Recurring concern

Failure to take timely escalation action when safety thresholds are breached

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First reported 27 Jan 2014•Latest report 16 Mar 2026

Definition

What this concern includes

Includes failures to initiate, progress or complete escalation when a defined safety threshold, failed contact or time limit has been reached, including escalation after repeated failed visits, breached response times or comparable triggers requiring senior review, resource allocation or welfare intervention.

Not included

  • Excludes the underlying safety concern, staffing shortage or clinical deterioration when no failure to escalate after a defined trigger is identified.
  • Excludes failures of ordinary communication or notification where no safety threshold, failed contact or breached time limit required escalation.
  • Excludes deficiencies confined to the substantive content of an escalation policy when the policy's operation after a trigger is not the unsafe condition.
  • Excludes the existing broader concern about failure to escalate patient-safety concerns to senior oversight when the assertion does not specifically identify a breached threshold, failed contact or time-based escalation trigger.
Reports
62

Distinct published reports

Individual concerns
65

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
84

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 Care6
NHS England5
Barts Health NHS Trust3
Care Quality Commission3
North West Ambulance Service NHS Trust3
East Midlands Ambulance Service NHS Trust2
Essex County Council2
Essex Partnership University NHS Foundation Trust2
Manchester University NHS Foundation Trust2
South East Coast Ambulance Service NHS Foundation Trust2
University Hospitals Sussex NHS Foundation Trust2
Adbolton Hall1
Aneurin Bevan University LHB1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Bedford Prison1

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. Mid Kent and Medway

    AI-generated summary

    STEVE MARTIN BRIAN COOKE · 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

    Steve Martin Brian Cooke had COVID-19 pneumonia following a COVID-19 infection and was found deceased at home on 26 December 2020. He had called an ambulance with extreme shortness of breath and apparent hypoxia, but communication difficulties led to the ambulance being sent to the wrong address and him not being located. Concerns included the failure to obtain his correct address, insufficient communication with his ex-partner, and failure to escalate the matter or review the original call when he could not be found.

    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 escalate when an unwell patient cannot be located

    Wider context from the report

    “Evidence was heard at the Inquest that there were communication difficulties that resulted in the ambulance being dispatched to the wrong address and Mr Cooke not being located: Mr Cooke made an emergency call taken by NHS 111 with symptoms of COVID-19 and was extremely breathless with apparent hypoxia, the call handler was struggling to understand him in a busy working environment. The call was transferred for clinical assessment and an ambulance was dispatched. Paramedic ambulance crew arrived in under five minutes to an address provided by the emergency operations control (EOC) and could not locate the patient, Mr Cooke. The crew checked the address with EOC and managed to gain access from a key holder to the address that was unoccupied and a thorough search and enquiries with neighbours established the address was unoccupied. (1) Ambulance crew updated EOC Mr Cooke could not be located. EOC made checks with a telephone number on the system to attempt to establish the location of Mr Cooke. This telephone number was Mr Cooke’s ex-partner on 25th December 2020.The EOC established that Mr Cooke was not with his ex-partner. The call handler when speaking to Mr Cooke’s ex-partner: (i) EOC terminated the call within 62 seconds – this very brief given the serious nature of the query to locate a missing sick patient (ii) did not give a complete explanation of the reason for the call (iii) did not ask for Mr Cooke’s current address (iv) instead suggested part of the address that the crew had been dispatched to knowing Mr Cooke could not be located there and did not listen to or give sufficient time for Mr Cooke’s ex-partner to respond (v) did not update Mr Cooke’s ex-partner that Mr Cooke had not be located (2) Mr Cooke was very unwell and in need of medical attention: (i) the matter was not escalated further when Mr Cooke could still not be located (ii) the original call was not listened to again to attempt to establish the correct address being given by Mr Cooke. Mr Cooke gave the address as ████████ Hammond Hill and it was the call handler who suggested a different part of the address as there was difficulty establishing the postcode and this was approximately five metres from where Mr Cooke lived. (iii) It was possible to hear Mr Cooke stating with difficulty the word ‘opposite’ when this part of the address was suggested. ”

    Source location

    STEVE MARTIN BRIAN COOKE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a patient-location verification process requiring team-leader escalation, call review, records checks, contact with information sources, and local hospital and police checks.

    Verbatim wording from the response

    “2. Our process upon a patient not being found by crew on scene”

    Source location

    2021-0266-Response-from-South-East-Coast-Ambulance-Service_Published
    Page 2 · response
    Published 12 August 2021

    Open published response

  2. Manchester West

    AI-generated summary

    KENNETH SMITH · 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

    Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.

    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 scale up care and prompt urgent review when problems arise

    Wider context from the report

    “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020. Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered. The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury. Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all. Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020. The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns: 1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful. 2. The failure to consider and specify a review date; 3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review. 4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority; ”

    Source location

    KENNETH SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Hannah Bampfylde · 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

    Hannah Bampfylde was found hanging in the garage of her mother’s home, where she had been staying, and the inquest determined that she took her own life. She had been referred to HATS for mental health input after an overdose, but missed or could not attend assessment appointments and was discharged without being assessed. The report identified unclear responsibility for rebooking missed appointments and a lack of routine notification to GPs when newly referred patients did not engage with the service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a clear escalation pathway for non-attendance by newly referred patients

    Wider context from the report

    “Hannah Bampfylde had a long history of mental health problems and was diagnosed with Borderline Personality Disorder. Following a settled period, her mental health deteriorated leading to the attempted overdose in October 2019. Following an unsuccessful referral to Time to Talk services, Hannah was referred to HATS, the entry point into specialist mental health services. Assessment appointments were made for 26th November 2019, which Hannah did not attend, and 4th December 2019, which was altered at short notice by HATS to 6th December 2019, when Hannah was at work. No further appointments were made by HATS and Hannah did not contact the service herself to reschedule. Hannah’s GP was not made aware that she had missed appointments and that she was not therefore effectively under the care of the service until HATS wrote to the GP on 1st April 2020 advising them that Hannah had been discharged for non-engagement. Whilst there was not sufficient evidence before the Court to conclude that the lack of an assessment by HATS and therefore Mental Health Services input into Hannah’s care caused or contributed to her death, the evidence highlighted a lack of clarity and potential for persons newly referred to the service to not engage without their GP being aware of this. The two GPs who had contact with Hannah both stated they were unaware of any protocols being in place, either at the time of Hannah’s death or in the interim, to ensure all non-engagement with services should be communicated with the patient’s GP, although the Trust’s own Serious Incident Report into Hannah’s death identified that such a protocol should be in place. HATS use the Trust’s “Active Engagement Incorporating Did Not Attend (DNA) Policy & Procedure” (“the Policy”) in governing the standards of how to promote engagement with service users, to include those awaiting assessment and those already under the care of the service. The Policy provides general guidance to professionals in deciding on the action to be taken when a person does not attend an appointment with them, but does not give a clear pathway to avoid newly referred patients slipping through the system. From the evidence given to the Court, it was not clear who was responsible for re-booking appointments in the event of a DNA, or at what stage non-attendances should be escalated for review with the Referrals Co-ordinator. The Policy describes a “Multi-Disciplinary Review Meeting” taking place prior to a non-attending person being discharged back to primary care, but this does not apply to new referrals to the HATS where a Multi-Disciplinary team would not be in place and discussion would instead take place between the Assessor and Referrals Co-ordinator. There was no detail of this discussion in Hannah’s notes although evidence was given that it had taken place. - Appointments are not automatically re-booked when a person has failed to attend an appointment. - It is not clear who should re-book appointments when a person has failed to attend (Administration or Assessors). - GPs are not routinely notified if a person has not attended an appointment with the HATS, meaning the GP would be unaware the person was not receiving input from the HATS until they had failed to attend a number of appointments and were discharged back to primary care, potentially many months after being referred. Consideration should be given to whether any steps can be taken to address the above concerns. ”

    Source location

    Hannah Bampfylde · Prevention of Future Deaths report
    Page 3 · 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

    Audit compliance with the strengthened referral follow-up arrangements over the forthcoming months.

    Verbatim wording from the response

    “The safety of patients referred to us is of paramount importance to the Trust. Our service cannot coerce engagement as the desire to engage must come from the patient themselves, particularly when they are capacious, like Hannah was. However, it is important for our systems to be effective and to ensure that no patient “falls” between services. I trust this letter demonstrates to you and Hannah’s family the action we took to strengthen our systems. I will ensure we audit compliance with this over forthcoming months.”

    Source location

    2021-0136-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
    Page 3 · response
    Published 5 May 2021

    Open published response

  4. Lancashire and Blackburn with Darwen

    AI-generated summary

    Gillian McKinlay · 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

    Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent measures.

    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 of nursing escalation when an NG tube cannot be sited and clinical review has not occurred

    Wider context from the report

    “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”

    Source location

    Gillian McKinlay · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. West Yorkshire Eastern

    AI-generated summary

    June Mavis Winterbottom · 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

    June Mavis Winterbottom, aged 90, lived alone in sheltered accommodation and was found semi-conscious in her own faeces and vomit, covered in pressure sores, after an urgent Adult Social Care referral received no contact. She was taken to hospital and treated for urosepsis, but died later that day. The report identified ineffective urgent-referral handling, unclear accountability, and no safety net for calling an ambulance when Adult Social Care could not respond promptly.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of an ambulance escalation safety net when Adult Social Care cannot respond promptly

    Wider context from the report

    “(1) The system for handling urgent referrals within Adult Social Care in Wakefield on 02/06/20 was ineffective. Despite being graded as ‘urgent’, no contact was made with an elderly, isolated, vulnerable lady, who was evidently in dire need of assistance (2) In consequence, Mrs Winterbottom was left alone without the medical assistance which would probably have been called in, had she been seen. It is, however, not possible to say whether her life would have been saved, had she been admitted to hospital on 02/06/20. (3) Even the following day, 03/06/20, no visit took place, despite the urgency of the situation. The urgent referral system was exposed as deficient. (4) Evidence taken at the Inquest indicated that the team in Adult Social Care were not aware of the need to watch out for such cases which had drifted outside of normal hours. Such a generalised instruction serves to diffuse responsibility, rather than establish accountability on the part of an identified manager. (5) There was no safety net in place, whereby an ambulance would have been called in the event the Adult Social Care team were unable to respond in a timely manner for any reason. ”

    Source location

    June Mavis Winterbottom · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish an on-call rota identifying a manager responsible for out-of-hours periods.

    Verbatim wording from the response

    “• A Team Managers on call rota was set up, to ensure that there was always a clearly identified manager responsible for out of hours, whether evenings or weekends.”

    Source location

    2020-0183-Response-from-Wakefield-Council_Redacted.pdf
    Page 3 · response
    Published 19 November 2020

    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

    Adult Social Care considers its reviewed and strengthened systems sufficiently robust, so no additional actions are required following the report.

    Verbatim wording from the response

    “I trust that the above information addresses the matters of concern you raise, and provides sufficient reassurance that Adult Social Care in Wakefield have already appropriately reviewed our systems following the death of Mrs Winterbottom, and taken action to ensure the robustness of our systems. As a consequence, Adult Social Care do not feel that there are any additional actions which need to be taken resulting from your issuance of the Regulation 28 Report.”

    Source location

    2020-0183-Response-from-Wakefield-Council_Redacted.pdf
    Page 4 · response
    Published 19 November 2020

    Open published response

  6. Inner North London

    AI-generated summary

    Moses Victor Boardman · 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

    Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.

    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 of a commissioned care provider to escalate inability to reach a patient for care visits

    Wider context from the report

    “4. The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr Boardman for his first 3 care visits. ”

    Source location

    Moses Victor Boardman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the care provider’s service quality and require achievement of improvement-plan targets.

    Verbatim wording from the response

    “Three Sisters Care not informing the LA that they had been unable to provide care to MB as arranged. The Failed Visits policy requires all commissioned domiciliary care providers to inform the local authority speedily of all occasions when the provider is unable to provide care as arranged because the provider does not seem to be at home or does not admit them. Commissioned providers are routinely reminded of the Failed Visits policy at quarterly providers meetings of the importance of adhering to the policy will be reiterated to them at the next forum. The quality of service provided by Three Sisters Care is currently under review with the lead commissioner requiring targets on an improvement plan to be met. Failure to achieve the standards required may result in the provider being de-commissioned.”

    Source location

    2020-0160-Response-from-London-Borough-of-Tower-Hamlets.pdf
    Page 1 · response
    Published 22 October 2020

    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

    Reiterate the Failed Visits policy and its reporting requirements to commissioned providers at the next provider forum.

    Verbatim wording from the response

    “Three Sisters Care not informing the LA that they had been unable to provide care to MB as arranged. The Failed Visits policy requires all commissioned domiciliary care providers to inform the local authority speedily of all occasions when the provider is unable to provide care as arranged because the provider does not seem to be at home or does not admit them. Commissioned providers are routinely reminded of the Failed Visits policy at quarterly providers meetings of the importance of adhering to the policy will be reiterated to them at the next forum. The quality of service provided by Three Sisters Care is currently under review with the lead commissioner requiring targets on an improvement plan to be met. Failure to achieve the standards required may result in the provider being de-commissioned.”

    Source location

    2020-0160-Response-from-London-Borough-of-Tower-Hamlets.pdf
    Page 1 · response
    Published 22 October 2020

    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

    Responsibility for the commissioned care provider’s failure to escalate missed visits rests with Tower Hamlets Local Authority.

    Verbatim wording from the response

    “4. The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr Boardman for his first 3 visits This is a matter for LBTH to respond to”

    Source location

    2020-0160-Response-from-Barts-Health-NHS-Trust_Redacted.pdf
    Page 2 · response
    Published 22 October 2020

    Open published response

  7. Manchester South

    AI-generated summary

    Evelyn Ross · 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

    Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.

    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 escalate deterioration to a consultant

    Wider context from the report

    “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration. ”

    Source location

    Evelyn Ross · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.

    Verbatim wording from the response

    “The Consultants in Care of the Elderly/Geriatricians at Trafford General Hospital input daily at the morning Board Rounds and all patients are discussed and followed up to Consultant level as needed. If clinical concerns are raised in respect of an individual patient’s case, a member of the Senior Medical team (Consultant or Registrar) will review the patient.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 9 · response
    Published 5 June 2020

    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 Trust concluded that regular Consultant reviews occurred and junior doctors escalated clinical concerns as required in Mrs Ross’ case.

    Verbatim wording from the response

    “Having undertaken a comprehensive review of the entries in Mrs Ross’ clinical notes, the Consultant team at Trafford General Hospital have been able to establish that in Mrs Ross’ case there were in fact regular Consultant reviews, in line with required standards, and there was no issue in respect of junior doctor escalation, which as documented in the clinical notes took place as required. I apologise if the evidence you heard at the Inquest did not accurately convey this.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 9 · response
    Published 5 June 2020

    Open published response

  8. Manchester South

    AI-generated summary

    Andrew Richard Hogg · 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

    Andrew Richard Hogg, who had Parkinson’s disease and possible dementia, died on 6 May 2019 after a fall at Meadway Court Care Home caused a head injury and subdural haematoma. The principal concerns were the absence of adequate falls assessment, escalation, investigation and proactive measures to reduce the risk after his repeated falls.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of an escalation pathway following sequential falls

    Wider context from the report

    “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk. In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:- 1. Not all the relevant paperwork was completed following the falls 2. There could have been engagement with other services such as the local falls clinic 3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder” 4. Relevant information should have been updated onto the patient’s electronic record. While I welcome his insightful comments I remain concerned that 1. There was no adequate falls assessment policy 2. There was no obvious escalation pathway following the sequential falls Andrew had 3. There was no internal investigation into any of the falls which occurred 4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision. It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing. While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced. ”

    Source location

    Andrew Richard Hogg · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Arrange a GP or CPN review for any resident experiencing more than two falls within two weeks.

    Verbatim wording from the response

    “However, to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. Managers will print the falls log for the week and add notes as to what actions have been taken. These notes will also be added to the support plans of those residents involved. Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN.”

    Source location

    2019-0400-Response-from-Borough-Care-Ltd-Redacted
    Page 1 · response
    Published 28 December 2019

    Open published response

  9. Lincolnshire

    AI-generated summary

    Helen BARKER · 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

    Helen BARKER, aged 50, called emergency services on 11 November 2018 reporting suicidal feelings and threatening to take an overdose. Although reviews were recorded as having been undertaken, they did not occur, and paramedics attended 6 hours and 35 minutes after the initial call; she was pronounced dead at home on 12 November 2018. The report raised concerns about implementation of an investigation recommendation and whether an emergency category 3 call could be escalated when the ambulance response time was exceeded.

    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 escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded

    Wider context from the report

    “1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:- Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust. Has this recommendation now been implemented particularly where attempted suicides have been reported. Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded? ”

    Source location

    Helen BARKER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Worcestershire

    AI-generated summary

    David John KIRSCH · 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

    David John Kirsch was found deceased in his cell on 19 March 2018 after inflicting a large wound to his neck with the lid of a tin. The principal concerns were the lack of allocated case-manager oversight for his ACCT document, deficiencies in recording and addressing risks, failure to escalate the case, and inadequate staff knowledge and assessment of his suicide risk.

    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 escalate open ACCT documents in accordance with policy

    Wider context from the report

    “(3) Despite the ACCT document having been open for more than 6 weeks, it was not escalated to a more senior member of staff, as per prison policy. ”

    Source location

    David John KIRSCH · 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

    Convene weekly multidisciplinary safety meetings to discuss complex cases and cases approaching six weeks for escalation or enhanced care planning.

    Verbatim wording from the response

    “At Long Lartin, a weekly multi-disciplinary safety intervention meeting is convened where cases that are complex and/or require a higher level of input are now discussed. This provides an opportunity to discuss cases approaching the six-week point in order to identify a more senior member of staff to take over as case manager and/or to devise an enhanced care plan as appropriate.”

    Source location

    2019-0362-Response-from-NOMS_Redacted
    Page 2 · response
    Published 9 December 2019

    Open published response
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Data last updated 7 September 2026