PFD report

BENJAMIN THOMAS GOODRUM · Prevention of Future Deaths report

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Issued 8 Dec 2017•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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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 allocate a specific individual Care Co-Ordinator or Lead Care Professional to service users receiving active treatment
    Part of recurring concern: Failure to maintain clear ownership of multi-agency support and carePart of recurring concern: Failure to provide continuity of patient care
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.1

  1. Action

    Recruit to fill the Central Norfolk Long Term Treatment Team’s band 5 vacancy.

    Stated by TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.

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 allocate a specific individual Care Co-Ordinator or Lead Care Professional to service users receiving active treatment

Wider context from the report

“(1) Although there was evidence of good communication between the various organisations involved with Mr Goodrum and attempts were ongoing to retain contact with him, there was no person taking overall responsibility for Mr Goodrum. (2) Mr Goodrum had originally been allocated a Care Co-Ordinator but on this person leaving, no new Care Co-Ordinator was appointed. (3) The Serious Incident Investigation recommended all service users receiving active treatment should be allocated a Lead Care Professional or a Care Co-Ordinator and this action was to be completed by 30/04/2017. At the time of the inquest this action had not been put in place and the Action Plan was regarded as complete. (4) Evidence was heard that alternative measures have been taken within the various teams to ameliorate the lack of sufficient Care Co-Ordinators for service users, for instance using a team-based approach, but that such measures are not as effective as services having a specific individual appointed as a Care Co-Ordinator. ”

Is this part of a recurring concern?

Yes — Failure to maintain clear ownership of multi-agency support and care; Failure to provide continuity of patient care.

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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 to fill the Central Norfolk Long Term Treatment Team’s band 5 vacancy.

Verbatim wording from the response

“The clinical team involved in the case (Central Norfolk Long Term Treatment Team) currently has one band 5 vacancy which is being recruited to.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 11 February 2018

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

    Develop staff through accelerated apprenticeship, foundation-degree and nurse-training pathways.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  2. 2

    Encourage retirees to return to flexible work to support staff retention.

    Stated by TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  3. 3

    Support staff wellbeing as part of the Trust’s retention work.

    Stated by TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  4. 4

    Continue embedding Trust values and putting listening into action to support staff retention.

    Stated by TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  5. 5

    Continuously review workforce skill mixes.

    Stated by TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  6. 6

    Promote Trust career opportunities through a partner-supported social media recruitment approach.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  7. 7

    Operate the TRAC recruitment system with progress information and activity-prioritisation dashboards.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  8. 8

    Work with the bank provider to increase appropriately skilled temporary-staff capacity.

    Stated by TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 February 2018.
  9. 9

    Reduce staff hiring times through a lean recruitment process review.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  10. 10

    Maintain targeted recruitment action plans for particularly challenging hotspot areas.

    Stated by TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.

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 staff through accelerated apprenticeship, foundation-degree and nurse-training pathways.

Verbatim wording from the response

“• In light of the national skills shortages, a key aspect of our recruitment approach is on growing our own staff. This includes accelerated pathways from apprenticeships to foundation degrees through to nurse training in order to become registered practitioners.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 11 February 2018

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 retirees to return to flexible work to support staff retention.

Verbatim wording from the response

“Alongside this, whilst our retention rate is generally good, we are also undertaking work to support the retention of experienced and engaged staff. This is includes encouraging retirees to return to work following retirement on a flexible basis, a significant focus on supporting staff wellbeing and a continued focus on embedding our Trust values and putting listening into action.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 11 February 2018

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 staff wellbeing as part of the Trust’s retention work.

Verbatim wording from the response

“Alongside this, whilst our retention rate is generally good, we are also undertaking work to support the retention of experienced and engaged staff. This is includes encouraging retirees to return to work following retirement on a flexible basis, a significant focus on supporting staff wellbeing and a continued focus on embedding our Trust values and putting listening into action.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 11 February 2018

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 embedding Trust values and putting listening into action to support staff retention.

Verbatim wording from the response

“Alongside this, whilst our retention rate is generally good, we are also undertaking work to support the retention of experienced and engaged staff. This is includes encouraging retirees to return to work following retirement on a flexible basis, a significant focus on supporting staff wellbeing and a continued focus on embedding our Trust values and putting listening into action.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Continuously review workforce skill mixes.

Verbatim wording from the response

“• We are continuously reviewing our skill mixes.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Promote Trust career opportunities through a partner-supported social media recruitment approach.

Verbatim wording from the response

“• We have engaged a partner organisation to support us in promoting career opportunities within the Trust through social media. The use of social media now forms a key aspect of our recruitment approach.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 11 February 2018

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 TRAC recruitment system with progress information and activity-prioritisation dashboards.

Verbatim wording from the response

“• We have implemented a new recruitment system, TRAC, which provides a greater level of information to candidates, recruiting managers and recruitment officers on progress and action required. This includes a dashboard to assist in the prioritisation of activities.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 11 February 2018

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

Work with the bank provider to increase appropriately skilled temporary-staff capacity.

Verbatim wording from the response

“• We are working closely with our bank provider to increase our bank capacity to ensure a ready supply of appropriately skilled temporary staff to provide short term cover where needed.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 11 February 2018

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

Reduce staff hiring times through a lean recruitment process review.

Verbatim wording from the response

“• Reducing the time it takes to hire staff. A lean process review has been undertaken resulting in the timeframe being reduced from sixteen to ten weeks; this is in line with the regional average.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 11 February 2018

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 targeted recruitment action plans for particularly challenging hotspot areas.

Verbatim wording from the response

“• We have action plans in place for ‘hotspot’ areas that are particularly challenging to recruit to. These include short term tactical as well as medium to longer term plans.”

Source location

2017-0362-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 11 February 2018

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