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. Brighton and Hove

    AI-generated summary

    Patricia Margherita WEBB · 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

    Patricia Margherita WEBB was an 86-year-old woman who was admitted to hospital after which she experienced six falls, fracturing her hip in the sixth fall. The report raised concerns about fall prevention, observation and meaningful activity, footwear and mobility, staffing and ward layout, handover arrangements, resources, and delays in 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

    Unavailability of safe, appropriately fitting non-slip footwear

    Wider context from the report

    “(2) There was a plan in mid-September put in place by the Dementia Nurse for Mrs Webb to have increased levels of observation, for her to be engaged in meaningful activity and for allowing her to be more mobile using non slip footwear and a mobility aid. With regard to the observations I really could not see any evidence that this was giving her enhanced protection. When analysing the falls and their timing it was clear that they always happened early in the morning and often round about the end of the night shift and the start of the day shift when clearly this particular lady was more vulnerable because I suppose she was more active, possibly also if she had been in bed for most of the night she might have been less safely mobile. It’s a shame that this pattern was not observed and arrangements put in place to keep a particular eye on her around this period of time. With regard to meaningful activity it never appeared in the notes following the mid-September plan and since it wasn’t in the notes I found no evidence that it happened. I would suggest that on each change of shift the meaningful activity which the patient has engaged in is recorded and noted so that if there is something that he or she finds particularly absorbing this activity can be offered at times of particular vulnerability. With regard to mobilising, I fully appreciate that the wandering patient who is mobile is at particular risk and I also appreciate the difficulty that might be encountered when trying to persuade such a patient to use a mobility aid. Non slip footwear however, is surely much easier to provide. I know that the hospital footwear comprises ‘short socklets’ in different sizes (thus the right size is always difficult to obtain) with non-slip soles. I was told that these can shift round on the foot so that the sole perhaps rides round to the top of the foot meaning the socklet then becomes dangerous. Wouldn’t it be an idea to see whether proper slippers can be sourced. Perhaps there is a local firm who would like to provide these – it would be a challenge to make them reusable or alternatively if they are cheap enough to be disposed of after use by one patient. Is it worthwhile liaising with South East Coast Ambulance asking them to encourage patients being bought to hospital to bring their own slippers in exactly the same way as they bring their own medications. Whilst I appreciate many of the slippers bought in by patients will be unsuitable by the same token many will be perfectly acceptable. ”

    Source location

    Patricia Margherita WEBB · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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 make mobility central to the care plan

    Wider context from the report

    “(3) His Falls Risk Assessment was flawed in that it failed to take into account information from his wife and son as to how he was mobilising at home. Mobilisation in Mr Lee’s case should have been at the core of the Care Plan because he was suffering from Parkinson’s Disease, where if possible, it is important to maintain mobility. Brunswick Ward should know that. ”

    Source location

    Derek LEE · 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 recognise deterioration in mobility

    Wider context from the report

    “(10) There was apparently no appreciation of the deterioration in Mr Lee’s mobility. He was at high risk of falls and yet the mobilisation of a Parkinson’s patient is imperative and also since he was being specialised during his entire admission there is absolutely no excuse for not trying to assist him with mobilising. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Brighton and Hove

    AI-generated summary

    Jack MOLYNEUX · 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

    Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.

    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 support mobility

    Wider context from the report

    “Mr Jack MOLYNEUX was awaiting discharge to an appropriate Nursing Home. He was on a 19 bedded ward for elderly male patients and during that time he was not suffering from any acute physical illness, but he did however have moderately advanced mixed alzheimer’s and vascular dementia and he needed to be mobilised, he needed to be appropriately hydrated and have his nutrition maintained. He needed mouth care, he had dentures but the top plate was lost. He needed personal hygiene, he needed to have his psychological wellbeing maintained and he needed stimulation and he also needed to have his medications given to him appropriately. It was clear that he did not have mental capacity, it was clear that he could not consider the consequences of his decisions not to accept care or hydration and nutrition or his medications and yet no consideration was given of placing him on a Deprivation of Liberty Safeguarding Order. He needed, but he didn’t receive full care in respect of all the matters mentioned above. Mobility He was never helped to mobilise or to maintain the good mobility which he had when he came into hospital. He was never offered to have his out door clothes and perhaps to be assisted to go down to the hospital shop to buy a newspaper which was something he used to do every day before he came into hospital. He lost 20% of his bodyweight in the one calendar month when he was in hospital and absolutely no note was taken of this and he wasn’t referred to the dieticians until he had been in hospital for almost that full calendar month. His mouth was in such an appalling state when he moved to his nursing home that the nursing home immediately raised a safeguarding alert on the grounds of neglect. His dentures were lost and his mouth was in such a poor state that the staff, on Vallance Ward, were unaware that he even had a lower plate in his mouth. His personal hygiene was such that whilst it was noted he was washed there was no evidence whatsoever that he was ever offered a bath or shower in the four weeks of his admission. There was no evidence whatsoever that any form of stimulation was provided. There was a television by his bed but no evidence that anybody ever discussed with him whether he might like to watch anything on it. With regard to his psychological wellbeing this appeared from the evidence before me to have been completely disregarded. Finally with regard to his medications he refused all his medications on an inconsistent basis but he did take his Memantine for pretty well every day of his hospital admission apart from on a couple of occasions just before he was discharged. At the Inquest I found that whilst he had been neglected during his admission, the circumstances did not reach the required standards for a conclusion of neglect contributing his death. I believe this to be one of the most disturbing cases of sub optimal care that I have come across recently and I am not at all satisfied that this Inquest will result in any effective action being taken which is why I am concerned to follow up this matter and to ensure that all those who should know about this situation are informed. Certainly I found that the above omissions and failings contributed to Mr Molyneux’s death. When he arrived at the nursing home he came on the evening of the 25th January and on the 26th the staff at Partridge House achieved an almost miraculous transformation. He was dressed, although he needed the help of two members of staff, he was on his feet and assisted to mobilise to the toilet, he was sitting out in a bucket chair with other residents and was entertained with a film, his mouth was cleaned, the GP provided mouth wash and mouth gel which was applied. His halitosis which had been so strong that it could be smelt outside his room at Partridge House was resolved, he was smiling and reasonably responsive and was eating and drinking again and also engaged with his son, waving goodbye to him when he had visited on the 26th or 27th. His death was unexpected. Partridge House staff had hoped that whilst he would not have been able to go home he could at least have a reasonable standard of life and be enabled to be content. Finally, it is of note that an urgent DOLS was put in place on the morning of the 27th January 2016. ”

    Source location

    Jack MOLYNEUX · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. North Wales (East and Central)

    AI-generated summary

    Annie Ceinwen Jones · 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

    Annie Ceinwen Jones was admitted to hospital on 1 December 2012 after feeling very poorly and sustaining extensive bruising in a fall from a stand aid. The investigation identified inadequate mobility assessment, an unsafe stand aid, and gaps in staff awareness and competence, although the report states that the incident did not contribute to her death; the inquest conclusion was natural, with bronchopneumonia, volvulus of the sigmoid colon with infarction, and intestinal obstruction recorded as the medical cause of 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

    Inadequate assessment of patient mobility

    Wider context from the report

    “During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years. 1. An inadequate assessment of the mobility of Mrs Jones was made 2. The stand aid was unsafe for use with Mrs Jones 3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility 4. Not all staff were able to operate the stand safely. Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”

    Source location

    Annie Ceinwen Jones · 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

    Improve the completeness and legibility of mobility risk-assessment paperwork.

    Verbatim wording from the response

    “We acknowledge that the paperwork accompanying the risk assessment was not as comprehensive or as legible as it could have been, and we have taken steps to overcome these issues.”

    Source location

    2013-0306-Response-by-Abbey-Dale-House
    Page 3 · response
    Published 20 November 2013

    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

    Complete specialised train-the-trainer education covering manual handling and person-handling risk assessments.

    Verbatim wording from the response

    “Following this event, and to improve the provision of manual handling training within Abbey Dale House, I undertook a 4-day specialised Train-the-trainer course in February 2012, run by Edge Services, a national company that specialise in Manual Handling Training. This course also involved a risk assessment element to the course, to enable full manual handling and person handling risk assessments to be performed by myself.”

    Source location

    2013-0306-Response-by-Abbey-Dale-House
    Page 3 · response
    Published 20 November 2013

    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

    Create an accessible resident mobility summary and person-handling plan for all care staff, including new and agency staff.

    Verbatim wording from the response

    “In order to overcome any communication issues with regards to manual-handling changes, and to provide a point of reference for all staff (including new/agency staff), an updated document has been created to provide a snapshot of each resident's needs, which includes a summary person handling plan, which is readily available to all care staff.”

    Source location

    2013-0306-Response-by-Abbey-Dale-House
    Page 4 · response
    Published 20 November 2013

    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 stand-aid was not considered unsafe because it had been successfully used, formally reviewed monthly, and supported by staff assessments.

    Verbatim wording from the response

    “Mrs Jones had successfully used this particular equipment since the original assessment in March 2012, and the manual handling plan was formally reviewed monthly. On each occasion that any resident is transferred with equipment, the staff have to assess their ability to follow instructions; and to also assess their physical capabilities, which can vary from day-to-day, and even from hour-to-hour.”

    Source location

    2013-0306-Response-by-Abbey-Dale-House
    Page 3 · response
    Published 20 November 2013

    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