PFD report

Elizabeth Rose CURTIS · Prevention of Future Deaths report

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Issued 11 Jan 2019•Avon

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

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 raised1

  1. Failure to incorporate patients' mobility into assessment of well-being
    Part of recurring concern: Failure to assess and meet patients’ mobility needs
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    A national mobility-score field on NEWS2 is not preferred; comprehensive specialty-tailored assessment and review alongside NEWS2 is considered better.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 incorporate patients' mobility into assessment of well-being

Wider context from the report

“A patient's mobility became an issue at the inquest and how this can help with assessing a patient's wellness. I was advised by ████████ at the Royal United Hospital, Bath, who gave evidence at this inquest that she was introducing to the hospital a mobility scale due to the impact that mobility or indeed frailty has on assessing well-being of patients when in hospital. ████████ has indicated that this is a simple scale noting a patient's best mobility in the previous 24hrs. and is recorded alongside the NEWS score. Often mobility is the first symptom demonstrating a decline in health. I am told that the Royal United Hospital have adopted this scale. For further details in relation to this I would suggest that you contact ████████ Consultant Geriatrician, at Royal United Hospital NHS Foundation Trust her email is ████████. I have also suggested that she write to you to outline her “mobility scale”, hence I have copied her into this report. ”

Is this part of a recurring concern?

Yes — Failure to assess and meet patients’ mobility needs.

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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

A national mobility-score field on NEWS2 is not preferred; comprehensive specialty-tailored assessment and review alongside NEWS2 is considered better.

Verbatim wording from the response

“The Royal College of Physicians, who lead on the National Early Warning Score (NEWS2) are very supportive of the need to assess, monitor and act on a range of other signs and symptoms and test results that indicate a patient is either not improving as fast as expected or is getting unexpectedly less well. They believe this is best done by comprehensive assessment and review tailored to patient specialities alongside NEWS2, rather adding a mobility score as an additional field on NEWS2 charts nationally; but we will keep them updated on any significant findings from the work at Royal United Hospital Bath NHS Foundation Trust.”

Source location

2019-0018-Response-by-NHS-Improvement
Page 1 · response
Published 23 May 2019

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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.7

  1. 1

    Work with ePMA manufacturers and configuring trusts to consider prescribing limits based on haloperidol dose and duration, 48-hour re-prescribing decisions, and senior authorisation for repeat doses.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  2. 2

    Use quality-improvement incentives to reduce hospital falls risk, including unnecessary haloperidol prescribing for older patients.

    Stated by NHS EnglandStatus unclearThe respondent did not make the status of this action clear when they made their response on 23 May 2019.
  3. 3

    Support further medication-safety improvement activities for older people through Patient Safety Collaboratives.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  4. 4

    Improve care for people with dementia, delirium and frailty through the NHS Long Term Plan.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
  5. 5

    Encourage appropriately trained specialist nurses to prescribe recommended medication directly through non-medical prescribing initiatives.

    Stated by NHS EnglandStatus unclearThe respondent did not make the status of this action clear when they made their response on 23 May 2019.
  6. 6

    Support Patient Safety Collaboratives to develop and share best practice for identifying deteriorating patients.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
  7. 7

    Continue supporting the trust as it implements local prescribing-system, haloperidol-information, consultant-rota and medical-staffing actions.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.

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

Work with ePMA manufacturers and configuring trusts to consider prescribing limits based on haloperidol dose and duration, 48-hour re-prescribing decisions, and senior authorisation for repeat doses.

Verbatim wording from the response

“Whilst we are not yet in position to use the local mobility score nationally, we are taking forward action to prevent future deaths related to the prescribing error that affected Mrs Curtis. Safe prescribing of haloperidol in acute hospital care can be challenging, as the doses that are appropriate for an older person with a lifelong history of a psychotic disorder differ from those appropriate to someone with delirium, and the dose that may be appropriate for using once to manage an emergency is different from a continued dose given regularly over days. This means that the standard limits within electronic Prescribing and Medication”

Source location

2019-0018-Response-by-NHS-Improvement
Page 1 · response
Published 23 May 2019

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 quality-improvement incentives to reduce hospital falls risk, including unnecessary haloperidol prescribing for older patients.

Verbatim wording from the response

“Some of our wider initiatives will also help improve the safety of older patients with similar needs to Mrs Curtis. Our Patient Safety Collaboratives support the development and sharing of best practice in identifying deteriorating patients, and they will support further improvement activities related to medication safety for older people in the coming year. Initiatives to encourage non-medical prescribing mean that specialist nurses, after appropriate training, can directly prescribe the medication they recommend, avoiding the risk of communication error when a doctor is asked to prescribe the recommended dose. Our quality improvement incentives for reducing risk of falls in hospital including prescribing of medication like haloperidol in older patients unless strictly necessary.”

Source location

2019-0018-Response-by-NHS-Improvement
Page 2 · response
Published 23 May 2019

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

Support further medication-safety improvement activities for older people through Patient Safety Collaboratives.

Verbatim wording from the response

“Some of our wider initiatives will also help improve the safety of older patients with similar needs to Mrs Curtis. Our Patient Safety Collaboratives support the development and sharing of best practice in identifying deteriorating patients, and they will support further improvement activities related to medication safety for older people in the coming year. Initiatives to encourage non-medical prescribing mean that specialist nurses, after appropriate training, can directly prescribe the medication they recommend, avoiding the risk of communication error when a doctor is asked to prescribe the recommended dose. Our quality improvement incentives for reducing risk of falls in hospital including prescribing of medication like haloperidol in older patients unless strictly necessary.”

Source location

2019-0018-Response-by-NHS-Improvement
Page 2 · response
Published 23 May 2019

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

Improve care for people with dementia, delirium and frailty through the NHS Long Term Plan.

Verbatim wording from the response

“The NHS Long Term Plan describes how we will improve the care we provide to people with dementia and delirium and frailty, whether they are in hospital or at home.”

Source location

2019-0018-Response-by-NHS-Improvement
Page 2 · response
Published 23 May 2019

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

Encourage appropriately trained specialist nurses to prescribe recommended medication directly through non-medical prescribing initiatives.

Verbatim wording from the response

“Some of our wider initiatives will also help improve the safety of older patients with similar needs to Mrs Curtis. Our Patient Safety Collaboratives support the development and sharing of best practice in identifying deteriorating patients, and they will support further improvement activities related to medication safety for older people in the coming year. Initiatives to encourage non-medical prescribing mean that specialist nurses, after appropriate training, can directly prescribe the medication they recommend, avoiding the risk of communication error when a doctor is asked to prescribe the recommended dose. Our quality improvement incentives for reducing risk of falls in hospital including prescribing of medication like haloperidol in older patients unless strictly necessary.”

Source location

2019-0018-Response-by-NHS-Improvement
Page 2 · response
Published 23 May 2019

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

Support Patient Safety Collaboratives to develop and share best practice for identifying deteriorating patients.

Verbatim wording from the response

“Some of our wider initiatives will also help improve the safety of older patients with similar needs to Mrs Curtis. Our Patient Safety Collaboratives support the development and sharing of best practice in identifying deteriorating patients, and they will support further improvement activities related to medication safety for older people in the coming year. Initiatives to encourage non-medical prescribing mean that specialist nurses, after appropriate training, can directly prescribe the medication they recommend, avoiding the risk of communication error when a doctor is asked to prescribe the recommended dose. Our quality improvement incentives for reducing risk of falls in hospital including prescribing of medication like haloperidol in older patients unless strictly necessary.”

Source location

2019-0018-Response-by-NHS-Improvement
Page 2 · response
Published 23 May 2019

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 supporting the trust as it implements local prescribing-system, haloperidol-information, consultant-rota and medical-staffing actions.

Verbatim wording from the response

“We appreciate that at the inquest you were made aware of additional local safety actions taken forward by Royal United Hospital Bath NHS Foundation Trust. Those including changes to prescribing systems, providing additional information for junior and locum doctors on the appropriate use of haloperidol, and review of consultant rotas and medical staffing levels. The regional team at NHS Improvement will continue to support the trust as it carries through these local actions.”

Source location

2019-0018-Response-by-NHS-Improvement
Page 2 · response
Published 23 May 2019

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