decided upon during weekly ward rounds, or the daily board review where the full MDT is present. To support this the ward round template has been updated to include the documentation of risk assessment analysis and clinical rationale linked to leave decisions. This will be monitored through the oversight quality checks completed by the Practice Development Leads and locally by the Ward Manager. It will also be added to the Adult Mental Health Operational Policy.”

Source location

Response from Nottingham Heathcare
Page 2 · response
Published 30 October 2023

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 consult on a Trust-wide collaborative risk assessment and care planning policy with implementation and compliance-monitoring requirements.

Verbatim wording from the response

“At a Trust level, we recognise that having one Policy that identifies the principles of risk assessments and collaborative and coproduced care planning for children, young people and adults is beneficial, and how it reduces confusion for the clinical teams. As a result, a Policy has been drafted and outlines the expectations for the clinical teams, while allowing flexibility to ensure that the correct risk assessment tools are used for each service. The Policy will also outline how the appropriate Risk Assessment tools are agreed, how the implementation will be managed and how the Trust will monitor the compliance with the Policy.”

Source location

Response from Nottingham Heathcare
Page 2 · response
Published 30 October 2023

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

Complete Triangle of Care self-assessments across Adult Mental Health inpatient areas and review findings to agree improvement actions.

Verbatim wording from the response

“The involvement of patient’s family, friends and carers is vital when planning and delivering the patients care and treatment. We recognise that at times, we have got this wrong. To understand how to improve in this area, all Adult Mental Health inpatient areas have completed the Triangle of Care Self-Assessment.”

Source location

Response from Nottingham Heathcare
Page 3 · response
Published 30 October 2023

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

Recruit and deploy a Carer Peer Support Worker for acute wards to strengthen liaison with patients, families, carers, and multidisciplinary teams.

Verbatim wording from the response

“To aid and support this partnership, all-acute wards have recruited a Carer Peer Support worker whose working week is dedicated to liaising with patients and their families/carers and ensuring the link with MDT members, and clinical discussions is strong. This person will also support the patients and their family/carers in Ward round discussions and ensure that follow up actions are completed and communicated effectively.”

Source location

Response from Nottingham Heathcare
Page 4 · response
Published 30 October 2023

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

Complete suicide awareness and response training for qualified nurses and multidisciplinary team members at Sherwood Oaks.

Verbatim wording from the response

“To ensure a consistent risk assessment skill level across the workforce, all the qualified nurses and MDT members at Sherwood Oaks have attended suicide awareness and response training, which includes a focus on risks associated with patient accessing leave. This is discussed further in section 4.”

Source location

Response from Nottingham Heathcare
Page 2 · response
Published 30 October 2023

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

    Provide the coroner with an update on completion of the collaborative care planning policy and associated training rollout.

    Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.

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 the coroner with an update on completion of the collaborative care planning policy and associated training rollout.

Verbatim wording from the response

“It is foreseen that the Policy will recommend that clinical teams will receive training in the clinical risk assessment tools employed by each service, The training will be sourced from external providers or developed with the learning and development team to make sure that the learning materials reflect the Policy requirements and the individual needs of the people that we support. We will ensure you are sighted on the completion of this policy and training roll out.”

Source location

Response from Nottingham Heathcare
Page 2 · response
Published 30 October 2023

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