PFD report

Richard Burgess · Prevention of Future Deaths report

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Issued 19 May 2021•Sunderland

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
7

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
17

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 raised7

  1. Failure to evidence or apply comprehensive assessments of the impact of a person’s difficulties
  2. Failure to provide a social environment supporting psychological and physical needs
    Part of recurring concern: Unreliable dementia care and management
  3. Failure to use a proactive dementia care model based on detailed assessment, intervention and evaluation of changing needs and risks
    Part of recurring concern: Unreliable dementia care and management
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.12

  1. Action

    Continue commissioning and funding training and programmes to recruit, develop and progress the social care workforce.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
  2. Action

    Implement the national Care Certificate training for newly appointed health and social care support workers.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  3. Action

    Explore options to increase uptake of Tier 2 dementia training among staff who require it.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    The NHS Foundation Trust is responsible for reflecting on the investigation findings and taking appropriate action to improve services.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 evidence or apply comprehensive assessments of the impact of a person’s difficulties

Wider context from the report

“I did not have a sufficient level of confidence about: • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts. ”

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

Failure to provide a social environment supporting psychological and physical needs

Wider context from the report

“I did not have a sufficient level of confidence about: • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts. ”

Is this part of a recurring concern?

Yes — Unreliable dementia care and management.

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 use a proactive dementia care model based on detailed assessment, intervention and evaluation of changing needs and risks

Wider context from the report

“I did not have a sufficient level of confidence about: • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts. ”

Is this part of a recurring concern?

Yes — Unreliable dementia care and management.

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 provide individualised person-centred care from the person’s perspective

Wider context from the report

“I did not have a sufficient level of confidence about: • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts. ”

Is this part of a recurring concern?

Yes — Failure to provide patient-centred care and 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

Failure to convert policy into practice

Wider context from the report

“I did not have a sufficient level of confidence about: • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts. ”

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

Lack of a multidisciplinary dementia care team with suitable skills, qualifications and competencies

Wider context from the report

“I did not have a sufficient level of confidence about: • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts. ”

Is this part of a recurring concern?

Yes — Unreliable dementia care and management.

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 maintain continuous family engagement in the “triangle of care”

Wider context from the report

“I did not have a sufficient level of confidence about: • the provision of a multidisciplinary team of professionals with suitable skills, qualifications and competencies commensurate with their role and the specialty of dementia care; • a prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need for medication; • the evidence of assessments or the application of assessments of the impact of a person’s difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, belief and thoughts of the person; • a continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories; • a focus on the person, asserting absolute value of the person, in an individualised approach, while understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs; • converting policy into practice. The Trust had done a lot of work since the death of Mr Burgess, and I should also be pleased to hear from the Secretary of State about wider learning for other Trusts. ”

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

Continue commissioning and funding training and programmes to recruit, develop and progress the social care workforce.

Verbatim wording from the response

“Ensuring that we have a workforce that has the right values, skills and knowledge, is essential to providing a high-quality service for all those who have need of care services, including those living with dementia. This is why the Department continues to commission and fund a range of training opportunities and other programmes to help recruit people into the sector and develop career pathways, and to support staff to progress to more senior management and leadership roles.”

Source location

2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Page 1 · response
Published 24 May 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

Implement the national Care Certificate training for newly appointed health and social care support workers.

Verbatim wording from the response

“Since 1 April 2015, newly appointed health care assistants and social care support workers, including those providing care to people with dementia and their carers, have been undergoing training as part of the national implementation of the Care Certificate.”

Source location

2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Page 2 · response
Published 24 May 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

Explore options to increase uptake of Tier 2 dementia training among staff who require it.

Verbatim wording from the response

“Good progress has been made to date in training the social care workforce, with around half of those estimated to require Tier 2 level training, having undertaken training to a level equivalent to it. The Department is currently exploring options for increasing uptake of Tier 2 training by everyone who needs it, and in March 2019, the Minister for Care co-signed a letter with the Chief Executive Officers of Skills for Care and Health Education England which was circulated to health and care organisations highlighting the importance of training.”

Source location

2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Page 2 · response
Published 24 May 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 more person-centred, coordinated social care responsive to individual needs, promoting choice and maintaining independence.

Verbatim wording from the response

“In summary, we recognise that personalised care is vital to those people that need care and support. It has demonstrated the ability to improve outcomes and enhance quality of life, enabling people to take control and responsibility for the things that are important to them as well as the care they need. Work is underway to deliver more person-centred, co-ordinated social care, that is responsive to individual needs, promotes choice, and maintains independence.”

Source location

2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Page 3 · response
Published 24 May 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

Review patient-care information regularly and adapt care plans using environmental, medication, health, engagement, incident, observation and risk data.

Verbatim wording from the response

“2.2. As presented at the inquest, changes have been made to the way in which reviews of patient care takes place, with an emphasis now on regularly reviewing all of the information available, which includes, but is not limited to, the environment, medication, physical health, engagement by staff, incidents, observation levels, risks, patterns in challenging behaviour and analysing how these are all impacting the patient so care plans can be adapted accordingly.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 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 10 staff members to provide dementia care mapping across relevant wards.

Verbatim wording from the response

“1.2. As part of the multi-disciplinary team (MDT), Mr Airey explained that the Trust employs specialist Psychiatrists who are trained to work with patients with dementia, in addition to Care of the Elderly nurses, who provide training and support to staff. The Trust also employs Activity Coordinators who are actively involved as part of the MDT process and has recently trained 10 members of staff to provide dementia care mapping training across the relevant wards.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 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

Engage families and friends in care planning and incorporate life stories and ongoing assessment information into regularly reviewed care plans.

Verbatim wording from the response

“4.1. As presented at the inquest, triangulation of care is an important aspect of care and the Trust regularly engages with families to help formulate care plans. As per ████████ evidence, care planning is an ongoing process, which evolves with the patient. Whilst the Trust uses life stories in the first instance to inform care plans, other information”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 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 policy and initiative champions to support implementation and embed new practices.

Verbatim wording from the response

“6.4. The Trust also has champions for some of its policies/initiatives so that extra support is provided to assist in embedding practices, especially when they are new.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 3 · response
Published 24 May 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

Audit policy compliance and require annual competency-based training for observation and engagement practice.

Verbatim wording from the response

“6.1. All Policies and guidelines which are implemented by the Trust are put into practice, with staff receiving information and/or training on the implementation of them. As explained at the inquest, audits are put in place to monitor compliance, with some policies, such as the observation and engagement policy, requiring staff to complete yearly competency based training.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 3 · response
Published 24 May 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

Apply a preventative, person-centred dementia-care model using assessment tools, tailored activities and proactive behavioural support plans.

Verbatim wording from the response

“2.1. As presented at the inquest, the Trust does adopt a preventative approach to person centred care. Tools such as the Newcastle Model, life stories, dementia mapping etc., are used to help formulate care plans, which include activities linked to these assessments and ways to engage patients in therapeutic interventions that are tailored to their specific needs. Stage behaviour support plans also, by their very nature, set out proactive steps to try and prevent behaviour from escalating from one stage to another, with medication prescribed only if required.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 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

Provide dementia care, care-planning formulation, observation and engagement training to relevant staff.

Verbatim wording from the response

“1.1. As presented at the inquest, all staff employed by the Trust have the relevant skills, qualifications and competencies for their role. All staff working with dementia patients have received appropriate dementia care training, with relevant staff receiving care planning formulation training, in addition to observation and engagement training.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 1 · response
Published 24 May 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

Conduct detailed multidisciplinary medication reviews with pharmacist input to assess use, effectiveness, prescriptions and changes.

Verbatim wording from the response

“2.3. As explained by ████████, due to the nature and degree of presentations with dementia that require admission and detention in hospital, patients sometimes require regular medication to assist with their behaviour. With the new review process there is more detailed analysis at MDT meetings, with the input of a Pharmacist, as to how often medication is being used, its effectiveness and whether a regular prescription is required, in addition to any changes in such medication. There are also safeguards within the Mental Health Act that monitor and review these treatments.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 2021

Open published response

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

The NHS Foundation Trust is responsible for reflecting on the investigation findings and taking appropriate action to improve services.

Verbatim wording from the response

“Finally, I expect the Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust to reflect on the findings of your investigation, and take appropriate action to strengthen and improve services. I am aware that the Trust has provided a response explaining the action it has taken following Mr Burgess’s death, particularly in relation to the way patient care is reviewed and monitored. I understand that the Trust’s strengthened review process now provides a more detailed analysis on each patient, which will assist multi-disciplinary teams to effectively plan care for dementia patients.”

Source location

2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Page 4 · response
Published 24 May 2021

Open published response

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

Existing training, audits, communications, supervision and policy champions are considered sufficient to convert Trust policy into practice.

Verbatim wording from the response

“6. Converting policy into practice.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 3 · response
Published 24 May 2021

Open published response

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

Regular review and analysis of relevant patient factors, with information translated into care plans, are considered sufficient assessment arrangements.

Verbatim wording from the response

“3. The evidence of assessments or the application of assessments of the impact of the persons’ difficulties, including cognitive and neurological difficulties, polypharmacy, psychological and personality, mental and physical health, social, environmental and care practices, emotions, beliefs and thoughts of a person.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 2021

Open published response

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

Existing family engagement, information gathering and regular care-plan reviews are considered sufficient for ongoing triangle-of-care communication.

Verbatim wording from the response

“4. A continuous engagement with the family in the “triangle of care”, including regular communication and updating life stories.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 2021

Open published response

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

Existing person-centred models, life stories and tailored activities are considered sufficient to address individuals’ psychological, physical and social needs.

Verbatim wording from the response

“5. A focus on the person, asserting absolute value of the person and individualised approach, whilst understanding the world from the person’s perspective and provision of a social environment that supports psychological and physical needs.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 3 · response
Published 24 May 2021

Open published response

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

Existing staffing, specialist expertise and dementia training are considered sufficient to provide staff with appropriate skills and competencies.

Verbatim wording from the response

“1. The provision of a multi-disciplinary team and professionals with suitable skills, qualifications and competencies commensurate with their role and the speciality of dementia care.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 1 · response
Published 24 May 2021

Open published response

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

Existing preventative, person-centred care processes, reviews and medication safeguards are considered sufficient to manage dementia-related needs, risks and medication use.

Verbatim wording from the response

“2. A prevention model and approach for dementia care that proactively uses detailed assessment, intervention and evaluation of changing care, needs and risks of the individual in order to provide therapeutic interventions and reduce the need of medication.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 2 · response
Published 24 May 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.5

  1. 1

    Disseminate the importance of dementia training to health and care organisations through a jointly signed ministerial and sector-leader letter.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  2. 2

    Monitor training compliance and provide further training when needs are identified.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  3. 3

    Present Central Business Unit discussions and findings to the Locality Quality Standards Meeting on 27 July 2021.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
  4. 4

    Share Serious Incident, inquest and independent-expert findings through Locality Quality Standards and Safety Meetings.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  5. 5

    Disseminate policy and guidance updates through staff bulletins, emails, team meetings and individual supervision.

    Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The relevant Safeguarding Adults Board should decide whether to undertake a Safeguarding Adult Review of the death.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 importance of dementia training to health and care organisations through a jointly signed ministerial and sector-leader letter.

Verbatim wording from the response

“Good progress has been made to date in training the social care workforce, with around half of those estimated to require Tier 2 level training, having undertaken training to a level equivalent to it. The Department is currently exploring options for increasing uptake of Tier 2 training by everyone who needs it, and in March 2019, the Minister for Care co-signed a letter with the Chief Executive Officers of Skills for Care and Health Education England which was circulated to health and care organisations highlighting the importance of training.”

Source location

2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Page 2 · response
Published 24 May 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 training compliance and provide further training when needs are identified.

Verbatim wording from the response

“6.2. Compliance with training is also monitored to ensure that all staff are fully up to date with relevant policies and practices, with additional training provided if a need is identified.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 3 · response
Published 24 May 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

Present Central Business Unit discussions and findings to the Locality Quality Standards Meeting on 27 July 2021.

Verbatim wording from the response

“This letter is written in response to the Regulation 28 Report which you issued against the Trust following the inquest into the death of Mr Richard Burgess. As you are aware, the Trust takes all patient deaths very seriously and investigates them very thoroughly to establish if lessons can be learned or services improved and this case was no exception. Following the inquest, the findings of the Trust’s Serious Incident Report have been shared again at the Trust’s Locality Quality Standards and Safety Meetings, in addition to the findings of the inquest and the reports of the independent expert. On 27 July 2021, the Central Business Unit will also feedback to the Locality Quality Standards Meeting the outcome of their discussions on the findings of the inquest and the independent expert reports to see if any additional learning can be identified.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 1 · response
Published 24 May 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

Share Serious Incident, inquest and independent-expert findings through Locality Quality Standards and Safety Meetings.

Verbatim wording from the response

“This letter is written in response to the Regulation 28 Report which you issued against the Trust following the inquest into the death of Mr Richard Burgess. As you are aware, the Trust takes all patient deaths very seriously and investigates them very thoroughly to establish if lessons can be learned or services improved and this case was no exception. Following the inquest, the findings of the Trust’s Serious Incident Report have been shared again at the Trust’s Locality Quality Standards and Safety Meetings, in addition to the findings of the inquest and the reports of the independent expert. On 27 July 2021, the Central Business Unit will also feedback to the Locality Quality Standards Meeting the outcome of their discussions on the findings of the inquest and the independent expert reports to see if any additional learning can be identified.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 1 · response
Published 24 May 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

Disseminate policy and guidance updates through staff bulletins, emails, team meetings and individual supervision.

Verbatim wording from the response

“6.3. In addition to formal training, the Trust also sends out regular bulletins and emails to staff to keep them updated about any relevant news and/or changes in policies or guidance, as well as relaying key information via team meetings and individual supervision.”

Source location

2021-0163-Response-from-St-Nicholas-Hospital-Published
Page 3 · response
Published 24 May 2021

Open published response

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

The relevant Safeguarding Adults Board should decide whether to undertake a Safeguarding Adult Review of the death.

Verbatim wording from the response

“The Care Act 2014 also requires each local authority to set up a Safeguarding Adults Board (SAB) in order to provide assurance that local safeguarding arrangements and partners are acting to help and protect adults who they suspect are at risk of abuse or neglect. Adult Safeguarding Boards have the authority to carry out a Safeguarding Adult Review (SAR), which should be undertaken in instances when serious abuse, neglect or a fatality has occurred and there is concern that providers could have worked more effectively to have better protected the vulnerable adult.”

Source location

2021-0163-Response-from-Department-of-Health-and-Social-Care_Published
Page 2 · response
Published 24 May 2021

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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