Recurring concern

Failure to assess and meet patients’ mobility needs

First to latest report 20 Nov 2013 — 11 Mar 2026

Reports that mention this concern
14
Times this concern has been raised
15
Stated actions linked to this concern
14

What this concern includes

Includes mobility assessment and provision or availability of required mobility aids and assistance during care.

What is not included
  • General falls assessment with no identified mobility need
  • Equipment maintenance unrelated to an individual mobility requirement
  • Transport between healthcare sites

Reports and published responses 14 reports

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

  1. North Yorkshire and York

    AI-generated summary

    Malcolm WELCH · 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 WELCH, who had a history including prostate cancer, pulmonary fibrosis and falls, suffered an unwitnessed fall in hospital on 22 January 2025, sustaining right-sided rib fractures. He developed pneumonia and deteriorated after discharge, dying at home on 22 February 2025. The principal concern was inconsistent provision of mobility aids when patients were transferred between hospital wards, creating a risk of future deaths.

    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 provision of assessed mobility aids during hospital admissions

    Wider context from the report

    “During the course of the inquest, evidence was heard from Ward Manager ████████ the Ward Manager from Ward 35. She confirmed that it was unlikely that the deceased had been provided with his allocated walking frame on admission to Ward 35; the clinical notes did not refer to him having been provided with that mobility aid. The evidence of ████████ was that even if a walking frame had been allocated to a patient at an earlier stage in the hospital admission process, that walking frame would not automatically follow the patient on their onward journey onto other wards or other areas of the hospital. The evidence was that a reassessment would be undertaken on admission to a new ward and a decision would then be taken in relation to the provision of such mobility aids. In this case, it is likely that the deceased had been on Ward 35 for around 2 hours and 40 minutes and he still had not been provided with an allocated walking frame for his own use. Whilst it cannot be said that this lack of a walking frame contributed to the deceased’s fall, given that he likely used a frame belonging to someone else, it is a matter of concern that a patient could be admitted onto a ward without being provided with the mobility aids that they had been previously assessed as needing at the hospital and which had been allocated to that patient at an earlier stage in the hospital admission process. I am therefore concerned about the consistency of the provision of such mobility aids during the course of a patient’s admission. I am concerned that this creates a risk of future deaths to other patients in circumstances where they are transferred onto wards without them having the mobility aids which they have been assessed as requiring, and with which they have already been provided at an earlier stage whilst in hospital. ”

    Source location

    Malcolm WELCH · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Deliver and disseminate a Learning from Falls briefing on walking-aid provision, including discussion with Falls Champions.

    Verbatim wording from the response

    “In response to this case the monthly Learning from Falls briefing focused on the provision of”

    Source location

    Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
    Page 1 · response
    Published 12 March 2026

    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

    Ward-level walking-aid stocks and access on each ward are relied on to manage mobility needs without transferring aids between wards.

    Verbatim wording from the response

    “Across York & Scarborough NHS Foundation Trust, each inpatient ward has their own stock of walking aids (mix of rollator frames and walking sticks) which are available for their patients to use during their inpatient stay. When a patient is assessed as needing a walking aid to support their mobility in the hospital, this is initially provided by each ward from the ward stock. The aid will then be accessible within the bay and in reach for the patient whilst they are on that ward.”

    Source location

    Response from York & Scarborough Teaching Hospitals NHS Foundation Trust
    Page 1 · response
    Published 12 March 2026

    Open published response

  2. Manchester South

    AI-generated summary

    Lesley Marie Krommendijk · 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

    Lesley Marie Krommendijk fell at home, fractured her right hip, and was discharged home on 5 June 2025. She was later found on the floor, admitted to hospital with confusion and abnormal clinical findings, and died on 20 June 2025. The principal concern was that discharge-assessment processes may have created an unrealistic impression of her mobility, leading to an unsafe discharge.

    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 discharge-safety assessment processes to accurately assess patient mobility

    Wider context from the report

    “(1) The current processes for assessing whether or not it is safe to discharge a patient appear to have led to an unrealistic impression of the patient’s mobility. ”

    Source location

    Lesley Marie Krommendijk · 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

    There was no discrepancy between the discharge referral information and the patient’s function at discharge, so mobility was not unrealistically represented.

    Verbatim wording from the response

    “Mrs Krommendijk was discharged from Ward D5 as planned into her son’s care. At the time of discharge there was no discrepancy between the information within the referral to D2A and her function at the time.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 2 · response
    Published 2 March 2026

    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 discharge planning, equipment provision and continuing mobility reviews were considered appropriate and sufficient under usual practice.

    Verbatim wording from the response

    “Following a full review of Mrs Krommendijk’s documentation whilst in hospital, during the discharge planning process and following her return to home, her mobility and function was continually reviewed as would be expected with appropriate equipment in place. Though Mrs Krommendijk declined physically following her discharge from hospital, the Divisional team believes her discharge was appropriately planned for and completed within our usual expectations. The D2A and ICAH team communicated with Mrs Krommendijk’s GP throughout this period, ensuring that she had timely interventions as required.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 3 · response
    Published 2 March 2026

    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 discharge information accurately reflected the patient’s function, and the discharge was appropriately planned within usual expectations.

    Verbatim wording from the response

    “Mrs Krommendijk was discharged from Ward D5 as planned into her son’s care. At the time of discharge there was no discrepancy between the information within the referral to D2A and her function at the time.”

    Source location

    Response from Stockport NHS Foundation Trust
    Page 2 · response
    Published 2 March 2026

    Open published response

  3. South Yorkshire (Eastern)

    AI-generated summary

    Jean MULLEN · 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

    Jean Mullen, an 87-year-old woman, was found collapsed and unresponsive at the bottom of the stairs at home after her pendant alarm was triggered on 22 June 2024; the inquest concluded that her death was accidental, involving a fall from height, fracture of the neck and subdural haemorrhage. Concerns included the failure to provide a recommended grab rail, failure to escalate a fall in the shower or reassess her mobility and equipment needs, and incomplete recording of stair-related risks.

    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 escalate falls for further assessment of safe home mobility

    Wider context from the report

    “During the course of the inquest I heard evidence regarding communications between various departments of Adult Social Care and Home First and in particular STEPS. There had been an assessment by the therapist at Doncaster Royal Infirmary regarding Mrs Mullen returning to a safe home environment and what support and equipment would be required to allow that to take place. This included an assessment in the home with social workers present. A care package was provided by STEPS and it quickly became apparent that long term care and support would be required in the home and thus an application was completed on the 12th April. Mrs Mullen's family referred to them being informed that a grab rail would be required at the top of the stairs near the bathroom to help Mrs Mullen navigate to the bathroom thus reducing the risk of falls. This was not provided. A fall occurred when Mrs Mullen was in the shower but the carers failed to escalate this and made no referrals for any further assessment to take place in relation to Mrs Mullen's mobility and ability to continue living safely at her home address. Further this was a missed opportunity to assess whether any other aids or equipment were needed to support her. Had this taken place it is likely that the absence of the grab rail would have been identified. This was a further missed opportunity. Finally, the care and support placement referred to in the second exhibit to ████████'s report made no reference to the issue of stairs and the risk of falling that they presented. ”

    Source location

    Jean MULLEN · 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

    Reinforce escalation of concerns through appropriate referrals to professionals who can assess risks and recommend protective measures.

    Verbatim wording from the response

    “➢ It should be noted that carers and social care staff are not qualified to diagnose medical conditions or to make recommendations for aids and equipment. Their role is to raise any perceived concerns and to direct the person in question to the relevant professional for advice, usually an occupational therapist, physiotherapist, or District Nurse. All staff are aware of this process and do not require permission to take such steps.”

    Source location

    Response from Doncaster Council
    Page 2 · response
    Published 20 February 2025

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    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

    Establish the Home First Forum to inform domiciliary care providers about referral routes for concerns.

    Verbatim wording from the response

    “Since this incident and as part of “lessons learnt” we have set up a “Home First Forum” with a view to providing all domiciliary home care providers information as to when and to whom they should direct any referrals. The first event was held on 30 January 2025 and further events will be held on a quarterly basis.”

    Source location

    Response from Doncaster Council
    Page 3 · response
    Published 20 February 2025

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    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

    Hold further Home First Forum events quarterly to maintain referral guidance for domiciliary care providers.

    Verbatim wording from the response

    “Since this incident and as part of “lessons learnt” we have set up a “Home First Forum” with a view to providing all domiciliary home care providers information as to when and to whom they should direct any referrals. The first event was held on 30 January 2025 and further events will be held on a quarterly basis.”

    Source location

    Response from Doncaster Council
    Page 3 · response
    Published 20 February 2025

    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

    Relevant professionals, rather than social care staff, must assess risks and recommend or order aids and equipment.

    Verbatim wording from the response

    “➢ It should be noted that carers and social care staff are not qualified to diagnose medical conditions or to make recommendations for aids and equipment. Their role is to raise any perceived concerns and to direct the person in question to the relevant professional for advice, usually an occupational therapist, physiotherapist, or District Nurse. All staff are aware of this process and do not require permission to take such steps.”

    Source location

    Response from Doncaster Council
    Page 2 · response
    Published 20 February 2025

    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

    A single fall would not ordinarily require a referral unless carers considered referral to be in the person’s best interests.

    Verbatim wording from the response

    “As a matter of practice, a single fall event would not be expected to raise a referral. Mrs Mullen was in receipt of care specifically to assist her with showering and any concerns in this respect would have been referred by the carers from Newdon Care to RDaSH for the falls service, occupational therapy, and physiotherapy, in the event that they considered this to be in Mrs Mullen’s best interests.”

    Source location

    Response from Doncaster Council
    Page 4 · response
    Published 20 February 2025

    Open published response

  4. East Sussex

    AI-generated summary

    Carol Ann DIVALL · 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

    Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and 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 provide regular mobilisation assistance

    Wider context from the report

    “B. Mrs Divall was referred to the Physiotherapy Department 2 weeks after admission but was rarely assisted with mobilisation and left to sit out in her chair for long periods. Action should have been taken to encourage Mrs Divall to mobilise more often in an attempt to rehabilitate her after her surgery. ”

    Source location

    Carol Ann DIVALL · Prevention of Future Deaths report
    Page 2 · concerns

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    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 Saturday physiotherapy assessments for new fractured-neck-of-femur patients.

    Verbatim wording from the response

    “When Mrs Divall was an in-patient, we did not have a routine Physiotherapy weekend service and had experienced staff sickness as well. We have now made changes to the rota for this service and since mid-May we now have a Saturday service for new assessments of patients who have sustained a fractured Neck of Femur.”

    Source location

    Response from East Sussex Healthcare
    Page 3 · response
    Published 15 May 2024

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    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

    Increase physical therapy capacity by employing two full-time Physical Therapist Assistants.

    Verbatim wording from the response

    “We have also increased staffing to include two full-time Physical Therapist Assistants (PTAs) in the period since this incident.”

    Source location

    Response from East Sussex Healthcare
    Page 3 · response
    Published 15 May 2024

    Open published response

  5. Sefton, St Helens and Knowsley

    AI-generated summary

    Julia MURPHY · 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

    Julia Murphy, known as Sheila, died in hospital on 9 April 2023 after a fall in her care home caused a hip fracture and her condition deteriorated. The report raises concerns about repeated falls, incomplete or inaccurate referrals to the falls prevention team, inadequate escalation, and failure to formally seek one-to-one supervision funding where appropriate.

    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 meet the mobility needs of a resident with evolving dementia

    Wider context from the report

    “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia; 1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team . 2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment. 4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis. 5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation. The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia. ”

    Source location

    Julia MURPHY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Birmingham and Solihull

    AI-generated summary

    Leonard Arthur PRITCHARD · 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

    Leonard Arthur Pritchard died on 18 February 2021 in Good Hope Hospital after sustaining injuries in an unwitnessed fall from a chair in an A&E cubicle on 12 February 2021. The report raised concerns about an inadequate supply of mobility aids in the emergency department and unclear responsibility and timescales for their assessment, selection and procurement.

    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

    Inadequate supply of mobility aids in the emergency department

    Wider context from the report

    “1. During the course of the inquest, I heard evidence that there is an inadequate supply of mobility aids within the emergency department of Good Hope Hospital which are utilised by the Older People Assessment and Liaison (OPAL) team when assessing patient's mobility, and which are given to patients who are identified as requiring an aid. I heard that there are presently 2 zimmer frames, whilst there are 17 cubicles in majors; 5 resuscitation cubicles; 6 trolleys in the new extension of the emergency department; and 8 chairs in the clinical decision unit. I heard from staff that they consider this mobility aid to patient bed ratio was inadequate. There is a clear risk of death for patients who require mobility aids but can not have access to them. The Trust should consider addressing this as a matter of urgency. ”

    Source location

    Leonard Arthur PRITCHARD · 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

    Ensure emergency departments in regional hospitals have access to an adequate supply of mobility aids.

    Verbatim wording from the response

    “However I can confirm that we have shared this Regulation 28 Report and both responses with the Regional NHSE/I teams to ensure that they have sight of this potential problem and will ensure that the ED departments in their hospitals have access to an adequate supply of mobility aids.”

    Source location

    2021-0207-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 2 · response
    Published 28 June 2021

    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

    Increase emergency-department mobility-aid stock to 12 immediately available zimmer frames.

    Verbatim wording from the response

    “I can however confirm that immediately following the Inquest 5 zimmer frames were sourced internally and were made available for immediate use within the ED the same evening. The OPAL team also obtained 5 zimmer frames, meaning that there were a total of 12 frames (inclusive of 2 existing frames) immediately available for patients within the department, which was deemed to be an appropriate number. A request for a further 10 frames to be procured was also made on 17 June by the ED team.”

    Source location

    2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
    Page 1 · response
    Published 28 June 2021

    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

    Request procurement of 10 additional zimmer frames for the emergency department.

    Verbatim wording from the response

    “I can however confirm that immediately following the Inquest 5 zimmer frames were sourced internally and were made available for immediate use within the ED the same evening. The OPAL team also obtained 5 zimmer frames, meaning that there were a total of 12 frames (inclusive of 2 existing frames) immediately available for patients within the department, which was deemed to be an appropriate number. A request for a further 10 frames to be procured was also made on 17 June by the ED team.”

    Source location

    2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
    Page 1 · response
    Published 28 June 2021

    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

    Standardise and implement a cross-site process for stocking, procuring, storing, labelling, providing and documenting mobility aids for patients assessed as needing them.

    Verbatim wording from the response

    “Following the Inquest we have also standardised the process across all of our sites so that all ED areas have a stock of zimmer frames and a process in place to ensure that patients are provided with a frame when they are assessed as needing one. The process includes the procurement, storage, labelling and auditing of their use.”

    Source location

    2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
    Page 1 · response
    Published 28 June 2021

    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’s local response adequately addresses mobility-aid supply and procurement concerns, so no further national response is proposed.

    Verbatim wording from the response

    “I note that your Regulation 28 Report was also sent to University Hospitals Birmingham NHS Trust. The Trust have kindly shared their response and I have seen that the matters of concern have been dealt with and responded too at a local level. Given the content and adequacy of the Trust’s response I do not propose responding further on a national level.”

    Source location

    2021-0207-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 2 · response
    Published 28 June 2021

    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 procuring additional mobility aids rests with the emergency department team, as needs are identified.

    Verbatim wording from the response

    “It is now the responsibility of the ED team to procure additional mobility aids and these can be requested as and when a need is identified. The frames are also stored within the sister’s office situated within the ED, which can be accessed for use at any time.”

    Source location

    2021-0207-Response-from-Queen-Elizabeth-Hospital-Birmingham_Published
    Page 1 · response
    Published 28 June 2021

    Open published response

  7. Nottinghamshire

    AI-generated summary

    Norma Lockton · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to recognise changing health and mobility needs

    Wider context from the report

    “3. The lack of recognition of Norma’s changing health and mobility needs, leading to no change in her general health and mobility care plans ”

    Source location

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

    Open source report

  8. County Durham and Darlington

    AI-generated summary

    Agnes Gwenllian SANSOM · 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

    Agnes Gwenllian Sansom was admitted to hospital on 15 July 2019 and, despite being at risk of falling and requiring supervision when mobilising, was not prevented from mobilising unaided. She fell on 20 July after nursing staff did not have access to important physiotherapy observations, sustaining the injury that led to her death; concerns included failures in patient information systems and the sharing of walking aids by vulnerable patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide sufficient walking aids for vulnerable patients on hospital wards

    Wider context from the report

    “(ii) vulnerable patients are obliged to share walking aids on hospital wards ”

    Source location

    Agnes Gwenllian SANSOM · 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

    Maintain buffer stocks of walking aids in hospitals for emergency out-of-hours use.

    Verbatim wording from the response

    “During traditional working hours walking aids are provided by physiotherapists following assessment of the patient. We have implemented a buffer stock of walking aids in the hospitals to ensure there is an adequate supply out of hours. Ideally the buffer stock should not be used as it is preferable that patients requiring a walking aid have a physiotherapist assessment first, however, if someone presents who does require a walking frame out of hours we have ensured that there is a buffer stock available for emergency use.”

    Source location

    Response from County Durham and Darlington NHS
    Page 2 · response
    Published 8 February 2020

    Open published response

  9. Black Country

    AI-generated summary

    Mrs Elsa Reid · 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 Elsa Reid, a 92-year-old woman, was admitted to hospital after a fall that caused a complex fractured hip and was later discharged to a care home for rehabilitation. She died on 20 December 2018 after developing a pulmonary embolism. The principal concerns were inadequate communication about her mobility and hoisting needs, delays in resolving conflicting instructions, and an insufficient mobility regime that may have increased the risk of complications including pulmonary embolism.

    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

    Minimal exercise and mobility regime

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inadequate communication between the Hospital and occupational therapist to resolve the issue in a timely manner which resulted in a minimal exercise/mobility regime being implemented. ”

    Source location

    Mrs Elsa Reid · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Avon

    AI-generated summary

    Elizabeth Rose CURTIS · 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

    Elizabeth Rose Curtis was admitted to hospital with a urinary tract infection and delirium, was treated with antibiotics and haloperidol, developed aspiration pneumonia, and died on 31 March 2018. The inquest noted that she was prescribed 2.5mg of haloperidol instead of the intended 0.25mg. A substantive concern was how patients’ mobility and frailty should be assessed as indicators of wellbeing and possible deterioration in hospital.

    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 incorporate patients' mobility into assessment of well-being

    Wider context from the report

    “A patient's mobility became an issue at the inquest and how this can help with assessing a patient's wellness. I was advised by ████████ at the Royal United Hospital, Bath, who gave evidence at this inquest that she was introducing to the hospital a mobility scale due to the impact that mobility or indeed frailty has on assessing well-being of patients when in hospital. ████████ has indicated that this is a simple scale noting a patient's best mobility in the previous 24hrs. and is recorded alongside the NEWS score. Often mobility is the first symptom demonstrating a decline in health. I am told that the Royal United Hospital have adopted this scale. For further details in relation to this I would suggest that you contact ████████ Consultant Geriatrician, at Royal United Hospital NHS Foundation Trust her email is ████████. I have also suggested that she write to you to outline her “mobility scale”, hence I have copied her into this report. ”

    Source location

    Elizabeth Rose CURTIS · 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

    A national mobility-score field on NEWS2 is not preferred; comprehensive specialty-tailored assessment and review alongside NEWS2 is considered better.

    Verbatim wording from the response

    “The Royal College of Physicians, who lead on the National Early Warning Score (NEWS2) are very supportive of the need to assess, monitor and act on a range of other signs and symptoms and test results that indicate a patient is either not improving as fast as expected or is getting unexpectedly less well. They believe this is best done by comprehensive assessment and review tailored to patient specialities alongside NEWS2, rather adding a mobility score as an additional field on NEWS2 charts nationally; but we will keep them updated on any significant findings from the work at Royal United Hospital Bath NHS Foundation Trust.”

    Source location

    2019-0018-Response-by-NHS-Improvement
    Page 1 · response
    Published 23 May 2019

    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