Recurring concern

Failure to ensure people are placed in care settings suitable for their needs

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First reported 23 May 2014•Latest report 10 Oct 2025

Definition

What this concern includes

Includes failures of the care-placement process to assess needs, identify suitable settings, match people to placements, or move them when an existing setting cannot safely meet their needs, including residential and nursing placements and comparable care settings.

Not included

  • Excludes generic discharge, transfer or care-coordination failures where placement suitability is not the identified unsafe condition.
  • Excludes shortages or unavailability of placements unless they directly result in a person being placed or left in a setting unsuitable for their needs.
  • Excludes inappropriate hospital, mental-health or custodial placements unless the assertion specifically concerns the suitability of a care placement for the person's needs.
  • Excludes failures limited to care quality after a placement is suitable, where the placement decision or suitability assessment is not deficient.
Reports
19

Distinct published reports

Individual concerns
20

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
12

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8
NHS England3
Barnsley Hospital NHS Foundation Trust1
Bolton Borough Council1
Care Quality Commission1
Community Disability Nurse1
Cornwall Council1
Essex County Council1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Greater Manchester Mental Health NHS Foundation Trust1
Independent Futures1
Kent County Council1
Littleborough Home for the Elderly1
Manchester University NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Liverpool and the Wirral

    AI-generated summary

    Linsay Bushell · 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

    Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.

    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 coordinate specialist placement decisions and timely funding for patients' needs

    Wider context from the report

    “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area. The Jury found: Para 3 1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital. 2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014. 3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation. 4. Linsay put herself in the position in which she was found however her intention was unclear. 5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder. 6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death. 7. The risk was managed adequately and effectively during Linsay's period as an in-patient. 8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made. a. In the Trust Position Statement Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them. 2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015. 3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material. 4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest. 5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity. 6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism. It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment. a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour. b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism. c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism. 7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust. 8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows: a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub. b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour. c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient. d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases. e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package. 9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation. 10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided. 11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels. 12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better. b. In the implementation of Lessons learnt the Trust further accepts 1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay". a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:- b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan. c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay. d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all. e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear. f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan. g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time. h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together. i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs. j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for. k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission. l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation. m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective. 2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation. Discontinuity of Care/Management of Care 3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B. 4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units. 5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach. 6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager. 7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse. 8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway. 9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible. Risk Assessment/Care Planning 10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk. 11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required. ”

    Source location

    Linsay Bushell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Captain James Michael Bedford · 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

    Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.

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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.

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    Inappropriate placement of Emergency Department patients in AMU

    Wider context from the report

    “4. An expert witness (an ED physician) was critical of the placement in AMU and clerking in by a medical student although it is not suggested this of itself made a difference as to survival. ”

    Source location

    Captain James Michael Bedford · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Mid Kent and Medway

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    Alan Ludlow · 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

    Alan Ludlow died in hospital after suffering a subdural haematoma following a blow to his face from another resident at his care home, and subsequently developing pneumonia. The principal concern was that relevant information about the incident was not passed to the care home where the other resident was later placed, and that residential placements and changing needs must be appropriately assessed and reviewed.

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    How this individual concern was interpreted

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

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    Failure to keep residential placement suitability under review

    Wider context from the report

    “Once a person is placed in a home the suitability of that placement must be kept under review to ensure that any changing needs continued to be met. It stands to reason if people are not appropriately placed there will be risks of harm to both themselves and to others. ”

    Source location

    Alan Ludlow · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

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    How this individual concern was interpreted

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    Lack of relevant information for residential and nursing placement assessments

    Wider context from the report

    “One of the matters which became apparent during the course of the evidence related to the issue of ensuring that when someone is assessed for a particular placement within residential and nursing environments that those undertaking the assessments and the home in which a person is placed, have all relevant information to ensure that the placement is the most appropriate for that person. ”

    Source location

    Alan Ludlow · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  4. Plymouth, Torbay and South Devon

    AI-generated summary

    William John Charles Harnell · 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

    William John Charles Harnell suffered a fractured left hip while attempting to mobilise from his wheelchair on 22 October 2014, remained in hospital, developed hospital-acquired pneumonia and died on 15 December 2014. Concerns included delays in recognising the difficulties surrounding his discharge, assessing his mental health, approaching suitable nursing homes, and a lack of resources and guidance for managing challenging and vulnerable patients.

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    Delays in approaching nursing homes able to accommodate patients

    Wider context from the report

    “(3) There appears to have been delay in approaching the Nursing Homes that may have been able to accommodate him. ”

    Source location

    William John Charles Harnell · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

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    How this respondent action was interpreted

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    Remind staff to seek timely placements for people requiring them.

    Verbatim wording from the response

    “I can confirm that we have a dedicated Social Work Service working in Derriford Hospital and that staff have been reminded of the requirements to seek timely placements for people who need such placements. The staff working in the Hospital are dedicated and committed. These cases are often complex and need careful management. In response to the matters of concern cited in the Report:”

    Source location

    william-harnell-Response
    Page 1 · response
    Published 22 September 2015

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    How this respondent position was interpreted

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    Robust senior management oversight is considered sufficient to prevent such delays recurring.

    Verbatim wording from the response

    “• We acknowledge that on occasion there may be delays; however with our robust Senior Management oversight I do not expect such delays in future.”

    Source location

    william-harnell-Response
    Page 1 · response
    Published 22 September 2015

    Open published response

  5. Manchester North

    AI-generated summary

    Dorothy McDermott · 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

    Dorothy McDermott, who was 80 and had been housebound for 2½ years, fell three times at home and was placed in emergency respite care. The care home provided residential but not nursing care, and staff were not trained to examine or care for pressure sores. An inquest concluded that opportunities to examine her sacrum were missed, and she died in hospital after developing a Grade 4 pressure sore and septicaemia.

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    Failure to ensure suitable placements guaranteeing a place of safety for vulnerable individuals

    Wider context from the report

    “Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated. Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved. ”

    Source location

    Dorothy McDermott · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. South Yorkshire (Eastern)

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    Phyllis Broomhead · 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

    Phyllis Broomhead, who had dementia and lived at Lord Hardy Court EMI Residential Home, suffered repeated falls, including three significant falls requiring hospitalisation. On 9 June 2013 she fell from her bed while trying to reach the toilet, sustained a head injury and died later that day from a traumatic left-sided subdural haemorrhage. Concerns included incomplete implementation of measures, staff training and record keeping, safeguarding screening, and the lack of closer monitoring or alternative placement for residents at high risk of serious injury.

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    How this individual concern was interpreted

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    Lack of suitable alternative residential placement for residents with high nursing needs

    Wider context from the report

    “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to: i. the head injury protocol, how this should be followed and the importance of doing so. ii. record keeping. iii. indicators and triggers to seek social worker input. (2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home. ”

    Source location

    Phyllis Broomhead · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Elsie Mallalie u · Prevention of Future Deaths report

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

    Report summary

    Mrs Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her death.

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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

    Placement of patients in inappropriate wards

    Wider context from the report

    “1. During the course of her relatively short stay in the hospital she was moved to Ward 41 which, as agreed in evidence by senior medical staff, was an inappropriate ward for her. ”

    Source location

    Elsie Mallalie u · 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

    Train orthopaedic doctors, including during junior-doctor induction, on senior approval, documentation and appropriate ward transfers.

    Verbatim wording from the response

    “Response Following detailed investigations, action has been taken to minimise the risk of inappropriate transfer occurring in the future. Training has been provided to doctors in the Orthopaedic Department to make them aware of the following:”

    Source location

    2014-0501-Response-by-Tameside-Hospital-NHS-Trust
    Page 1 · response
    Published 17 November 2014

    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

    Communicate requirements to consider staffing levels and skills before transfers between specialties or ward areas.

    Verbatim wording from the response

    “We have taken action to address this by communicating to all staff that where possible, staffing levels and skills must be considered prior to transfer between specialties and / or ward areas, to ensure that patients continue to receive the appropriate level of care. Additionally, a schedule of training has been put in place for the staff on Ward 41 regarding high-flow oxygen, although it is rarely used by staff on Ward 41. Training by the Trust’s equipment trainer has progressed and sessions will be on the wards where all staff would be able to attend as appropriate. In the meantime, the physiotherapists are also providing staff with training on the wards when there is a patient requiring high flow oxygen. Following feedback, we know that the physiotherapists are being very supportive in this interim role.”

    Source location

    2014-0501-Response-by-Tameside-Hospital-NHS-Trust
    Page 2 · response
    Published 17 November 2014

    Open published response

  8. Manchester South

    AI-generated summary

    THOMAS PATRICK MAHER · 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

    Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

    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

    Inappropriate placement of patients on a complex discharge ward

    Wider context from the report

    “6. On the 5th February 2014 ████████ elderly care consultant, read Mr Maher’s notes and said that the complex discharge ward was not the appropriate place for Mr Maher to be and that he should be transferred to a medical or orthopaedic ward. Why was he on the inappropriate ward in the first place? ”

    Source location

    THOMAS PATRICK MAHER · Prevention of Future Deaths report
    Page 1 · 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

    Specialist orthopaedic transfer was unnecessary because the fracture required bed rest, pain relief and pressure-area care available through nursing care on any ward.

    Verbatim wording from the response

    “On 03 February 2014, ████████ agreed with ████████ view that Mr Maher should move to an Orthopaedic ward at Manchester Royal Infirmary as Mr Maher had a fractured pelvis. Mr Maher was not transferred on 03 February 2014, as previously explained, due to the unavailability of a bed. Mr Maher was discussed by the Trauma team at MRI on 04 February 2014. The team made the decision that Mr Maher did not require transfer to Manchester Royal Infirmary as he was confident that Mr Maher did not need to be on an Orthopaedic ward as he did not require any level of specialised orthopaedic care for his fracture. Mr Maher needed bed rest, pain relief and pressure area care, all of which can be provided through good nursing care on any ward.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 4 · response
    Published 5 June 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Ward 16 was considered capable of providing the required medical and nursing care despite specialising in complex discharge planning.

    Verbatim wording from the response

    “Ward 16 is a ward which specialises in complex discharge planning. The Trust would like to reassure the family that the level of medical and nursing input on Ward 16 is as good as on a Medical ward and Ward 16 is able to manage patients with complex problems.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 5 · response
    Published 5 June 2014

    Open published response

  9. Milton Keynes

    AI-generated summary

    Ross Robson · 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

    Ross Robson Boyd died following a number of falls from his wheelchair while resident at the Willows Care Home in Milton Keynes. The principal concern was that he was admitted without an adequate assessment of his needs and placed in a setting that was inappropriate for those needs.

    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 place people in settings appropriate for their needs

    Wider context from the report

    “Ross Boyd was admitted to the Willows without an adequate assessment as to his needs being carried out with the result that he was placed at the Willows that was totally inappropriate for his needs. ”

    Source location

    Ross Robson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure social care team managers discuss respite-bed use, clear assessment, and support planning with their teams.

    Verbatim wording from the response

    “In summary Mr Boyd’s placement at the Willows was made in an emergency as he was not managing at home and he, his family, and professionals involved believed a period of respite was in the best interests. Although it became apparent the Willows had difficulties meeting all of his needs I do not find that this was because of inadequate assessment prior to the placement. The Willows is a well-regarded care home and Adult Social Care use our contracted respite beds in the Centre for emergency care when required. I will ensure that managers of the social care teams discuss the use of respite beds with their teams and the need for clear assessment and support planning.”

    Source location

    2014-0313-Response-by-Milton-Keynes-Council
    Page 2 · response
    Published 23 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The temporary placement was appropriate and did not result from inadequate assessment or support planning.

    Verbatim wording from the response

    “An assessment of Mr Boyd’s needs was conducted on 4 October 2013 by ████████ and a care package at home was provided; additionally there was involvement and assessment from Community Occupational Therapy, Physiotherapy and the Rapid Assessment Team (RAIT) which is part of intermediate care. The District nurses were visiting and reviewed Mr Boyd’s medication and ████████ visited regularly. The decision to move Mr Boyd was based on his deterioration at home and increased risks to his wellbeing which included increased difficulties with transfers and falls which, at that time, did not appear to require a hospital admission or a specific health intervention. The decision was taken in consultation with Mr Boyd, and his family and other professionals involved.”

    Source location

    2014-0313-Response-by-Milton-Keynes-Council
    Page 1 · response
    Published 23 May 2014

    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

    Continued falls were not caused by the type of care and support provided at the care centre.

    Verbatim wording from the response

    “when he was in the Willows however it is not apparent that this was in any way due to the type of care and support he received when staying there. Mr Boyd continued to try to transfer from his wheelchair unaided and did not use his pendant to call the care staff for assistance hence putting himself at risk of injury.”

    Source location

    2014-0313-Response-by-Milton-Keynes-Council
    Page 2 · response
    Published 23 May 2014

    Open published response
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Data last updated 7 September 2026