PFD report

Susan Nora Elizabeth YOUNG · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 24 Jun 2025•Norfolk

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
18

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 raised3

  1. Failure to secure patients' own medication
    Part of recurring concern: Failure to secure and control medication
  2. Lack of clinical handover to receiving wards
    Part of recurring concern: Unreliable clinical handover processesPart of recurring concern: Unreliable healthcare patient transfer processes
  3. Failure to pass on doctors' instructions for cardiac monitoring
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

    Develop and implement a standard ED-to-EADU handover process and form that includes specialist requirements such as cardiac monitoring.

    Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
  2. Action

    Share the updated Self-Harm Policy and patient-search procedure with Emergency Care staff and support acknowledgement of understanding.

    Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
  3. Action

    Audit the implemented ED Patient Handover Form monthly from September until consistent compliance is demonstrated.

    Stated by James Paget University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.

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 secure patients' own medication

Wider context from the report

“NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her, after her death allowing her the opportunity to take another overdose. ”

Is this part of a recurring concern?

Yes — Failure to secure and control medication.

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

Lack of clinical handover to receiving wards

Wider context from the report

“NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her, after her death allowing her the opportunity to take another overdose. ”

Is this part of a recurring concern?

Yes — Unreliable clinical handover processes; Unreliable healthcare patient transfer processes.

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 pass on doctors' instructions for cardiac monitoring

Wider context from the report

“NO clinical handover to receiving ward. No instructions passed on from the doctor re cardiac monitoring. Patients own medication found in her belongings which had been with her, after her death allowing her the opportunity to take another overdose. ”

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

Develop and implement a standard ED-to-EADU handover process and form that includes specialist requirements such as cardiac monitoring.

Verbatim wording from the response

“vi. As a Trust, we are developing a communication process for handover with a task and finish group commencing 23rd May 2025. This includes leads from each department including ED and EADU. The flow chart is in the design phase, with an aim to commence the new process mid-June. Specialist requirements for the patient including cardiac monitoring will be included in the handover template. Once embedded, an audit will take place to monitor compliance and identify gaps needing further education and support.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 6 · response
Published 14 July 2025

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 updated Self-Harm Policy and patient-search procedure with Emergency Care staff and support acknowledgement of understanding.

Verbatim wording from the response

“ii. Action C2 - To share the self-harm policy across Emergency Care with a reference to this patient safety incident once the addendum as above has been added. I can confirm that the search policy has been shared with all ED clinical staff on the 16th April 2025 and was added to the self-harm policy as an addendum which is available on the intranet for all staff to access. Following this, a signatory list will be collected to ensure that all staff have read and understood the policy and its implications for patients presenting with self harm.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 9 · response
Published 14 July 2025

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

Audit the implemented ED Patient Handover Form monthly from September until consistent compliance is demonstrated.

Verbatim wording from the response

“To support and evidence our addressing of all three matters of concern raised, we have included the updated Trust Transfer Policy, including the trust handover process which has been communicated and promoted to staff, the summary of the policy expectations that has been communicated to ED staff, evidence of the associated staff training undertaken and a copy of the ED Patient Handover Form now in use for all patient transfers. An audit of the implemented ED Patient Handover Form is scheduled in September and will be ongoing monthly until results demonstrate good and consistent compliance.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 11 · response
Published 14 July 2025

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 a patient-search procedure to the Self-Harm Policy covering searches for medication and other items that could enable overdose or self-harm.

Verbatim wording from the response

“I can confirm that the Trust's Self Harm Policy (copy attached) now includes an addendum (Appendix C) an SOP (Standard Operating Procedure) Search of Patients within the ED. The policy describes the rationale behind searching patients attending the ED in Mental Health crisis to reduce the risk of patients attempting further overdose or self-harm during their time in the ED. The updated policy has been uploaded to the Trust's intranet.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 9 · response
Published 14 July 2025

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

Audit compliance with the ED patient handover form monthly after the scheduled September audit until consistent compliance is demonstrated.

Verbatim wording from the response

“To support and evidence our addressing of all three matters of concern raised, we have included the updated Trust Transfer Policy, including the trust handover process which has been communicated and promoted to staff, the summary of the policy expectations that has been communicated to ED staff, evidence of the associated staff training undertaken and a copy of the ED Patient Handover Form now in use for all patient transfers. An audit of the implemented ED Patient Handover Form is scheduled in September and will be ongoing monthly until results demonstrate good and consistent compliance.”

Source location

Response from James Paget University NHS Foundation Trust
Page 11 · response
Published 14 July 2025

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

Disseminate the updated Self Harm Policy and patient-search procedure to Emergency Care staff and promote its requirements through written and face-to-face communication.

Verbatim wording from the response

“C2 Action Required – Local To share the self-harm policy across Emergency Care with a reference to this patient safety incident once the addendum as above has been added. Responsibility: Matron Urgent Care Timescale: 30th July 2025 RAG: W”

Source location

Response from James Paget University NHS Foundation Trust
Page 8 · response
Published 14 July 2025

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 the ED patient handover process and form for transfers, including communication of cardiac monitoring and other specialist requirements.

Verbatim wording from the response

“vi. As a Trust, we are developing a communication process for handover with a task and finish group commencing 23rd May 2025. This includes leads from each department including ED and EADU. The flow chart is in the design phase, with an aim to commence the new process mid-June. Specialist requirements for the patient including cardiac monitoring will be included in the handover template. Once embedded, an audit will take place to monitor compliance and identify gaps needing further education and support.”

Source location

Response from James Paget University NHS Foundation Trust
Page 6 · response
Published 14 July 2025

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 a patient-search procedure to the Self Harm Policy, covering removal and safe storage of medications and other harmful items in Emergency Department patients at risk.

Verbatim wording from the response

“C1 Action Required – Local To complete the agreed process for searching patients to maintain patient safety (this will form an addendum to the self-harm policy). Responsibility: Matron Mental Health Liaison / Consultant Timescale: 30th June 2025 RAG: A”

Source location

Response from James Paget University NHS Foundation Trust
Page 8 · response
Published 14 July 2025

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.10

  1. 1

    Conduct monthly audits of transfer safety-checklist compliance while the process is being embedded.

    Stated by James Paget University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
  2. 2

    Implement and train staff on the Emergency Care transfer safety checklist for ED-to-EADU transfers.

    Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
  3. 3

    Train staff on the patient transfer and escort policy, including risk assessment and escort requirements, and disseminate supporting materials.

    Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
  4. 4

    Provide bespoke transfer training for ED staff unable to attend the initial training and collect staff signatories confirming policy and checklist understanding.

    Stated by James Paget University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
  5. 5

    Provide ongoing Trust oversight, assurance reporting and audit updates on ward-transfer and handover safety actions.

    Stated by James Paget University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
  6. 6

    Use safety huddles, escalation, incident reporting and daily incident review to identify and share learning from patient-transfer concerns.

    Stated by James Paget University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
  7. 7

    Conduct safety huddles and escalate transfer concerns through nurse-in-charge discussions, QSAFE reporting and incident-learning channels.

    Stated by James Paget University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
  8. 8

    Complete monthly safety-checklist compliance audits while remaining staff receive bespoke transfer training.

    Stated by James Paget University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
  9. 9

    Train staff on the patient transfer and escort policy, including risk assessment and circumstances requiring an escort, and distribute supporting materials.

    Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
  10. 10

    Implement and reinforce the Emergency Care transfer safety checklist through staff training, hot-topic teaching and completion guidance.

    Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.

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 monthly audits of transfer safety-checklist compliance while the process is being embedded.

Verbatim wording from the response

“iii. Whilst the remaining staff are captured in the bespoke training sessions, the Clinical Educator will complete safety checklist compliance audits monthly to provide assurance that the process is embedded. This audit is in the planning phase; however, it is anticipated this will enable the team to monitor compliance, identify any gaps and support the team with any additional training needs.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 6 · response
Published 14 July 2025

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 and train staff on the Emergency Care transfer safety checklist for ED-to-EADU transfers.

Verbatim wording from the response

“D1 Action Required - Local: To complete the Emergency Care transfer safety checklist as seen within the Emergency Care record, to support safe transfer of patients from ED to EADU, by relaunching the safety checklist with registered nurses in Emergency Care. Responsibility: Clinical Educator ED. Timescale: 30th July 2025. RAG: G. Comments/Evidence of Achievement/Reason for Slippage: The Senior Nursing Team have shared during huddles key points from the transfer policy and highlighted to all staff the importance of completing a transfer checklist and how to compile. Clinical Educator has provided additional teaching to workforce and has supported completion of a transfer checklist. A learning board has been completed on 20th January showing staff how to correctly fill in the Emergency Care record.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 6 · response
Published 14 July 2025

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 on the patient transfer and escort policy, including risk assessment and escort requirements, and disseminate supporting materials.

Verbatim wording from the response

“D2 Action Required - Local: To include the patient transfer policy as part of the relaunch that highlights within, the transfer escort checklist, if one or more of the following apply to this patient then an escort is required this includes any patient that causes concern as in this scenario. Responsibility: Clinical Educator ED. Timescale: 30th July 2025. RAG: G. Comments/Evidence of Achievement/Reason for Slippage: Clinical Educator transfer training completed at ED educational away days (register attached). Key points from transfer policy shared with staff. Pocket size cards laminated and shared with staff.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 6 · response
Published 14 July 2025

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 bespoke transfer training for ED staff unable to attend the initial training and collect staff signatories confirming policy and checklist understanding.

Verbatim wording from the response

“i. I can confirm that the Clinical Educator has completed transfer training at the ED educational away days, which included training on the transfer checklist within the emergency care record documentation and the patient transfer and escort policy. These were held on the 4th and 9th April and the 7th and 16th May 2025. 68% of the current ED nursing and support staff attended. In addition, the Clinical Educator circulated the patient transfer and escort policy and the transfer checklist to all staff via email. Those who were unable to attend the away days due to sickness or maternity leave will attend a bespoke training session at the earliest opportunity. A signatory list will be commenced to ensure all ED nursing staff have read and understood the policy and checklist.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 5 · response
Published 14 July 2025

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 ongoing Trust oversight, assurance reporting and audit updates on ward-transfer and handover safety actions.

Verbatim wording from the response

“We have identified Ward Transfer and Handover as an important Patient Safety Issue in the trust for action. There has been significant action achieved and ongoing.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 10 · response
Published 14 July 2025

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 safety huddles, escalation, incident reporting and daily incident review to identify and share learning from patient-transfer concerns.

Verbatim wording from the response

“iv. EADU nursing leadership have supported staff to complete safety huddles following this incident, which included information about this incident, initial learning including the requirement of a nurse escort when clinically required. Additionally, staff escalate to the Nurse in Charge on EADU if they have any clinical concerns about patients who are transferred from ED, the Nurse in Charge will discuss this with the ED nurse in charge to gain further information about the patient. A QSAFE incident is completed if there are concerns about patient transfers and learning from these incidents is shared with the teams.”

Source location

Response from James Paget University Hospitals NHS Foundation Trust
Page 6 · response
Published 14 July 2025

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 safety huddles and escalate transfer concerns through nurse-in-charge discussions, QSAFE reporting and incident-learning channels.

Verbatim wording from the response

“iv. EADU nursing leadership have supported staff to complete safety huddles following this incident, which included information about this incident, initial learning including the requirement of a nurse escort when clinically required. Additionally, staff escalate to the Nurse in Charge on EADU if they have any clinical concerns about patients who are transferred from ED, the Nurse in Charge will discuss this with the ED nurse in charge to gain further information about this patient. A QSAFE incident is completed if there are concerns about patient transfers and learning from these incidents is shared with the teams.”

Source location

Response from James Paget University NHS Foundation Trust
Page 6 · response
Published 14 July 2025

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 monthly safety-checklist compliance audits while remaining staff receive bespoke transfer training.

Verbatim wording from the response

“i. I can confirm that the Clinical Educator has completed transfer training at the ED educational away days, which included training on the transfer checklist within the emergency care record documentation and the patient transfer and escort policy. There were held on the 4th and 9th April and the 7th and 16th May 2025. 68% of the current ED nursing and support staff attended. In addition, the Clinical Educator circulated the patient transfer and escort policy and the transfer checklist to all staff via email. Those who were unable to attend the away days due to sickness or maternity leave will attend a bespoke training session at the earliest opportunity. A signatory list will be commenced to ensure all ED nursing staff have read and understood the policy and checklist.”

Source location

Response from James Paget University NHS Foundation Trust
Page 5 · response
Published 14 July 2025

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 on the patient transfer and escort policy, including risk assessment and circumstances requiring an escort, and distribute supporting materials.

Verbatim wording from the response

“D2 Action Required - Local To include the patient transfer policy as part of the relaunch that highlights within, the transfer escort checklist, if one or more of the following apply to this patient then an escort is required this includes any patient that causes concern as in this scenario.”

Source location

Response from James Paget University NHS Foundation Trust
Page 5 · response
Published 14 July 2025

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 and reinforce the Emergency Care transfer safety checklist through staff training, hot-topic teaching and completion guidance.

Verbatim wording from the response

“D1 Action Required - Local To complete the Emergency Care transfer safety checklist as seen within the Emergency Care record, to support safe transfer of patients from ED to EADU, by relaunching the safety checklist with registered nurses in Emergency Care.”

Source location

Response from James Paget University NHS Foundation Trust
Page 5 · response
Published 14 July 2025

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