Recurring concern

Failure to assess and respond promptly to significant signs of injury

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First reported 17 Nov 2014•Latest report 26 Jun 2026

Definition

What this concern includes

Includes failures to monitor progression, reassess, revise management, seek medical advice or provide a prompt clinical response when significant bruising, deterioration or other signs indicate an apparent fall, impact or head injury.

Not included

  • Skin changes or bruising with no apparent injury or material safety concern
  • Generic delays in medical review where no significant injury sign is identified
  • Treatment-quality failures after the injury has been adequately assessed and escalated
  • Incident-prevention controls before an injury occurs
Reports
21

Distinct published reports

Individual concerns
25

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
31

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.

Care Quality Commission5
Recipient name withheld3
National Institute for Health and Care Excellence2
Audlem Medical Practice1
Barts Health NHS Trust1
Borough Care Ltd1
Cardiff & Vale University LHB1
Care First Class (UK) Limited1
Castlehill Specialist Care Centre1
Community Disability Nurse1
Cwm Taf Morgannwg University Local Health Board1
Daryel Care1
Deerlands Residential Home1
Department of Health and Social Care1
Eldercare (UK) 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.

  1. 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

    Delays in seeking medical advice after apparent impact injury bruising

    Wider context from the report

    “(c) On or around 25 May 2012 bruising on the left side of Mrs Smith's bottom cheek was noted by a Care Home staff together with a blister. However, District Nurse attendance in respect of an open area on Mrs Smith's bottom on her left side took place 7 (seven) days later on 11 June 2012. In the circumstances, Care Home staff should ensure appropriate medical advice is sought at the first available opportunity upon noticing a bruise to a resident following an apparent impact injury; ”

    Source location

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

    Open source report
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Data last updated 7 September 2026