Recurring concern

Unreliable plaster-cast care and management

First to latest report 10 Aug 2015 — 12 Dec 2017

Reports that mention this concern
2
Times this concern has been raised
6
Stated actions linked to this concern
5

What this concern includes

Includes failures of controls specifically dedicated to plaster-cast care and management, including staff competence and refresher training, patient assessment in the Plaster Room, protocols, monitoring, documentation, escalation and related follow-up where these affect the safety of patients with plaster casts.

What is not included
  • Excludes generic staff training or competence deficiencies not specifically tied to plaster-cast care and management.
  • Excludes general patient assessment, treatment or documentation failures that do not concern patients with plaster casts or the Plaster Room process.
  • Excludes failures in orthopaedic care unrelated to plaster-cast assessment, management or associated safety controls.
  • Excludes equipment or staffing deficiencies unless they directly impair the plaster-cast care and management process.

Reports and published responses 2 reports

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

  1. Birmingham and Solihull

    AI-generated summary

    Francis Robert Beech · 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

    Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.

    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 the nursing home with information about monitoring a high risk plaster cast

    Wider context from the report

    “5. Failing to provide any information to the nursing home about the need to monitor the plaster cast and that it was high risk. ”

    Source location

    Francis Robert Beech · 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

    Lack of a care plan for management and monitoring of the plaster cast

    Wider context from the report

    “1. Failing to have any care plan for the management and monitoring of his plaster cast. ”

    Source location

    Francis Robert Beech · 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

    Lack of further staff training on plaster casts

    Wider context from the report

    “4. There has been no further training for staff on plaster casts. The nursing home should review the training needs for staff on the care and management of plaster casts. ”

    Source location

    Francis Robert Beech · 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 adequately check the plaster cast for signs of infection

    Wider context from the report

    “2. Failing to adequately check the plaster cast for signs of infection ”

    Source location

    Francis Robert Beech · 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 document pus on the plaster cast

    Wider context from the report

    “6. Failing to document pus on the cast when he attended for a hip x-ray on 01/07/17. ”

    Source location

    Francis Robert Beech · 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

    Include plaster-cast management literature in discharge document checklists sent to care homes.

    Verbatim wording from the response

    “In future, nursing staff will ensure that the literature on all plaster cast management is included within the checklist of documents to be sent to the home and not simply provided to the patient.”

    Source location

    2017-0367-Responses
    Page 3 · response
    Published 11 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

    Implement a care-of-plaster-cast policy and procedure at Avery Healthcare Group.

    Verbatim wording from the response

    “In response to your concerns I can confirm that we have implemented the following:”

    Source location

    2017-0367-Responses
    Page 5 · response
    Published 11 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

    Implement a plaster-cast care plan at Avery Healthcare Group.

    Verbatim wording from the response

    “In response to your concerns I can confirm that we have implemented the following:”

    Source location

    2017-0367-Responses
    Page 5 · response
    Published 11 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

    Provide staff supervision and training on safe management of residents with plaster casts.

    Verbatim wording from the response

    “In response to your concerns I can confirm that we have implemented the following:”

    Source location

    2017-0367-Responses
    Page 5 · response
    Published 11 February 2018

    Open published response
  2. Bedfordshire and Luton

    AI-generated summary

    LORRAINE JOYCE BIRD · 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

    Lorraine Joyce Bird fractured her ankle after a fall and later attended a plaster room with numbness in her foot. The report identifies concerns that a developing deep vein thrombosis was not recognised or medically reviewed, that there was no adequate assessment protocol, and that she had not received low molecular weight heparin. The inquest concluded that this resulted in a lost opportunity for further treatment and that she died on 13 September 2014.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a protocol for assessing patients attending the Plaster Room

    Wider context from the report

    “(2) There appears to be a complete lack of a Protocol for the assessment of patients who attend for treatment at the Plaster Room. ”

    Source location

    LORRAINE JOYCE BIRD · 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

    Issue interim guidance requiring plaster-room technicians and fracture-clinic staff to obtain medical review in specified circumstances.

    Verbatim wording from the response

    “Prior to this incident there was no written guidance available to the Plaster room technicians. Current venous thromboembolic (VTE) guidance (incorporating NICE and Royal College of Emergency Medicine recommendations) is under review with full compliance with all recommendation currently anticipated for March 2016. Pending approval and ratification of this new overarching policy, the Clinical Director for Orthopaedics has issued immediate interim guidance to all plaster room technicians and fracture clinic medical staff.”

    Source location

    2015-0315-Response-by-East-North-Hertfordshire-NHS-Trust
    Page 1 · response
    Published 10 August 2015

    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