Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
James Quinton · 22 Feb 2018 · Nicola Mundy, South Yorkshire (East)
“During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring.”
judiciary.uk/prevention-of-future-death-reports/james-quinton
What was promised
Stated action 1 · response to James Quinton (22 Feb 2018) · stated timescale: end of April
“1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department. The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the”
judiciary.uk/…/2018-0056-Response-by-Doncaster-Bassetlaw-Teachi…
Stated action 2 · response to James Quinton (22 Feb 2018) · stated timescale: end of April
“a working group has been set up with representation from ED and Anaesthetics to explore further the issue of IV drug administration in emergencies during resuscitation. The first meeting is scheduled for the end of April to look at systems and processes for working together within the Resus area.”
judiciary.uk/…/2018-0056-Response-by-Doncaster-Bassetlaw-Teachi…
Stated action 3 · response to Robert Fuller (2 Apr 2024) · stated timescale: coming weeks
“We have taken the opportunity to review and refine our Enhanced Care Policy and this is proceeding through our governance process for sign off over the coming weeks. One of the changes has been to separate our Falls Risk Assessment and Confusion Risk Assessment to support easier recognition of patients who are either a falls risk or those patients who need a designated level of supervision due to behaviours of concern.”
1 further stated action is listed on the full chain page.
What recurred
- 2 Apr 2024 · Robert Fuller · Sarah Slater · Closely related · confidence 0.92 (high)
- 22 Aug 2025 · Lee Stammers · Louise Slater · Closely related · confidence 0.86 (high)
The clearest link, quoted from both reports:
Earlier · James Quinton · 22 Feb 2018
“During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring.”
Later · Robert Fuller · 2 Apr 2024
“There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”
What happened next
No web check of the stated actions has been published for this chain.