Recurring concern

Unreliable objective criteria for safety risk assessment

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First reported 3 Dec 2013•Latest report 7 Apr 2026

Definition

What this concern includes

Includes failures of generic safety risk-assessment criteria, tools or processes where objective criteria are absent, inconsistently applied, unclear, incomplete or insufficient to support consistent risk ratings across practitioners.

Not included

  • Excludes risk assessments belonging to a separately named system, pathway or hazard when that named concern provides the more specific parent boundary.
  • Excludes failures limited to recording, communicating or acting on a risk assessment when the assessment criteria themselves are adequate.
  • Excludes generic training, staffing or supervision deficiencies unless they directly cause unreliable application or design of the risk-assessment criteria.
  • Excludes clinical or operational decisions that do not identify an unsafe deficiency in the objectivity, consistency or clarity of risk-assessment criteria.
Reports
26

Distinct published reports

Individual concerns
26

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
35

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.

HM Prison and Probation Service4
Department of Health and Social Care3
Greater Manchester Police3
Metropolitan Police Service2
Ministry of Justice2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Barts Health NHS Trust1
B & D Civil Engineers Ltd1
Care Quality Commission1
Care UK1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Dorset Healthcare University NHS Foundation Trust1
East London NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
G4S1

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. East London

    AI-generated summary

    Mrs Surekha Pandharinath Shivalkar · 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 Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.

    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 formal preoperative risk assessment tool requirement

    Wider context from the report

    “1. No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Health NHS Trust since 2018, there remains no requirement to utilise such a tool. ”

    Source location

    Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Manchester South

    AI-generated summary

    ANTHONY JAMES FITZPATRICK · 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

    Anthony James Fitzpatrick had a long history of mental health problems and attended local A&E departments on three occasions in the year before his death, with two attendances followed by custody. The report identified inconsistent and inaccurate assessment of risk by healthcare professionals, with unclear risk grades recorded in the electronic custody record and no plan to address the problem despite it being known.

    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 objective and consistent criteria for risk assessment

    Wider context from the report

    “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record. (2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials. (3) Despite being aware of this problem, there was no plan in place to address it. ”

    Source location

    ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Cambridgeshire and Peterborough

    AI-generated summary

    Jonathan Mark Kingsman · 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

    Jonathan Mark Kingsman died from a pulmonary thromboembolism caused by deep vein thrombosis after admission to Fulbourn Hospital. The VTE risk assessment considered mobility first and did not consider other risk factors unless that step was passed, while the form provided no guidance or definitions for certain terms. The report raised concern that this process could fail to identify risk in other patients with significant risk factors but no obviously reduced mobility.

    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

    Risk assessment excluding other risk factors unless the mobility threshold is passed

    Wider context from the report

    “That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased mobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future; The risk assessment form contains no guidance on its completion and no definition of certain terms. ”

    Source location

    Jonathan Mark Kingsman · 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

    Identify the best route for developing an updated VTE risk assessment tool covering acute psychiatric wards.

    Verbatim wording from the response

    “I am informed by the National Institute for Health Research (NIHR) that it has supported or funded a number of research studies in relation to VTE prevention. This includes studies in relation to the cost-effectiveness of VTE risk assessment tools for hospital inpatients and looking at the risk of VTE in patients admitted to acute psychiatric wards. NHSEI advise that once these studies are complete, it will then be feasible to create an updated tool to encompass patients on acute psychiatry wards, where NICE guidelines recommend that VTE prophylaxis (usually through injections of Low Molecular Weight Heparin) should be given if the risk of VTE exceeds the risks of bleeding. The National Patient Safety Committee will work to identify the best route to take this forward.”

    Source location

    2021-0238-Response-from-Department-of-Health-Social-Care_Published
    Page 2 · response
    Published 15 July 2021

    Open published response
  4. South Yorkshire (Western)

    AI-generated summary

    Keith Dransfield · 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

    Keith Dransfield died in Northern General Hospital on 30 September 2017 from cerebral hypoxia due to hanging, with psychiatric depression also recorded. The inquest identified concerns about an inappropriate observation regime, inadequate risk assessment, failure to routinely consult patient records, and insufficient staff training.

    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 clear patient risk assessments

    Wider context from the report

    “During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”

    Source location

    Keith Dransfield · 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

    Check acute-ward care records for timely updating of risk assessments, care plans and significant care changes.

    Verbatim wording from the response

    “• To determine whether the lack of recording of information was a problem in other wards the Nurse Consultant undertook a care records check in each acute ward. These checks included reviewing evidence that risk assessments, care plans and significant changes to care had been regularly updated. These checks identified that records on the acute wards are being updated regularly and key clinical information recorded.”

    Source location

    2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
    Page 2 · response
    Published 30 October 2018

    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 quarterly inpatient-ward audits of care records, risk assessments and care plans for timeliness and quality.

    Verbatim wording from the response

    “Formal audits of care records on all inpatient wards are now conducted on a quarterly basis. These incorporate an audit of care records, risk assessments and care plans for timeliness and quality. The quarterly audits commenced in April 2018.”

    Source location

    2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
    Page 2 · response
    Published 30 October 2018

    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

    Roll out bespoke suicide-prevention training and continue refining its content using feedback.

    Verbatim wording from the response

    “• The Regulation 28 ruling states that Mr Dransfield was on an inappropriate level of observation at the time of his death. The Trust takes a thorough and proactive approach to the management of risk and, to support our staff in making clinical decisions about levels of risk, the Trust has initiated a programme of bespoke suicide prevention training. This programme of training has commenced, and the Trust has and will continue to review the course content in light of feedback received to improve, refocus and to ensure it is effective and fit for purpose.”

    Source location

    2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
    Page 3 · response
    Published 30 October 2018

    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 refresher training on the policy requirement for a 72-hour post-admission service-user review.

    Verbatim wording from the response

    “The Trust policy requires that a review takes place of each service user on the ward 72 hours after admission. We will ensure that refresher training around the policy and the requirement of the 72 hour review is provided to staff so that an opportunity is not missed for the ward team to consider the needs and presentation of service users in their care to support a clinical assessment around their risks and plan accordingly.”

    Source location

    2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
    Page 3 · response
    Published 30 October 2018

    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 update clinical risk training to strengthen its focus on suicide-risk assessment.

    Verbatim wording from the response

    “The content of our Clinical Risk Training has also been reviewed and updated with an enhanced focus on Suicide Risk Assessment.”

    Source location

    2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
    Page 4 · response
    Published 30 October 2018

    Open published response
  5. Bedfordshire and Luton

    AI-generated summary

    Matthew James WILMOT · 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

    Matthew James WILMOT went out with friends to watch the FA Cup Final and was dropped off near his home at 00.45 hours on 28 May 2017. At 07:14, he was found upside down in an excavated hole on a closed path. The principal concern was that the risk assessment did not give enough consideration to the different risks of a unique route, where pedestrians may be more likely to use the shortest path despite barriers and closure signs.

    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

    Insufficient consideration of unique-route risks in path risk assessments

    Wider context from the report

    “The accident happened on a path which had been excavated to find a stop cock. The excavation had been abandoned as a Deep Excavation Team was required. The path was closed by placing a sign at each end of the path stating that the path was closed. The hole and spoil were fenced off by using a metal railed fence which was alongside the path and 4 plastic yellow barriers which were secured to the metal fence. A risk assessment had taken place. The evidence was that the risk assessment was in line with the Red Book and Industry Standards. The Red Book encourages a risk assessment based on the locality, footfall, etcetera. My concern is that not enough consideration was given to the nature of the path. To all intents and purposes there are two types of paths. The most common is the path that runs parallel to a highway. If that path is closed, the pedestrian can be guided around the excavation or told to cross the road. It is unlikely that the pedestrian would walk through a barriered area in such circumstances as that would be slower than walking around it. The second type of path is one that is unique in its journey from A to B, ie there is no road to the side. This particular path lead from the road to a row of houses, which were not accessible by road. The alternative route (which was not signposted) was 150 metres away, meaning a diversion of about 300 metres. The path was not located in an area of risk. However, my concern is that a route that is unique is always at risk as pedestrians will want to travel the shortest route. This is backed up by the evidence in the Inquest which recorded 9 pedestrians (including the deceased) travelling through the closed path in the 7 hours before the deceased was found. The excavators took photographs of the site just before they left it. Looking at those photographs, I would have risked walking down the closed path. My concern is that there is not enough emphasis within the risk assessment process that a route that is unique has different risks to a path that is parallel. ”

    Source location

    Matthew James WILMOT · 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

    Amend the operative briefing to require assessment of alternative pedestrian routes and supervisory escalation for unsuitable routes at unique locations.

    Verbatim wording from the response

    “It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the M&S operatives were required to complete the Amey Utility Services Limited risk assessment template.”

    Source location

    2018-0107-Response-by-M-S-Water-Services
    Page 2 · response
    Published 17 June 2018

    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 amended briefing mandatory in new-operative induction and refresh it for existing operatives every six months.

    Verbatim wording from the response

    “The briefing will be a mandatory part of the induction process for any new operatives and will be refreshed for all existing operatives at six monthly intervals.”

    Source location

    2018-0107-Response-by-M-S-Water-Services
    Page 2 · response
    Published 17 June 2018

    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 risk assessment complied with the Red Book and industry standards, and the path was not located in an area of risk.

    Verbatim wording from the response

    “We note the concern is that there was not enough emphasis within the risk assessment process that a route that does not run parallel to a highway has different risks to a path that is parallel to a highway.”

    Source location

    2018-0107-Response-by-B-D-Civil-Engineering-Limited
    Page 1 · response
    Published 17 June 2018

    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

    Additional operative guidance is considered sufficient to address concerns about unique sites and public use of alternative routes.

    Verbatim wording from the response

    “It is submitted that the additional guidance given to operatives within three days of the accident on 28 May 2017 should assuage the concern regarding unique sites and whether or not there is sufficient focus in the risk assessment process on the likelihood of the public using the alternative route. It will be appreciated that on the Devon Road site the M&S operatives were required to complete the Amey Utility Services Limited risk assessment template.”

    Source location

    2018-0107-Response-by-M-S-Water-Services
    Page 2 · response
    Published 17 June 2018

    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

    Job planning and identifying unique locations are assigned to the Job Initiator and Job Planner, not M&S.

    Verbatim wording from the response

    “It is important to stress that M&S does not fulfil the role of the Job Initiator or Job Planner. The evidence of Amey (paragraph 4.5 of statement dated 14th December 2017) was that the Job Planner reviews the job for any special requirements based on the Job Initiator's comments. The process involves a visit to the site by the Customer Services Technician. To this extent there is also the opportunity within the planning / permitting process to identify any 'unique' locations.”

    Source location

    2018-0107-Response-by-M-S-Water-Services
    Page 2 · response
    Published 17 June 2018

    Open published response
  6. Manchester South

    AI-generated summary

    Leigh William Wilde · 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

    Leigh William Wilde had raised concerns about issues at his workplace and was found suspended from a ligature at his home after being suspended from employment. Concerns included a lack of documentation and risk assessment relating to the suspension, no evidence of discussion of risk or referral to support services, and unclear approaches to whistleblowers and their support.

    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 consider risk factors and risk minimisation when deciding whether to suspend an employee

    Wider context from the report

    “• Leigh William Wilde had been suspended from his employment shortly before his death. There was no supporting documentation to set out the rationale for the decision. There was no evidence of risk factors or how to minimise them being considered when deciding whether to suspend an employee under the company policy. ”

    Source location

    Leigh William Wilde · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Inner South London

    AI-generated summary

    Rastislav Petrisko · 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

    Rastislav Petrisko, who had a history of suicide attempts, drug and alcohol misuse, and mental health admissions, took a fatal overdose after being granted unescorted leave from a mental health ward. The concerns included an apparently unsuitable low-risk assessment, inappropriate unescorted leave, delayed notification of police when he failed to return, and differing approaches to risk assessment.

    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 a consistent risk-assessment method for vulnerable patients granted leave

    Wider context from the report

    “The responsible clinician (RC) assessed the patient as low risk on granting an hour’s unescorted leave in the local area from 13th. He said that he was not mentally unstable, which would trigger an escort. He was no longer expressing suicidal thoughts. The RC did not consider that Mr Petrisko was an immediate risk to himself, although the past medical history established a higher long term risk. He had already taken leave several times without self-harming (although unknown to the doctor he had returned drunk on 8th whilst in another unit). Although there was reference to recent or pending drug testing there was no record of the result of any drug screening on return from leave in this admission. A nurse indicated that being high risk made no difference to the likelihood of drug screening and the RC indicated that he may still be given leave if he was high risk. However a mental health nurse on the ward said that he was given leave as he was low risk. The risk assessments were guided by the statutory guidance of the Mental Health Act and were not subject to further local guidance. In retrospect the RC did not change his risk assessment. A missing persons form was completed by the ward. His risk was described as concern he would take large amount of drugs and alcohol, which would affect his mental state and that it was not out of character. In answer to the question whether he was likely to commit suicide, was written: “Was admitted with overdose cocaine and medication with suicidal intent”. The police were called at 21.56 and attended at 23.30, by which time emergency services were already in attendance to him in the car park, following a 999 call. As he was low risk the local policy on handling patients who had absconded at the time indicated that he could be given a period of grace before the police were notified, if he did not return at the allotted time. This was given as he had a history of being late back from leave. The ward notified the police 1 hour 49 minutes after he was due back, a period of time acknowledged to be too long. The policy in place made clear that a high risk patient should be reported immediately. The revised Trust policy continues that requirement, removes the period of grace but leaves it to the discretion of the clinicians when to call the police, if the patient is deemed not to be high risk. The DI from the Metropolitan Police Service indicated on reviewing the case, that he would be classed as medium risk, not low risk. High risk is an immediate risk to life, when a DI is deployed immediately to investigate and search. Medium Risk is that the risk to life is not immediate, but is a concern. An investigation and search is begun within the hour. Low risk is where there are no immediate concerns. The investigation may not begin straight away but take a few days. She further said that an immediate action would be to identify the places from which he had been admitted before. The medical records indicated that of the last three admissions he had been brought in from the Calderwood Street Car Park on two occasions (13.12.16 and 05.01.17). That was the site where he took the final fatal overdose. Thus if the police had been rung immediately, and assuming they took no action for the whole of the first hour, they would have had at least 49 minutes to find him in this site, which on the facts of the present case would enable an inference to be drawn that his life would have been saved. Thus the risk assessment by the police would seem to enable some deaths to be prevented, which would not necessarily on application of the assessment of the responsible physician, as immediate reporting only occurs if the patient is high risk. It is of concern that there are two different methods of assessing the risk when a vulnerable patient is granted leave, both in operation, one with greater potential of saving his life than the other. ”

    Source location

    Rastislav Petrisko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Inner North London

    AI-generated summary

    MARK ANTHONY DOYLE · 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

    Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing prison officers.

    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 clear criteria and defined information for assessing fitness for transfer from F Wing

    Wider context from the report

    “(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise. ”

    Source location

    MARK ANTHONY DOYLE · 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

    Use a Patient Wing Movement Assessment requiring senior clinical review, documented fitness decisions and reasons, regular review meetings, and communication of outcomes before transfers.

    Verbatim wording from the response

    “Response: We agree the system described above requires improvement. We have therefore, with immediate effect, implemented a Patient Wing Movement Assessment. This is similar system to what we have in the in-patients unit as follows.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 12 February 2018

    Open published response
  9. Avon

    AI-generated summary

    Rebecca Jay ROMERO · 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

    Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric services.

    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

    Inconsistent terminology and grading in risk assessment

    Wider context from the report

    “(3) That the issue of inconsistent terminology when assessing risk is reviewed to ensure a consistent approach. In this case there were a number of different phrases and grading's used to determine the deceased's risk. ”

    Source location

    Rebecca Jay ROMERO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Birmingham and Solihull

    AI-generated summary

    Mildred Joan Griffiths · 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

    Mildred Joan Griffiths fell at home in May 2017, sustained a femur fracture, developed a deteriorating sacral pressure sore, and died after collapsing in the early hours of 03/08/17. The report raised concerns that differing pressure-sore risk assessment tools could cause confusion and that the Braden Score might underestimate risk because it did not account for existing lesions.

    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

    Use of pressure sore risk tools with opposing score interpretations

    Wider context from the report

    “1. The pressure sore risk tool used in the home is the Braden Score. The community Healthcare Trust use the Walsall score – which is nationally recognised. I note the Braden score does not take into account any existing lesion when calculating the risk which means it may under estimate the risk. In addition the Braden score calculates in an opposite way to the Walsall score – thus a low score is high risk in the Braden score, but low risk in the Walsall score. This can lead to confusion between professionals and the home should consider changing to the Walsall score. ”

    Source location

    Mildred Joan Griffiths · 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

    Keep use of the Braden tool under ongoing review against national guidance and standards.

    Verbatim wording from the response

    “Thus having reviewed your recommendation and the evidence we propose to continue to use the Braden pressure ulcer risk tool but will keep this under ongoing review considering national guidance and standards.”

    Source location

    2017-0400-Response-by-Avery-Health-Group
    Page 2 · response
    Published 15 February 2018

    Open published response
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Data last updated 7 September 2026