Recurring concern

Unsafe moving and handling of patients

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First reported 4 Dec 2013•Latest report 11 Jun 2025

Definition

What this concern includes

Includes failures of the dedicated patient moving and handling process, including moving and handling risk assessments, appropriate equipment, safe positioning or securing, and correct repositioning or transfer practices.

Not included

  • Excludes generic staffing, training, documentation or record-keeping failures unless they are explicitly tied to the patient moving and handling process.
  • Excludes pressure-ulcer prevention and general personal-care failures that are not specifically about moving, handling, positioning or repositioning patients.
  • Excludes unrelated clinical risk assessments, including VTE, falls or malnutrition assessments, unless the assertion concerns moving and handling itself.
Reports
20

Distinct published reports

Individual concerns
23

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
14

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

University Hospitals Sussex NHS Foundation Trust2
Bluebird Care Harrow and Brent1
Care First Homes1
Care Quality Commission1
Care UK1
Care UK Community Partnerships Ltd1
Court Nursing Home1
Doctor1
East of England Ambulance Service NHS Trust1
East Sussex Healthcare NHS Trust1
Elizabeth House (Oldham) Limited1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Happy at Home Community Care Services Ltd.1
Leeds City Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Nottinghamshire

    AI-generated summary

    Norma Lockton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to regularly document repositioning

    Wider context from the report

    “2. The lack of regular documented repositioning of Norma, with no understanding by the management team as to how and why this issue had occurred. ”

    Source location

    Norma Lockton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Inner North London

    AI-generated summary

    John Francis GREGORY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to secure patients safely in wheelchairs

    Wider context from the report

    “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff. He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself. ”

    Source location

    John Francis GREGORY · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Strengthen wheelchair-safety training with dedicated guidance and complete one-to-one supervision sessions for all staff.

    Verbatim wording from the response

    “Notwithstanding this, since Mr Gregory’s sad death, Muriel Street has reviewed the manual handling training provided. Following this, it was identified that the training surrounding the use of wheelchairs could be strengthened. Consequently, the training has been improved, and the manual handling training now includes a specific section on wheelchair safety guidance. This includes highlighting and working through the "How to Guide – Wheelchair safety Guidance" (copy attached) during the training session. Due to the current pandemic, and the consequent restrictions placed upon the ability to provide group training, Muriel Street has undertaken 1:1 supervision / training sessions with all staff members in order to go through the how to guide, and ensure staff are familiar with the expectations set out therein.”

    Source location

    2020-0073-Response-from-Care-UK_Redacted
    Page 2 · response
    Published 9 April 2020

    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 wheelchair-safety guidance through laminated copies at nurses’ stations and copies in relevant resident care-plan folders.

    Verbatim wording from the response

    “Further, there is now a laminated copy of this guide at every nurse's station to ensure that the guide is easily accessible. Additionally, where a resident's care plan requires the use of a wheelchair, a hard copy of the guide is placed into that resident's care plan folder in their room.”

    Source location

    2020-0073-Response-from-Care-UK_Redacted
    Page 2 · response
    Published 9 April 2020

    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 full-group refresher training on wheelchair safety, appropriate dressing, oral-fluid encouragement and updated welfare-check documentation after restrictions are lifted.

    Verbatim wording from the response

    “As is clear from the above, there has been a number of changes made since the death. Ordinarily group training would be provided in order to re-inforce the improvements made. However, given the current pandemic, this has not been possible, and training has instead taken place in smaller groups. Notwithstanding this, once the current restrictions have been lifted, it is the intention of Muriel Street to have full group training on the following relevant areas:”

    Source location

    2020-0073-Response-from-Care-UK_Redacted
    Page 6 · response
    Published 9 April 2020

    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 incident occurred on arrival at Muriel Street, not during hospital readmission, and the resident was neither in public nor unresponsive.

    Verbatim wording from the response

    “For completeness, our understanding of the evidence, supported by the documentation from the family, is that the incident when Mr Gregory was found unsecured in a wheelchair was on arrival at Muriel Street, and not on the day he was readmitted to hospital. Further, our understanding of the evidence is that Mr Gregory was not in a public place, nor was he unresponsive at this time. That said, he should have been transferred into an armchair in his room.”

    Source location

    2020-0073-Response-from-Care-UK_Redacted
    Page 1 · response
    Published 9 April 2020

    Open published response
  3. Norfolk

    AI-generated summary

    ROBERT CHARLES CHANDLER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robert Charles Chandler collapsed and suffered a pneumothorax on 24 September 2018. An ambulance arrived 50 minutes after the first telephone call, and he died in hospital on 25 September 2018 from his injury. Concerns included equipment failure and transfer without pain relief or safety straps, incomplete records, inconsistent equipment checks and assistance-seeking, and delayed implementation of investigation recommendations.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use safety straps during patient transfer

    Wider context from the report

    “(1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used. ”

    Source location

    ROBERT CHARLES CHANDLER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    Safety for Mangar Elk use is considered adequately managed by attending ambulance staff, despite the equipment lacking safety straps.

    Verbatim wording from the response

    “In terms of your comments regarding pain relief and safety straps, Entonox is not indicated with potential chest injuries so IV cannulation would be needed to administer the drug. The crew felt to do this they would need to take many layers of clothes off the patient in a cold outside area and it was more appropriate to complete when in the ambulance. The Mangar Elk piece of equipment does not have safety straps attached to it as the safety element is managed by the attending ambulance staff.”

    Source location

    2019-0060-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 26 May 2019

    Open published response
  4. Manchester North

    AI-generated summary

    Thomas Allan Ratchford · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Allan Ratchford had been immobile for six years and was admitted to Marland Court Residential Home for respite care on 4 October 2017. During his admission, he developed a deep tissue injury that extended from his sacrum to his inner thighs, and the report states that inappropriate use of a hoist for pressure relief more likely than not contributed to his death. The principal concern was that the home manager and carers had insufficient training in moving and handling and pressure relief, and had not obtained appropriate advice about using the hoist.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of sufficient training in moving and handling and pressure relief

    Wider context from the report

    “The use of the hoist to provide pressure relief is not one that was either recognised or recommended by the Tissue Viability Nurse who gave evidence at the inquest. It was a practice that had been adopted by the carers at Marland Court Residential Home without obtaining advice from either the hoist manufacturers or the District Nurses. Had advice been taken, the carers would have been informed that it was not recommended. The matter of concern that neither the Home Manager or the carers had received sufficient training in moving and handling and pressure relief. ”

    Source location

    Thomas Allan Ratchford · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Brighton and Hove

    AI-generated summary

    Leslie Isaac LERNER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide appropriate positioning and personal care

    Wider context from the report

    “17th May – 22nd May 2016 There is no evidence of any continuity of care. There is good evidence of “hands off” care and nursing. In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering. No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics. In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing, because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing. ”

    Source location

    Leslie Isaac LERNER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Norman Arthur BEARD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete turning charts

    Wider context from the report

    “(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided. ”

    Source location

    Norman Arthur BEARD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Mid Kent and Medway

    AI-generated summary

    Lilian Hursell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Lilian Hursell died at Pembury Hospital on 6 July 2015 from pneumonia contracted following reduced mobility associated with unstable fractured cervical vertebrae after a fall from bed at Maidstone Care Centre. The concerns included bedrails not being securely engaged and the handling of Lilian Hursell after a significant uncontrolled fall before the extent of her injuries had been assessed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use safe post-fall handling for patients with possible head or cervical spine injury

    Wider context from the report

    “(2) Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had however additionally suffered a subdural haematoma and had fractures to her cervical vertebra ”

    Source location

    Lilian Hursell · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Retrain all care-delivering staff in moving and handling through e-learning and competency-based workbooks.

    Verbatim wording from the response

    “• A programme of moving and handling re-training has been commenced and will be completed by the 1st June 2016, this is carried out in the blended approach of e-learning and via competency based workbooks for all staff delivering care.”

    Source location

    Hursell-Response
    Page 1 · response
    Published 1 April 2016

    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

    Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.

    Verbatim wording from the response

    “• All staff have been advised that following a fall no person should be moved until a full assessment by a suitably trained person has been carried out.”

    Source location

    Hursell-Response
    Page 2 · response
    Published 1 April 2016

    Open published response
  8. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use the required trolley for patient transfer

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete handling assessments

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Incomplete and poor repositioning records

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Monitor documentation more closely and provide nurses with real-time feedback.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    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 and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.

    Verbatim wording from the response

    “Extensive and complex work is also being undertaken to”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 7 May 2015

    Open published response
  9. West Yorkshire (East)

    AI-generated summary

    Mrs Gladys Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to complete turning and repositioning charts

    Wider context from the report

    “(a) Advice and instruction given to Care Home staff as to the turning and repositioning of Mrs Smith was not followed and repositioning charts were not completed. In the circumstances, all Care Home staff should ensure that all advice and instruction given by medical practitioners, that is to say by General Practitioners and District Nurses, in relation to residents is appropriately implemented and that turning/repositioning charts are completed; ”

    Source location

    Mrs Gladys Smith · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  10. Leicester City and South Leicestershire

    AI-generated summary

    Marjorie Evelyne Keogh · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marjorie Evelyne Keogh, a resident of Scraptoft Court Residential Care Home, fell through a first-floor landing balustrade while transferring to breakfast on 6 March 2010 and died the following day from bilateral pneumonia and multiple injuries. Concerns included the assessment of her suitability for a first-floor room, staffing levels and the absence of a manager, inconsistent risk and manual-handling assessments, and the strength and compliance of staircase furniture.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Conflicting falls-risk and manual-handling assessments for resident mobilisation

    Wider context from the report

    “(3) It seemed that there was evidence to indicate that there was conflict between the assessment of risk of falls and the assessment of manual handling, as to how serious a risk there was when Mrs Keogh mobilised. Please provide written evidence of how care plans and associated assessments are carried out. ”

    Source location

    Marjorie Evelyne Keogh · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026