Recurring concern

Unreliable coordination of safety equipment installation requests

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First reported 3 Oct 2013•Latest report 19 Mar 2024

Definition

What this concern includes

Includes failures in arrangements specifically dedicated to coordinating safety-equipment installation requests from assessment or request through delivery notification, correct installation, completion of associated repairs, tracking of delays or issues and review of equipment performance.

Not included

Excludes generic equipment availability, maintenance or serviceability failures where no equipment-installation request or follow-up process is deficient.
Excludes generic inter-agency communication, policy or documentation deficiencies unless they directly concern coordination of a safety-equipment installation request.
Excludes clinical assessment or care failures after equipment has been correctly installed and its performance reliably reviewed.
Excludes equipment risks unrelated to a request, installation, repair or post-installation review process.

Reports: 2
Individual concerns: 5
Date range: 2013–2024
Stated actions: 9

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Associate Director of Consumer Relations and Legal Affairs1

Floron Residential Home1

Stockport Borough Council1

Stockport Homes Limited1

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.

19 Mar2024
Manchester South
Concerns raised2
1. Failure to review completion and delays in urgent equipment installation and repairs
2. Lack of a policy governing interaction following equipment installation requests
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Develop, agree with SMBC, and publish target timescales for adaptations.
  Stated by Stockport Homes Group (SHGStated planned
2. Action
  Monitor major adaptations through the established monthly joint Adaptations Panel.
  Stated by Stockport Homes Group (SHGStated completed
3. Action
  Develop a shared SharePoint site for SMBC and SHG staff to monitor minor adaptation installations and provision.
  Stated by Stockport Homes Group (SHGStated planned
1. Action
  Develop, agree and publish target timescales for adaptation installations.
  Stated by Stockport Borough CouncilStated planned
2. Action
  Monitor major adaptation progress through the monthly Adaptations Panel.
  Stated by Stockport Borough CouncilStated planned
3. Action
  Develop a shared SharePoint site for monitoring minor adaptation installation and provision.
  Stated by Stockport Borough CouncilStated planned
4. Action
  Make the ordering worker responsible for confirming adaptation requests are actioned before case closure.
  Stated by Stockport Borough CouncilStated completed
5. Action
  Assign the Team Manager oversight of the process and use the Adaptations Panel to monitor the changes.
  Stated by Stockport Borough CouncilStated planned
6. Action
  Strengthen the service-level agreement with formal governance, agreed targets and monitoring arrangements.
  Stated by Stockport Borough CouncilStated planned
AI-generated summary

Ian Dixon · 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

Ian Dixon, who had confusion, was unsteady on his feet and had a history of falls, was found deceased at the bottom of the stairs in his home on 8 June 2023 after suffering an extensive skull fracture and acute right-sided subdural haematoma. A principal concern was that there was no policy or review process to confirm that urgent equipment requested through the council and Stockport Homes had been installed or to identify delays, and the handrail had not been fitted despite being recorded as complete.

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 review completion and delays in urgent equipment installation and repairs
Wider context from the report
“The Inquest heard that there is no policy in place governing the interaction between Stockport Metropolitan Borough Council and Stockport Homes following a request for the installation of equipment. This means that there is no review undertaken to check whether urgent equipment has been installed, urgent repairs completed or if there are delays/issues with the works requested. ”
Source location
Ian Dixon · 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
Lack of a policy governing interaction following equipment installation requests
Wider context from the report
“The Inquest heard that there is no policy in place governing the interaction between Stockport Metropolitan Borough Council and Stockport Homes following a request for the installation of equipment. This means that there is no review undertaken to check whether urgent equipment has been installed, urgent repairs completed or if there are delays/issues with the works requested. ”
Source location
Ian Dixon · 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
Develop, agree with SMBC, and publish target timescales for adaptations.

Verbatim wording from the response
“• Target timescales will be developed, agreed with SMBC and published by the end of May 2024.”

Source location
Response from Stockport Homes
Page 2 · response
Published 21 March 2024
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 major adaptations through the established monthly joint Adaptations Panel.

Verbatim wording from the response
“• The progress of major adaptations (e.g. stairlifts, level access showers etc) will be monitored via the monthly Adaptations Panel attended by both SMBC and SHG Officers. This meeting is already established.”

Source location
Response from Stockport Homes
Page 2 · response
Published 21 March 2024
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
Develop a shared SharePoint site for SMBC and SHG staff to monitor minor adaptation installations and provision.

Verbatim wording from the response
“• A SharePoint site will be developed providing access to both SMBC and SHG staff to monitor the progress of the installation and provision of minor adaptations (e.g. handrails, grab rails etc) - this will be in place by the end of May 2024.”

Source location
Response from Stockport Homes
Page 2 · response
Published 21 March 2024
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
Develop, agree and publish target timescales for adaptation installations.

Verbatim wording from the response
“To address these issues SMBC have liaised with Stockport Homes and have seen evidence of changes they will implement and will ensure we are active participants including:”

Source location
Response from Stockport Metropolitan Borough Council
Page 1 · response
Published 21 March 2024
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 major adaptation progress through the monthly Adaptations Panel.

Verbatim wording from the response
“2. The progress of major adaptations (e.g. stairlifts, level access showers etc) will be monitored via the monthly Adaptations Panel attended by both SMBC and SHG Officers. This meeting is already established.”

Source location
Response from Stockport Metropolitan Borough Council
Page 1 · response
Published 21 March 2024
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
Develop a shared SharePoint site for monitoring minor adaptation installation and provision.

Verbatim wording from the response
“3. A Sharepoint site will be developed providing access to both SMBC and SHG staff to monitor the progress of the installation and provision of minor adaptations (e.g. handrails, grab rails etc) - this will be in place by the end of May 2024.”

Source location
Response from Stockport Metropolitan Borough Council
Page 2 · response
Published 21 March 2024
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
Make the ordering worker responsible for confirming adaptation requests are actioned before case closure.

Verbatim wording from the response
“In addition to the changes that will be made in collaboration with Stockport Homes SMBC will take the following actions:”

Source location
Response from Stockport Metropolitan Borough Council
Page 2 · response
Published 21 March 2024
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
Assign the Team Manager oversight of the process and use the Adaptations Panel to monitor the changes.

Verbatim wording from the response
“3. The Team Manager will have responsibility for oversight of this process and will retain the role of chair of the Major Adaptations Panel and has close links with Stockport Homes colleagues and will use this forum to monitor the changes described above.”

Source location
Response from Stockport Metropolitan Borough Council
Page 2 · response
Published 21 March 2024
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
Strengthen the service-level agreement with formal governance, agreed targets and monitoring arrangements.

Verbatim wording from the response
“4. In relation to all actions identified above, strengthening of the current SLA is required to ensure that both consistency of approach between both organisations and necessary targets are set and monitored. This will be completed by the end of June ensuring formal governance and sign off is agreed and understood.”

Source location
Response from Stockport Metropolitan Borough Council
Page 2 · response
Published 21 March 2024
Open published response
3 Oct2013
East London
Concerns raised3
1. Lack of a written procedure or policy for notifying district nurses of delivery of assessed equipment
2. Lack of a written procedure or policy for correct installation of assessed equipment
3. Lack of a written procedure or policy for reviewing equipment performance
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Douglas Grey · 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

Douglas Grey, a resident of a residential home, suffered two falls after an inflatable mattress was placed on top of his original mattress and later became unconscious. He died in hospital in the early hours of 5 May 2012; the medical cause of death was recorded as right-sided pneumonia due to an acute subdural haematoma. Concerns included the absence of a clear procedure for notifying district nurses, correctly installing equipment and reviewing its performance, and staff not recognising or reporting faults with the mattress in line with the home's policy.

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 a written procedure or policy for notifying district nurses of delivery of assessed equipment
Wider context from the report
“1. Evidence was given at the inquest that there was no clear written procedure or policy in place to ensure notification to the district nurses of delivery of equipment they had assessed as being needed, correct installation of that equipment and review of the equipment’s performance. ”
Source location
Douglas Grey · 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
Lack of a written procedure or policy for correct installation of assessed equipment
Wider context from the report
“1. Evidence was given at the inquest that there was no clear written procedure or policy in place to ensure notification to the district nurses of delivery of equipment they had assessed as being needed, correct installation of that equipment and review of the equipment’s performance. ”
Source location
Douglas Grey · 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
Lack of a written procedure or policy for reviewing equipment performance
Wider context from the report
“1. Evidence was given at the inquest that there was no clear written procedure or policy in place to ensure notification to the district nurses of delivery of equipment they had assessed as being needed, correct installation of that equipment and review of the equipment’s performance. ”
Source location
Douglas Grey · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to review completion and delays in urgent equipment installation and repairs

Lack of a policy governing interaction following equipment installation requests

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Concerns raised3

Lack of a written procedure or policy for notifying district nurses of delivery of assessed equipment

Lack of a written procedure or policy for correct installation of assessed equipment

Lack of a written procedure or policy for reviewing equipment performance

Actions described in response 9