Recurring concern

Failure to assess and respond promptly to significant signs of injury

First to latest report 17 Nov 2014 — 26 Jun 2026

Reports that mention this concern
21
Times this concern has been raised
25
Stated actions linked to this concern
31

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.

What is 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 and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    John Robert Maltby Worthington · 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 Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.

    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 undertake further imaging in borderline presentations of significant head injury

    Wider context from the report

    “(1) The deceased attended A&E on the 4th April 2017.He had a very significant head injury 10 cm long requiring 15 stitches and exposing the skull. He had fallen downstairs. He gave a history of a fall from 4 steps. He complained of back and neck pain. Examination of the spine did not reveal any tenderness and other observations were within normal parameters. Further investigations were considered unnecessary and the NICE guidelines were considered. . The deceased’s presenting complaint appeared to fall within a grey area/borderline decision warranting further investigation by way of x-ray/scan. A decision was made not to do this. He later died from injuries sustained in that fall. It is understood that nationally work may be underway to reduce the threshold in such borderline cases. It may be of benefit to future patients for this matter to be further considered. ”

    Source location

    John Robert Maltby Worthington · Prevention of Future Deaths report
    Page 2 · 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

    No further investigations were considered necessary because there were no clinical signs indicating a need at the time.

    Verbatim wording from the response

    “████████ felt that she provided a high standard of care to Dr Worthington at this consultation; having insisted that he attended the Practice for a face to face consultation and the carrying out a detailed assessment. ████████ clinical opinion at the time was that there were no untoward signs of head injury and there were no clinical signs at the time to suggest that any further investigations were needed. ████████ had listened to Dr Worthington’s chest and concluded that the lungs were clear.”

    Source location

    2018-0204-Response-by-MDDUS
    Page 2 · response
    Published 14 August 2018

    Open published response

  2. Staffordshire South

    AI-generated summary

    John Keith Edwards · 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 Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.

    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 deal with significant bruising

    Wider context from the report

    “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. ”

    Source location

    John Keith Edwards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    William Henry BERGMAN · 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

    William Henry Bergman, who had vascular dementia, was admitted to hospital with pneumonia and died after sustaining a forehead impact while being changed on 19 December 2016. He was later found to have a subdural haematoma and massive intracranial bleed. The principal concern was that the staff nurse treated the injury as minor without requesting immediate observations or medical review, and did not change the management plan when a bruise and lump were later noted.

    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 obtain medical review after head injury

    Wider context from the report

    “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

    Source location

    William Henry BERGMAN · 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 revise management when new signs emerge after head injury

    Wider context from the report

    “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

    Source location

    William Henry BERGMAN · 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 obtain and repeat immediate general observations after head injury

    Wider context from the report

    “The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”

    Source location

    William Henry BERGMAN · 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

    Introduce a formal trust-wide policy for managing head injury in patients and staff.

    Verbatim wording from the response

    “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).”

    Source location

    2017-0343-Barts-NHS-Trust
    Page 1 · response
    Published 4 February 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 new post-head-injury guidance and training across Royal London Hospital Older Peoples Service wards.

    Verbatim wording from the response

    “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).”

    Source location

    2017-0343-Barts-NHS-Trust
    Page 1 · response
    Published 4 February 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

    Extend the post-head-injury guidance and training rollout to other inpatient areas.

    Verbatim wording from the response

    “Certain preventative measures have already been taken. Since October 2017 new post management of head injury guidance and a training package has been rolled out within the Royal London Hospital Older Peoples Service wards with other inpatient areas to follow. The guidance ‘Observation of patients’ with head injury in hospital’ was developed as an interim measure prior to the role out of a more formal and trust wide policy for the management of head injury (patients and staff) next year when this is completed (March 2018).”

    Source location

    2017-0343-Barts-NHS-Trust
    Page 1 · response
    Published 4 February 2018

    Open published response

  4. Milton Keynes

    AI-generated summary

    Peter (Peirce) Cotter · 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

    Peter (Peirce) Cotter suffered an unwitnessed fall at home on 27 January 2017, sustaining a head injury and fractured hip, and later underwent hip surgery. The principal concern was that clinical decision support software did not appear to recognise the head injury despite his use of anticoagulant drugs.

    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 of clinical decision support software to register head injuries

    Wider context from the report

    “During the course of the evidence it became apparent that Mrs Cotter had telephoned emergency services on 27th January 2017 and reported that her husband had had a fall, hit his head and hurt his hip. My concern is that the clinical decision support software system did not appear to register that Mr Carter had suffered a head injury. He was receiving anticoagulant drugs and even a minor head injury could have had catastrophic results if the head injury was not recognised and treated. I believe that there should be a review of the triage system to ensure that all head injuries are recognised and treated as emergencies. ”

    Source location

    Peter (Peirce) Cotter · 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

    Existing head-injury questioning and NICE-consistent triage are considered sufficient to identify relevant risks and provide the appropriate emergency response.

    Verbatim wording from the response

    “Having reviewed the case and the Coroner’s concerns, I am in a position to reassure HM Coroner that NHS Pathways identifies and assesses head injuries through a detailed series of questions, and specifically identifies if callers are on anti-coagulant treatment. In this particular case we triaged the call via our head injury flow as an emergency and this resulted in an emergency department disposition via ambulance transport within 1 hour.”

    Source location

    2017-0388-Response-by-NHS-Digital
    Page 2 · response
    Published 9 February 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 Trust cannot change NHS Pathways because it is designed and managed by NHS Digital.

    Verbatim wording from the response

    “To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.”

    Source location

    2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 9 February 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

    Responsibility for reviewing and changing NHS Pathways should be directed to NHS Digital.

    Verbatim wording from the response

    “To confirm the advice that you were given at the inquest hearing by ████████ our Legal Services Manager, NHS Pathways is a national clinical decision software service designed and managed by NHS Digital. Accordingly, the Trust is unable to make any changes to the software system and as advised your concerns should be directed to NHS Digital themselves.”

    Source location

    2017-0388-Response-by-South-Central-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 9 February 2018

    Open published response

  5. Manchester West

    AI-generated summary

    Helen Theresa Cannon · 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

    Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent investigation.

    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 seek medical or paramedic assistance when warranted by a person's condition

    Wider context from the report

    “1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain. It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon. ”

    Source location

    Helen Theresa Cannon · 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

    Integrate a pain-assessment profile into the client assessment process and review the revised process with the service committee.

    Verbatim wording from the response

    “1. The seeking of medical assistance associated with the client expressing that she was “aching rather than in pain”. Presuming that a service can operate without the express requirement for a medical assessment, then the procedures in place at the time of the lady’s fall, the staff carried out an assessment of the client, and part of that assessment was to determine whether it was in pain. However it is clear from your concern that there is an ambiguity around the definition of ‘pain’ vs ‘ache’ and we agree that this could potentially blur the outcome of the evaluation. As a consequence a full review of the surrounding process of patient assessment and a ‘pain assessment profile questionnaire’ has been integrated within the process. This has been reviewed and agreed with the service committee at Wigan Council in order to seek their opinion and agreement as to its suitability.”

    Source location

    2017-0260-Response
    Page 1 · response
    Published 8 November 2017

    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

    Redesign the investigation checklist with STOP alerts, defined sections, clearer larger formatting, and clarified second-responder accuracy checks.

    Verbatim wording from the response

    “2. With regard to the second concern expressed, namely the thoroughness of the investigation, we acknowledge, after further review of the documentation, that the review was conducted with the level of rigor and accuracy that the checklist has also been fully reviewed as part of (i) above. We have introduced “STOP” elements to alert the responders where their answers are such that further assistance may be necessary. We have also separated the checklist out into defined areas and made the layout of the checklist easier and larger which we believe will also assist the staff in completing the documentation. Additionally, the responsibility for the second responder to review the accuracy of a colleague’s client assessment has been clarified with all of the staff, and the timeline of the update has been agreed with Wigan Council.”

    Source location

    2017-0260-Response
    Page 2 · response
    Published 8 November 2017

    Open published response

  6. Birmingham and Solihull

    AI-generated summary

    James Albert Harris · 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

    James Albert Harris died in hospital on 3 April 2017 after a fall at his care home, sustaining a fractured neck of femur and subsequently deteriorating with pneumonia, Clostridium difficile infection and underlying health conditions. Concerns included inadequate falls-policy awareness and application, failure to seek medical attention after he reported pain, lack of analgesia, inadequate records of routine checks, and the care home being without a registered manager.

    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 follow the falls protocol requiring immobilisation and medical attention after a painful fall

    Wider context from the report

    “3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████ ████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017, although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident. ”

    Source location

    James Albert Harris · 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

    Disseminate the falls protocol to staff and incorporate it into new-staff induction.

    Verbatim wording from the response

    “3) Protocol for falls – this document has been given to all staff and a signed copy is kept on their personnel file. This has also been made part of the induction protocol for new staff.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 1 · response
    Published 2 December 2017

    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

    Include the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.

    Verbatim wording from the response

    “7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 2 · response
    Published 2 December 2017

    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

    Add the falls policy to staff-meeting agendas as a lessons-learned item.

    Verbatim wording from the response

    “7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.”

    Source location

    2017-0334-Response-by-Care-First-Class-UK
    Page 2 · response
    Published 2 December 2017

    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 Registered Provider is responsible for ensuring staff competence, training, and compliance with care plans, risk assessments, policies and procedures.

    Verbatim wording from the response

    “The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and the appropriate actions to take by following a service users care plan. If care staff fail to read care plans there is a risk that they will not provide the care that is appropriate to a specific service user and thus putting that service user’s safety at risk.”

    Source location

    2017-0334-Response-by-Care-Quality-Commission
    Page 3 · response
    Published 2 December 2017

    Open published response

  7. Black Country

    AI-generated summary

    Mrs Beryl Farmer · 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 Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the fall.

    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 perform CT head scans after significant facial and head bruising

    Wider context from the report

    “4. In addition no CT Head scan was performed despite evidence of significant bruising to her face and head. ”

    Source location

    Mrs Beryl Farmer · 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

    Recheck head-injury and inpatient-falls policies against NICE and NPSA standards.

    Verbatim wording from the response

    “We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff”

    Source location

    2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    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

    Install the new electronic patient record to provide decision support and alerts reinforcing inpatient-falls and head-injury standards.

    Verbatim wording from the response

    “We are going to amend our inpatient falls policy. This will help us to ensure that post incident monitoring is undertaken. It will also more clearly link our standards in ED and on the wards. It is unacceptable that in this situation the requested monitoring was discontinued. Our use of Vital Pac and the upcoming installation of our new electronic patient record by Christmas 2017 will provide decision support and alerts to reinforce our standards. These changes will be complete by the end of March 2017.”

    Source location

    2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
    Page 2 · response
    Published 19 February 2017

    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

    Existing head-injury and inpatient-falls policies meet NICE and NPSA standards and remain suitable for staff use.

    Verbatim wording from the response

    “We have the necessary policies and procedures in place to manage Head Injuries which present in our Emergency Departments. Equally the management of patients who have fallen during an admission is detailed in policies and guidance for staff. These provide both advice and instruction to staff. Having had this material re-checked by our Medical Director and Chief Nurse, it meets both NICE and NPSA standards and remains suitable. It is available to staff”

    Source location

    2016-0420-Response-by-Sandwell-and-West-Birmingham-Hospitals-NHS-Trust
    Page 1 · response
    Published 19 February 2017

    Open published response

  8. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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

    Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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 intracranial bleeding when assessing new confusion after a fall

    Wider context from the report

    “4. Mrs Tuck had been alert and orientated upon admission on 13 October, and remained so until the afternoon of 16 October, despite her persistently low sodium. When a haematology registrar found her to be confused however, an assumption was made that this confusion was the result of low sodium. It may be that this doctor was unaware of the falls and as a consequence did not consider the possibility that the confusion had been caused by a bleed, but this was the time when a CT scan was indicated. ”

    Source location

    Margaret Emily TUCK · Prevention of Future Deaths report
    Page 3 · 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

    Discuss serious incidents and morbidity and mortality issues through governance meetings and disseminate learning points to the acute admissions team.

    Verbatim wording from the response

    “7. All Serious Incidents and Morbidity and Mortality issues are discussed at our monthly and quarterly unit Governance meetings. All learning points are discussed and disseminated to all members of the AAU team, including all grades of nursing and medical staff. During the investigation the author of the report sought medical advice from the Clinical Director in Neurosciences. Both AAU and HCoE teams see such cases on a near daily basis, and are expert in dealing with the acutely unwell medical patient. We regret that miscommunication led to the delay in obtaining the relevant scan and believe the measures outlined will address such communication barriers.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 4 · response
    Published 26 July 2016

    Open published response

  9. Manchester South

    AI-generated summary

    Malcolm Bennett · 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

    Malcolm Bennett, a resident of a care establishment, sustained injuries in falls and altercations with other residents. After an alleged assault on 15 December 2015, he was taken to hospital several hours later and died the following day from a head injury; the principal concern was the delay in arranging hospital treatment despite his care plan.

    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 arranging emergency hospital assessment and transport after suspected significant injury

    Wider context from the report

    “In the care Plan for this person, it clearly indicated that in the event of any significant injury he should be taken as expeditiously as possible to the Emergency Dept. of the hospital. Clearly this was not done, in that the staff left him knowing that he had apparently been hit by someone and he might well be injured, and they did not call for an ambulance for another three hours. In the light of his cause of death, this delay might have been contributory. ”

    Source location

    Malcolm Bennett · 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

    Update risk management plans for residents prescribed anticoagulants to require calling 999 immediately after a fall, accident or injury.

    Verbatim wording from the response

    “1. All Home Managers in each of Borough Care's care homes were instructed to update the risk management plans (which form part of a care plan) for all residents who have been prescribed Warfarin or any other anti-coagulant, with an instruction to ring 999 without delay in the event that a resident has, or is suspected of, having had a fall, accident or injury. Registered Managers at all care homes have been asked to confirm that risk management plans for residents prescribed with such medication have now been updated.”

    Source location

    2016-0232-Response-by-Borough-Care
    Page 1 · response
    Published 22 June 2016

    Open published response

  10. 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 assess injuries after a significant uncontrolled fall before repositioning the patient

    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 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

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026