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recurance

Inadequate nighttime patient observation documentation

Identical hazardConfidence 0.90 · high2 reports · 2014–2016 One-page brief (print or PDF)

The Priory Group received 2 coroners' reports about this hazard between 5 Mar 2014 and 31 Oct 2016.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 1 specific action.

2
reports
2
different coroners
2014–2016
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Neil Carter↗

    5 Mar 2014 · Sean Cummings · London (West)

    “There were repeated failures to perform basic nursing observations”
    Original on judiciary.uk ↗

    The Priory Group responded, stating 1 specific action.Response (PDF) ↗

    “In response to points one and three, | understand that the records falsification and a number of key missing observations in Mr [name redacted] case for the afternoon he absconded from the ward, fell to one nurse, | am informed that the relevant individual was disciplined through Priory's internal processes and dismissed from employment. She was also referred to the NMC as her actions fell short of the standard required.”
  2. 2 years 8 months later

    Raised again · 1st time

    Anthony McManus↗

    31 Oct 2016 · Thomas Osborne · Milton Keynes

    Identical hazardConfidence 0.90 · higha different coroner
    “The system of observations carried out within the unit, particularly at night is in need of reform.”
    Original on judiciary.uk ↗

    The most recent report. A response may not be due or published yet.

  3. All reports to The Priory Group

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error