25 Feb 2026 Raymond John MORAN · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 2
Incomplete falls risk documentation View source Failure to update falls risk assessments as required View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Humber Health Partnership
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Humber Health Partnership
Complete multidisciplinary post-fall debrief and SWARM review to identify systemic falls-prevention learning.
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Humber Health Partnership
Introduce Ward 32 spot checks and leadership oversight of documentation and reassessment completion.
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Humber Health Partnership
Provide Falls Prevention Team educator support to Ward 32 staff on completing falls assessments and associated documentation.
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Humber Health Partnership
Conduct a specialist falls audit or accreditation review of Ward 32 to identify gaps, recommend improvements, and assess measurable progress.
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Humber Health Partnership
Monitor training, falls assessments, transfer reassessments, documentation, delirium assessment, post-fall reviews, and audit findings through local and group governance.
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Humber Health Partnership
Implement Ward 32 actions covering falls training, documented call-bell education, timely post-fall medical review, 4AT assessment, lying and standing blood pressure, transfer assessments, and AFLOAT checks.
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Humber Health Partnership
Reinforce reassessment of relevant clinical assessments when patients transfer between clinical areas across inpatient wards.
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AI-generated summary
Raymond John MORAN · 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
Raymond John Moran, who had metastatic prostate cancer and other significant comorbidities, died on 24 December 2025 after an unwitnessed fall in hospital caused a right femur fracture. The report identifies concerns that his falls risk assessment was inaccurate, was not updated as required, and was incompletely documented.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Incomplete falls risk documentation
Wider context from the report “Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been. In addition, the documentation was incomplete .
” Source location Raymond John MORAN · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to update falls risk assessments as required
Wider context from the report “Evidence was heard at inquest that not only was the falls risk assessment inaccurate, but also, it was not updated as it should have been . In addition, the documentation was incomplete.
” Source location Raymond John MORAN · Prevention of Future Deaths report
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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 Complete multidisciplinary post-fall debrief and SWARM review to identify systemic falls-prevention learning.
Verbatim wording from the response “Following the incident, the Trust undertook both an immediate post-fall debrief and a multidisciplinary post-fall SWARM review. Those reviews identified local learning, including the need to strengthen documentation and reassessment processes, particularly in relation to ensuring multifactorial falls assessments are completed and updated on transfer, ensuring recent falls history and other relevant risk factors are clearly reflected in the assessment, ensuring formal assessment of suspected confusion or delirium is undertaken where indicated, ensuring lying and standing blood pressure is reconsidered when a patient becomes more mobile enough for this to be completed, reinforcing expectations regarding timely medical review after a fall, and improving the consistency of contemporaneous recording of falls prevention activity and post-fall management.” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Ward 32 spot checks and leadership oversight of documentation and reassessment completion.
Verbatim wording from the response “4. Additional ward-level assurance measures
Further local assurance measures are being put in place within Ward 32 to improve completion of documentation and reassessments. These include increased spot checks by ward leadership, review of whether assessments have been completed at the start of the day and strengthened local oversight involving ward sisters and junior sisters. The purpose of this is to embed compliance and ensure incomplete documentation is identified promptly and addressed.” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Falls Prevention Team educator support to Ward 32 staff on completing falls assessments and associated documentation.
Verbatim wording from the response “5. Targeted support from the Falls Prevention Team
The Falls Prevention Team has agreed to provide additional practical support to Ward 32, including educator input to work directly with staff on the ward in relation to the correct completion of assessments and associated documentation. This support is intended to help embed practice and improve consistency.” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a specialist falls audit or accreditation review of Ward 32 to identify gaps, recommend improvements, and assess measurable progress.
Verbatim wording from the response “6. Specialist audit / accreditation review
Ward 32 is being prioritised for a specialist falls audit / accreditation review to identify any remaining gaps, to provide targeted recommendations, and to support the ward in achieving the required standard. This will also provide further assurance regarding whether the actions taken have resulted in measurable improvement.” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor training, falls assessments, transfer reassessments, documentation, delirium assessment, post-fall reviews, and audit findings through local and group governance.
Verbatim wording from the response “9. Monitoring and assurance
The Trust will monitor the effectiveness of these actions through local and group governance processes. This will include review of:” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
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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 Implement Ward 32 actions covering falls training, documented call-bell education, timely post-fall medical review, 4AT assessment, lying and standing blood pressure, transfer assessments, and AFLOAT checks.
Verbatim wording from the response “1. Immediate local review and learning
The incident was subject to an immediate post-fall debrief and subsequent multidisciplinary SWARM review. These identified a number of specific actions for Ward 32, including:” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce reassessment of relevant clinical assessments when patients transfer between clinical areas across inpatient wards.
Verbatim wording from the response “2. Reinforcement of transfer reassessment requirements
The Trust has reinforced with ward teams the requirement that, when a patient transfers between clinical areas, the relevant assessments must be reviewed and repeated in accordance with policy. This learning has been recognised not simply as a ward-specific issue but as a theme relevant to inpatient ward areas more broadly. The SWARM expressly identified this learning as applicable group wide.” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Falls risk had been recognised and multiple prevention measures were in place before the fall, despite shortcomings in transfer reassessment and documentation.
Verbatim wording from the response “However, the Trust considers it important to clarify that the patient’s falls risk had been recognised during the admission and that a number of falls prevention measures were in place prior to the fall. The post-fall debrief and SWARM review record that the patient had access to the call bell and had previously used it, had non-slip socks in place, had an appropriate bed rail assessment with bed rails raised in accordance with that assessment, had a Zimmer frame at the bedside, and had a mobility plan of Zimmer frame with assistance of two. The reviews also record that he was identified as being at risk of falls, that a falls risk assessment had been completed on admission, and that the relevant falls prevention measures were in place, albeit with shortcomings in reassessment and documentation on transfer.” Source location Response from City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Open published response
Concerns raised 1
Failure to document falls prevention measures at the first falls assessment View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Hazel Gambles · 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
Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.
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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 falls prevention measures at the first falls assessment
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” Source location Hazel Gambles · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make falls-prevention documentation mandatory in risk assessments and audit compliance through Tendable.
Verbatim wording from the response “At the time of Mrs Gambles’ admission, the falls prevention measures part of the risk assessment was not a mandatory field and so there was a risk that this would be missed. Since Mrs Gambles’ death, this has now been changed to a mandatory field within the risk assessment. This means that nursing staff are unable to progress with documentation until they have completed the entry, and so it should be clear as to what falls prevention measures are required for each individual patient. Compliance with this is audited as part of the Tendable audit. The Tendable falls inspection overall outcome score from February 2025 to August 2025 shows that overall compliance has risen from 78% in February 2025 to 98% in August 2025.” Source location Response from Rotherham NHS Foundation Trust
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20 Sep 2024 Margaret Rose MAYCROFT · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to document falls prevention measures following falls risk assessments View source
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Margaret Rose MAYCROFT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Rose Maycroft was readmitted to Worcestershire Royal Hospital after falls and was found to have suffered an ischaemic stroke. During her admission, she sustained further falls resulting in a displaced fractured neck of femur, underwent surgery, and later died at Princess of Wales Community Hospital, Bromsgrove, while receiving palliative care. The principal concern was that, although falls risk assessments were completed, no falls prevention measures were documented or put in place, and there was no evidence that this issue had since been addressed.
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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 falls prevention measures following falls risk assessments
Wider context from the report “2) In respect of each of these falls, Matron ████████ gave evidence that whilst staff in the Emergency Department and the Acute Frailty Unit had completed falls risk assessments, no measures to mitigate that risk, such as might be found in a falls prevention, assessment and intervention plan, were documented in Ms. Maycroft’s notes . This meant that no documented falls prevention measures were put in place for her .
3) Furthermore, I heard no evidence at the inquest which satisfied me that the steps have now been taken to ensure falls prevention measures are now being properly considered and documented in both the Emergency Department and the Acute Frailty Unit at the hospital .
” Source location Margaret Rose MAYCROFT · Prevention of Future Deaths report
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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 Review the electronic post-fall record and intervention document and clarify completion expectations.
Verbatim wording from the response “• There are trust wide falls prevention measures in place and work is being undertaken to review the post fall record and intervention document on the electronic patient record and for the expectations around completion to be clarified.” Source location Response from Worcestershire Acute Hospitals NHS Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore barriers to documenting falls interventions on the electronic patient record, take resulting actions and monitor them through the Improving Safety Action Group.
Verbatim wording from the response “• The barriers faced by staff in documenting falls interventions in place on EPR will be explored and actions taken and monitored through Improving Safety Action Group (ISAG)” Source location Response from Worcestershire Acute Hospitals NHS Trust
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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 Distribute guidance on documenting falls interventions in Sunrise.
Verbatim wording from the response “• The EPR team will distribute an update on how to document interventions on Sunrise.” Source location Response from Worcestershire Acute Hospitals NHS Trust
Open published response
Concerns raised 1
Inadequate and inconsistent documentation of falls risk management View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Care UK
Review risk management plans and clarify documentation, review, updating and clinical-rationale expectations for staff.
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Care UK
Make falls-documentation compliance and quality a continuing review point in annual appraisals.
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Care UK
Review accident and incident reports to identify required responses and further falls-mitigation measures.
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Care UK
Discuss accidents and incidents in weekly clinical reviews and assign actions to update assessments and management plans.
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Care UK
Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.
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Care UK
Audit high-risk patients’ assessments and management-plan documentation to verify appropriate assessment and recording.
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Care UK
Maintain improved falls-documentation standards through an ongoing audit programme.
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AI-generated summary
Margaret AUSTIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Austin died at Stanley Park Care Home on 17 September 2023, following an unwitnessed fall from her bed on 1 July 2023 that caused a pubic rami fracture and contributed to her overall decline. Concerns included incomplete and discrepant documentation about managing her high falls risk, lack of evidence that the risk management plan was reviewed as her risks changed or after falls, and outstanding falls-risk training for most care-home staff at the date of the inquest.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate and inconsistent documentation of falls risk management
Wider context from the report “1. The deceased was known to be at high risk of falls and the documentation in relation to how to manage that known high risk of falls was not comprehensive and contained significant discrepancies as to what should, in fact, be in place , and contained no rationale for why further measures which may have been considered appropriate were not in situ or considered appropriate or necessary .
” Source location Margaret AUSTIN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review risk management plans and clarify documentation, review, updating and clinical-rationale expectations for staff.
Verbatim wording from the response “Stanley Park has taken a number of steps to improve documentation around assessment and management of falls, including documentation to reflect the rationale sitting behind clinical decision making. The steps taken are as follows:” Source location Response from Care UK
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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 Make falls-documentation compliance and quality a continuing review point in annual appraisals.
Verbatim wording from the response “December 2023. Compliance and quality in terms of falls documentation will remain a review point in annual appraisals going forward.” Source location Response from Care UK
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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 Review accident and incident reports to identify required responses and further falls-mitigation measures.
Verbatim wording from the response “b. The management team are reviewing all accident and incident reports to ensure that appropriate actions in response have been identified, including any further mitigation steps such as sensory equipment, roll mats and requests to the GP for a secondary care falls referral.” Source location Response from Care UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Discuss accidents and incidents in weekly clinical reviews and assign actions to update assessments and management plans.
Verbatim wording from the response “c. Accidents and incidents are being discussed during the weekly clinical review meetings, with specific actions being assigned to staff members around ensuring that the individual's assessment and management plan is updated.” Source location Response from Care UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have the Deputy Manager review assessments and plans to triangulate care and verify completion of assigned clinical-review actions.
Verbatim wording from the response “d. Assessments and plans are being reviewed by the Deputy Manager to ensure triangulation of care and to confirm that actions set in the clinical review meetings have been fully completed.” Source location Response from Care UK
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit high-risk patients’ assessments and management-plan documentation to verify appropriate assessment and recording.
Verbatim wording from the response “To ensure that the learning from points (1) and (2) above has been fully embedded, an audit was carried out (starting first with high risk patients to ensure timely review) with the purpose of verifying that care needs have been appropriately assessed and that the assessment and subsequent management plan is properly documented. This audit was completed on 31 December 2023 and demonstrates that staff are compliant with the standards expected of them. There is a planned programme of ongoing audit to ensure that the improved standards are maintained.” Source location Response from Care UK
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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 Maintain improved falls-documentation standards through an ongoing audit programme.
Verbatim wording from the response “To ensure that the learning from points (1) and (2) above has been fully embedded, an audit was carried out (starting first with high risk patients to ensure timely review) with the purpose of verifying that care needs have been appropriately assessed and that the assessment and subsequent management plan is properly documented. This audit was completed on 31 December 2023 and demonstrates that staff are compliant with the standards expected of them. There is a planned programme of ongoing audit to ensure that the improved standards are maintained.” Source location Response from Care UK
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9 Feb 2023 Bridget GORMLEY · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to update residents’ falls risk assessment and care plan documentation following falls View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barchester Healthcare Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Barchester Healthcare Limited
Amend monthly clinical governance meetings to review each resident’s falls and falls history.
View source
Barchester Healthcare Limited
Introduce a regional falls champion forum chaired by divisional clinical lead nurses.
View source
Barchester Healthcare Limited
Deliver refresher training at Latimer Court on completing documentation, including risk-related detail and timely updates.
View source
Barchester Healthcare Limited
Develop Latimer Court checklists or prompts with the Clinical Development Nurse in line with the Falls Management Policy.
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AI-generated summary
Bridget GORMLEY · 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
Bridget Gormley fell at her care home in Worcester on 20 July 2022 and was found to have significant traumatic intracranial bleeding. She was transferred to Worcestershire Royal Hospital, where she died on 31 July 2022. The principal concerns were that her falls risk assessment and care plan were not updated after repeated falls, and that staff may not have understood their duties to update residents’ documentation.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to update residents’ falls risk assessment and care plan documentation following falls
Wider context from the report “(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls , and that they should have been so updated. This meant that:
(a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and
(b) Measures to mitigate that increased risk were not considered. Such measures could have included:
(i) Asking a GP to refer Mrs. Gormley to the falls clinic;
(ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising;
(iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame;
(iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance.
(2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such circumstances.
” Source location Bridget GORMLEY · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend monthly clinical governance meetings to review each resident’s falls and falls history.
Verbatim wording from the response “entered onto the clinical governance system within 24 hours. To address this, we have amended our monthly clinical governance meeting requirements to include a review of falls for any one individual and their falls history. These meetings are minuted and require discussion of residents having a fall or found on the floor in line with Barchester’s Falls Management Policy to ensure that all measures are in place to mitigate the risk of further falls and that the relevant Healthcare Professionals and equipment is accessed and utilised. We have also introduced a regional falls champion forum, chaired by our Divisional clinical lead nurses. This will have an emphasis on prevention but also include reviews of individuals who have fallen, and the documentation required to support them and plan for their needs.” Source location Response from Barchester Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a regional falls champion forum chaired by divisional clinical lead nurses.
Verbatim wording from the response “entered onto the clinical governance system within 24 hours. To address this, we have amended our monthly clinical governance meeting requirements to include a review of falls for any one individual and their falls history. These meetings are minuted and require discussion of residents having a fall or found on the floor in line with Barchester’s Falls Management Policy to ensure that all measures are in place to mitigate the risk of further falls and that the relevant Healthcare Professionals and equipment is accessed and utilised. We have also introduced a regional falls champion forum, chaired by our Divisional clinical lead nurses. This will have an emphasis on prevention but also include reviews of individuals who have fallen, and the documentation required to support them and plan for their needs.” Source location Response from Barchester Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver refresher training at Latimer Court on completing documentation, including risk-related detail and timely updates.
Verbatim wording from the response “(j) As part of the lessons learnt as identified by the General Manager at Latimer Court it was highlighted that staff required further training from the organisation’s Clinical Development Nurse in the approach to and completion of documentation. Specifically, when to complete documentation and the requisite detail to be included in the entries into documentation. Following completion of the inquest and receipt of the Regulation 28 Report, the Managing and Regional Directors have made arrangements for further refresher training to be delivered at Latimer Court with follow up by the Regional Manager and Quality” Source location Response from Barchester Healthcare
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop Latimer Court checklists or prompts with the Clinical Development Nurse in line with the Falls Management Policy.
Verbatim wording from the response “Any checklists or prompts to be used at Latimer Court by the home team will be developed in liaison with the Clinical Development Nurse and will follow the requirements of the Falls Management Policy as to actions to be taken. As part of the training staff will be required to review the environment in which the residents live, practice writing risk assessments and consider how residents needs and risks may change and to develop professional curiosity about residents’ presentation and any referrals and actions that should flow from a falls incident.” Source location Response from Barchester Healthcare
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The identified practice matters were unlikely to have affected the resident’s outcome.
Verbatim wording from the response “Following this very sad incident we have made a number of changes to the provision of care and services at Latimer Court, and these have been adopted across the organisation in other services and divisions where appropriate. For the purpose of this response, we have considered the concerns raised by you and where possible we have grouped together details of assurance measures where these appear to deal with more than one area of concern. Whilst it is unlikely that the matters referred to below would have affected the outcome for Mrs Gormley, there are matters of practice identified where the need for improvement has been recognised and dealt with.” Source location Response from Barchester Healthcare
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12 Aug 2022 Gerald Kenneth Tuck · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure to complete and record falls risk assessments after falls View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Tricuro Ltd
Upload the post-falls assessment tool to the electronic recording system for staff use and recording.
View source
Tricuro Ltd
Disseminate the updated falls policy across the service and wider company, including requirements to update risk assessments and mobility care plans after falls.
View source
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AI-generated summary
Gerald Kenneth Tuck · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Gerald Kenneth Tuck, who had dementia and lived in a residential home, sustained repeated falls in December 2021 and January 2022. After the final fall, he was diagnosed with two acute subdural haematomas, his condition deteriorated, and he died on 2 March 2022. The concern was that the home had no written policy or guidance requiring care plans and falls risk assessments to be reviewed after incidents.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete and record falls risk assessments after falls
Wider context from the report “iv. The Registered Manager of Sidney Gale House gave evidence that his last falls risk assessment is documented to have taken place on the 16th December 2021. There is no evidence one was completed after this prior to the fatal fall on the 28th January 2022 . The monthly review was due on the 31st January 2022 and there was no assessment recorded after the falls on the 25th December 2021 and 27th January 2022 .
” Source location Gerald Kenneth Tuck · Prevention of Future Deaths report
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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 Upload the post-falls assessment tool to the electronic recording system for staff use and recording.
Verbatim wording from the response “To mitigate further risks we have uploaded the post falls assessment tool to the electronic recording system that is used to ensure staff do see, follow and record on this.” Source location Response from Tricuro
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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 Disseminate the updated falls policy across the service and wider company, including requirements to update risk assessments and mobility care plans after falls.
Verbatim wording from the response “Our policy also reflects that staff are expected to update the falls risk assessments and mobility care plans after any fall to ensure that the care, support and risks are managed accordingly. We have ensured that all staff within the service and the wider company are very clear of the policy and that this must be followed.” Source location Response from Tricuro
Open published response
Concerns raised 2
Failure to maintain observational charts for patients at risk of falls View source Failure to document daily and post-change falls-risk reassessments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Benjamin Clark · 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
Benjamin Clark died in hospital on 17 January 2021 after a series of falls, including an unwitnessed fall on the ward, resulting in Acute on Chronic Subdural Haematomas. The concerns included an undocumented downgrading of his falls-risk assessment, unclear observation requirements, suboptimal record keeping, lack of observational charts, and insufficient written evidence of daily reassessment or reassessment after significant changes.
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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 observational charts for patients at risk of falls
Wider context from the report “3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital . Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation. There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’s case.
” Source location Benjamin Clark · Prevention of Future Deaths report
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 daily and post-change falls-risk reassessments
Wider context from the report “3. The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) was used in both hospitals but only NSECH evidenced use of this tool in writing. Observational charts were not in use in North Tyneside General Hospital. Matron ████████ told me that every patient should be reassessed every day and following any significant change in presentation . There was a lack of written evidence at North Tyneside General Hospital to demonstrate that this had been done in Mr. Clark’s case .
” Source location Benjamin Clark · Prevention of Future Deaths report
Open source report
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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 Implement a ward observation chart specifying enhanced-observation levels and required frequencies.
Verbatim wording from the response “1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.” Source location 2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.
Verbatim wording from the response “4. Discussions are ongoing between the Matrons within NTGH in order to place the AFLOAT risk assessment and observation chart onto the electronic care record NerveCentre. The Trust can confirm that this will be done before the end of August 2021. Notwithstanding this, the documents are in use in paper form.” Source location 2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing observation charts, safety huddles, AFLOAT use and planned electronic alerts sufficiently reduce the risk of similar incidents, making further PFD action disproportionate.
Verbatim wording from the response “1. Since the incident involving Mr Clark, the ward at NTGH have now implemented a new observation chart. This chart determines the frequency that observations should be taken on the front of the chart. The reverse of the chart is set out differently to the standard observations chart to allow for increased frequency observations to be completed. A copy of this observation chart was shared with the family and HM Assistant Coroner on the day of the inquest. It was confirmed that the use of this chart was a pilot and is well used within NSECH and had also been adopted by NTGH.” Source location 2021-0236-Response-from-Northumbria-Healthcare-NHS-Foundation-Trust_Published
Open published response
12 Mar 2021 Elizabeth Robinson · Prevention of Future Deaths report Gwent
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Concerns raised 1
Failure to complete falls risk assessments and documentation View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Elizabeth Robinson · 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 Robinson, an 87-year-old woman at Ysbyty Ystrad Fawr for rehabilitation after hip surgery, fell and sustained a fatal head injury on 21 October 2019. Concerns included inadequate falls-risk assessment and documentation, staffing levels that nurses considered insufficient to deliver safe care, and nursing staff not having seen the internal investigation findings more than a year after her death.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete falls risk assessments and documentation
Wider context from the report “1. Staffing Levels
Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by ████████ and ████████ confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling . Whilst the documentation was not completed , two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients. Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients.
Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist.
” Source location Elizabeth Robinson · Prevention of Future Deaths report
Open source report
8 Feb 2019 Jean Mary Cutler · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Undated and unsigned falls risk management and assessment documents View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Cole Valley Nursing Home
Introduce and complete comprehensive Falls Risk Assessments for all residents, with monthly or condition-triggered recalculation.
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AI-generated summary
Jean Mary Cutler · 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 Mary Cutler had severe dementia, osteoporosis and no independent mobility, and was at high risk of falling. On 5 October 2018 she fell from her wheelchair at Cole Valley Nursing Home, sustaining a fractured left femur, and died there on 18 October 2018. Concerns included inconsistent use of lap belts, reliance on staff intervention despite understaffing, and inadequate post-incident investigation and falls risk assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Undated and unsigned falls risk management and assessment documents
Wider context from the report “6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed.
” Source location Jean Mary Cutler · Prevention of Future Deaths report
Open source report
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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 Introduce and complete comprehensive Falls Risk Assessments for all residents, with monthly or condition-triggered recalculation.
Verbatim wording from the response “ii) New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed. The FRAs consider internal and external risk factors, provide a risk score which then generates a “Low”, “Medium” or “High” risk rating (colour-coded Green, Amber or Red) and incorporate suggestions for risk management dependent on the level of risk identified. Risks will be recalculated on a (minimum) monthly basis (but sooner should an individual’s condition change i.e. through the contraction of an acute infection). Initial FRAs for people living in the Home were completed 03rd April 2019.” Source location 2019-0040-Response-by-Cole-Valley-Nursing-Home
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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 Implemented control measures are considered sufficient to resolve the identified falls, wheelchair restraint and investigation concerns.
Verbatim wording from the response “Cole Valley Nursing Home and its Directors accept and acknowledge the Coroner’s Concerns and believe that the control measures implemented by the Home serves to demonstrate how the Home and Cole Valley Care Ltd. have resolved said concerns - learning from both the inquest and the concerns detailed within your Regulation 28 report.” Source location 2019-0040-Response-by-Cole-Valley-Nursing-Home
Open published response
12 May 2018 CHARLES EVAN GRAINGER · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 1
Failure to undertake basic and proper investigations of falls risk assessments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
CHARLES EVAN GRAINGER · 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
Charles Evan Grainger was admitted to Milford House Residential Unit after a fall and later sustained injuries in a witnessed fall there on 24 November 2013. The inquest concluded that his death was accidental, with the medical cause recorded as bronchopneumonia and central cord syndrome. Concerns included failures to share his history of falls between relevant agencies and inadequate investigation of the circumstances surrounding his fall.
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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 Failure to undertake basic and proper investigations of falls risk assessments
Wider context from the report “(2) ████████ did not consider it important or necessary to request, review or retain copies of Mr Grainger's falls risk assessment as part of her basic investigation enquiries . Failure to undertake a basic and proper investigation could result in future deaths occurring.
” Source location CHARLES EVAN GRAINGER · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.