Recurring concern

Unreliable physiotherapy provision for patients requiring care

First to latest report 5 Mar 2014 — 29 Jul 2025

Reports that mention this concern
8
Times this concern has been raised
9
Stated actions linked to this concern
10

What this concern includes

Includes failures in physiotherapy provision and its dedicated access pathway, including staffing capacity, referral and initiation, timely availability, weekend or bank-holiday cover, contingency arrangements, and access to physiotherapy advice or treatment for patients whose care needs require it.

What is not included
  • Excludes occupational therapy, dietetic or other specialist services unless the assertion also explicitly concerns physiotherapy provision.
  • Excludes generic staffing, communication, documentation or care-planning deficiencies unless they directly impair physiotherapy provision or access.
  • Excludes failures in the quality of physiotherapy treatment or records where the issue is not the reliability of physiotherapy provision or access.
  • Excludes general rehabilitation or mobility-care failures without an explicit physiotherapy component.
  • Excludes routine delays or isolated missed referrals where no continuing or system-level physiotherapy provision deficiency is identified.

Reports and published responses 8 reports

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

  1. Manchester South

    AI-generated summary

    Leslie Thompson · 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

    Leslie Thompson died at Tameside General Hospital on 20 February 2025 following a fall in hospital, which caused a head injury against a background of chronic subdural haematoma and multiple complex health problems. The concern was that he had been assessed as medically fit for discharge but was awaiting physiotherapy, with limited evening and weekend physiotherapy services potentially causing discharge delays and exposing patients to risks associated with remaining in an acute hospital environment.

    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 core physiotherapy services during evenings and weekends

    Wider context from the report

    “At inquest, the court heard evidence that this hospital (in common with many others) does not have core physiotherapy services operating at evenings and weekends. I am concerned as to the effects of this in terms of delays to discharge, and the resultant exposure to risk of patients for whom an acute hospital environment is not most suitable. ”

    Source location

    Leslie Thompson · 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

    Provide £9 billion through the Better Care Fund to support timely, joined-up health and social care, including discharge-related services.

    Verbatim wording from the response

    “Furthermore, the Better Care Fund (BCF) is a key part of our plan to address discharge delays, especially where they are caused by a lack of a necessary service such as physiotherapy. The BCF supports Integrated Care Boards and local authorities to deliver joined-up health and social care, and this year, the BCF will provide £9 billion to help ensure patients receive appropriate and timely care in the right place, with shared accountability for discharge planning. Starting in the financial year 2026/27, we will reform the BCF to ensure consistent joint NHS and local authority funding for those services that are essential for integrated health and social care, such as hospital discharge, intermediate care, rehabilitation and reablement.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 29 July 2025

    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

    Reform the Better Care Fund from 2026/27 to establish consistent joint NHS and local-authority funding for essential integrated care services.

    Verbatim wording from the response

    “Furthermore, the Better Care Fund (BCF) is a key part of our plan to address discharge delays, especially where they are caused by a lack of a necessary service such as physiotherapy. The BCF supports Integrated Care Boards and local authorities to deliver joined-up health and social care, and this year, the BCF will provide £9 billion to help ensure patients receive appropriate and timely care in the right place, with shared accountability for discharge planning. Starting in the financial year 2026/27, we will reform the BCF to ensure consistent joint NHS and local authority funding for those services that are essential for integrated health and social care, such as hospital discharge, intermediate care, rehabilitation and reablement.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 29 July 2025

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    EMILY DAISY SIMS · 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

    Emily Daisy Sims, a 101-year-old care home resident, died after bilateral spiral fractures to both femurs sustained when she was held by the ankles and swung out of bed. The report identified concerns about care plans not being updated to reflect changing needs, inadequate equipment and specialist advice, and insufficient training in equipment use and moving and handling.

    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 provision of or access to specialist occupational therapy and physiotherapy advice

    Wider context from the report

    “4)    The lack of the provision, or access to, specialist advice from occupational therapists and physiotherapists to assist with measures to address changing needs ”

    Source location

    EMILY DAISY SIMS · Prevention of Future Deaths report
    Page 3 · 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 referral relationships with occupational therapists, the community rehabilitation team, general practitioners and district nurses are relied upon for specialist advice.

    Verbatim wording from the response

    “4. Lack of provision or access to specialist advice from occupational therapists and physio therapists to assist with measures to address changing needs. The home has good working relationships with the community rehab Team and Occupational Therapist. We access referrals for specialist advice through the G.P practice and are very well supported by the district nursing team.”

    Source location

    2019-0336-Response-by-Antron-Manor-Care-Home
    Page 1 · response
    Published 10 November 2019

    Open published response

  3. 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

    Delays in referring patients to required specialist services

    Wider context from the report

    “(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days. It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late. ”

    Source location

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

    Open source report

  4. Manchester West

    AI-generated summary

    Harry Pryal · 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

    Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.

    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 physiotherapy and occupational therapy for Lakeside Unit patients

    Wider context from the report

    “vi. Evidence was given at the Inquest that there was no physiotherapy or occupational therapy at the Lakeside Unit to deal with the physical health needs of any patients on the Unit. There was no Service Agreement for the provision of physiotherapy and occupational therapy and no understanding as to who would provide such services. The evidence indicated that the Clinical Commissioning Group in Wigan would provide the services and 5BP were not in a position to enter into agreements for the provision of services from elsewhere. Evidence was given by 5BP that the Clinical Commissioning Group in Wigan had not provided services so that the physical health needs of patients in the Lakeside Unit, were not being satisfied in relation to physiotherapy and occupational therapy. ”

    Source location

    Harry Pryal · Prevention of Future Deaths report
    Page 4 · 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

    Formally request that 5BP establish a service agreement for physiotherapy and occupational therapy provision.

    Verbatim wording from the response

    “In response to the above recommended action, the CCG has formally written to 5BP on 13th October 2015, stating that the CCG should have a service agreement in place with a suitable provider for the provision of physiotherapy and occupational therapy. Please see letter attached (Appendix A).”

    Source location

    2015-0391-Response-by-Wigan-Borough-CCG
    Page 1 · response
    Published 28 September 2015

    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

    Review physiotherapy and occupational-therapy need, pathways and demand.

    Verbatim wording from the response

    “The Trust has carried out a review to identify need in this area and to identify the clinical pathway and demand.”

    Source location

    2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
    Page 4 · response
    Published 28 September 2015

    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

    Clarify senior-level arrangements for physiotherapy and occupational-therapy provision with the partner provider.

    Verbatim wording from the response

    “Discussions at a senior level are taking place between 5 Boroughs Partnership NHS Foundation Trust and Bridgewater NHS Foundation Trust to clarify arrangements for the provision of physiotherapy and occupational therapy.”

    Source location

    2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
    Page 4 · response
    Published 28 September 2015

    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

    Urgently flag inpatient physiotherapy and occupational-therapy requests to the allied-health professional lead for sourcing from wider Trust resources.

    Verbatim wording from the response

    “For the interim period, requests for physiotherapy and occupational therapy from the in-patient wards at Leigh Infirmary are being flagged urgently to our Professional Lead for Allied Health Professionals who will source the appropriate professional from our wider Trust resource.”

    Source location

    2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
    Page 4 · response
    Published 28 September 2015

    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 the service specification for submission to the commissioning group.

    Verbatim wording from the response

    “She will also complete the required specification for submission to Wigan Clinical Commissioning Group to maintain the service either from Bridgewater NHS Foundation Trust or the Trust will identify an alternative supplier.”

    Source location

    2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
    Page 4 · response
    Published 28 September 2015

    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 arrangements are considered sufficient to ensure physiotherapy and occupational therapy needs are met, with requests flagged to 5BP and monitored through contract meetings.

    Verbatim wording from the response

    “5BP has since confirmed via e-mail dated 28th October that assurance that all requests for physiotherapy or occupational therapy will be flagged to 5BP Clinical Director who will ensure that this need is met. Please see e-mail attached (Appendix B).”

    Source location

    2015-0391-Response-by-Wigan-Borough-CCG
    Page 1 · response
    Published 28 September 2015

    Open published response

  5. Brighton and Hove

    AI-generated summary

    MR. ANTHONY GEERTS · 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

    Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his 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

    Insufficient physiotherapy staffing for rehabilitation patients

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · Prevention of Future Deaths report
    Page 1 · 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 maintain a physiotherapy plan

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · 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

    Increase trained and therapy-support physiotherapy staffing to reduce missed planned physiotherapy and prioritise patients missed the previous day.

    Verbatim wording from the response

    “d) increased physiotherapy staffing (both trained and therapy support staff), reducing the occasions when it is not possible for a patient to have physiotherapy as planned, with recognition that any patient that is not seen on one day must become one of the highest priorities for the next day”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    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

    Introduce integrated documentation for all clinical staff treating patients on Twineham ward.

    Verbatim wording from the response

    “b) introduction of integrated documentation for use by all the clinical staff treating each patient on the ward”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    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

    Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.

    Verbatim wording from the response

    “c) joint development of a training package for all the staff based on Twineham ward, by the senior physiotherapy and nursing staff, to assist with accurate and detailed documentation. This includes a specific focus on the potential consequences of poor documentation”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    Open published response

  6. Manchester South

    AI-generated summary

    Barbara Joan Harrison · 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

    Barbara Joan Harrison was admitted on 5 February 2015 for surgery after worsening swallowing and regurgitation symptoms, and subsequently developed significant surgical emphysema and undetected mediastinitis. Concerns included potentially harmful postoperative physiotherapy, failed attempts to site an endotracheal tube due in part to unavailable fibre-optic equipment, inadequate lighting during critical surgery, distress caused to her family, and delayed recognition of swelling around her neck and face.

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    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 clear authorisation for postoperative physiotherapy

    Wider context from the report

    “1. After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter. This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site. It is unclear as to who ordered this physiotherapy, as ████████ the surgeon and ████████ the anaesthetist both indicated that they did not do so and would not have done so. ”

    Source location

    Barbara Joan Harrison · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Sunderland

    AI-generated summary

    Leonard Henry Hudson · 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 Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.

    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 contingency provision for physiotherapy

    Wider context from the report

    “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted. Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor. Mr Hudson ought to have been referred to the foot protection team in a more timely manner. The nursing documentation was not as comprehensive as it ought to have been. The classification of Mr Hudson’s heel injuries was “variable”. From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: - 1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this; 2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist; 3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis; 4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy; 5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; 6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding. However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention. I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths. ”

    Source location

    Leonard Henry Hudson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Inner West London

    AI-generated summary

    Mr John Patrick Fox · 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

    Mr John Patrick Fox, aged 93, sustained a fractured neck of femur in an accidental fall at home and died on 1 January 2014 after treatment for the fracture and underlying heart problems. The report raised concern that reduced physiotherapy services on bank holidays and weekends could increase the risk of post-operative complications in 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

    Reduced physiotherapy services on bank holidays and weekends

    Wider context from the report

    “That there is a reduced level of physiotherapy services on bank holidays and weekends, increasing the risk of post operative complications developing in vulnerable patients. ”

    Source location

    Mr John Patrick Fox · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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