25 Jul 2019 Stanislawa Kmiecik · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 2
Lack of signage highlighting the risk of fall View source Lack of fall protection below the mezzanine openings View source
This report raised 5 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. 3
Urbn UK Limited
Place no-unauthorised-access signage beside the gate.
View source
Urbn UK Limited
Replace the scaffolding with high railings throughout.
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Urbn UK Limited
Infilling the voids with steel plates.
View source
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AI-generated summary
Stanislawa Kmiecik · 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
Stanislawa Kmiecik entered an inaccessible mezzanine area in a Nottingham store and fell approximately 18 feet through an open space to the basement floor, sustaining multiple injuries and dying at the scene. The concerns identified included public and staff access to the area, lack of warning signage and fall protection, uneven flooring, and the risk of objects falling through the openings onto people below.
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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 Lack of signage highlighting the risk of fall
Wider context from the report “(2) There is no signage highlighting the risk of fall
” Source location Stanislawa Kmiecik · 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 Lack of fall protection below the mezzanine openings
Wider context from the report “(5) If a member of staff or the public were to access the area, there remains a risk of falling from height as there is no safety netting or other safety structure below either of the two openings in the mezzanine floor .
” Source location Stanislawa Kmiecik · 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 Place no-unauthorised-access signage beside the gate.
Verbatim wording from the response “• signage has been placed adjacent to the gate indicating no unauthorised access ;” Source location 2019-0258-Response-by-URBN-UK-Limited
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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 Replace the scaffolding with high railings throughout.
Verbatim wording from the response “• removal of all of the scaffolding and replaced with high railings throughout ;” Source location 2019-0258-Response-by-URBN-UK-Limited
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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 Infilling the voids with steel plates.
Verbatim wording from the response “• infilling the voids with steel plates ;” Source location 2019-0258-Response-by-URBN-UK-Limited
Open published response
18 Apr 2019 Graham Philip Jones · Prevention of Future Deaths report Gloucestershire
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Concerns raised 2
Insufficient consideration of falls prevention measures on the surgical ward View source Insufficient understanding of the post-falls protocol on the surgical ward 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
Graham Philip Jones · 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
Graham Philip Jones, a 63-year-old man with significant medical conditions, was admitted to hospital with vomiting and abdominal pain and underwent repair of a perforated duodenal ulcer. He suffered several falls in hospital, including a fall that caused a significant head injury; the injury was diagnosed after a delay, and he died on 13 April 2018. The principal concerns related to falls prevention, adherence to the post-falls protocol, review of medication after a fall, and the handover of safety information between wards.
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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 Insufficient consideration of falls prevention measures on the surgical ward
Wider context from the report “1. Whether sufficient consideration is given to falls prevention measures on the surgical ward ,
2. Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward,
3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications,
4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient.
” Source location Graham Philip Jones · 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 Insufficient understanding of the post-falls protocol on the surgical ward
Wider context from the report “1. Whether sufficient consideration is given to falls prevention measures on the surgical ward,
2. Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward ,
3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications,
4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient.
” Source location Graham Philip Jones · 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 Train Trust nursing staff in falls assessment, prevention, documentation and post-fall management, with mandatory and educational refreshers.
Verbatim wording from the response “All Trust nursing staff are trained locally in their ward areas on the use of Trust policy and documentation connected with falls assessment, preventative measures and the protocol for managing a patient following a fall. These are regularly refreshed by mandatory training and other educational opportunities.” Source location 2019-0131-Response-by-Gloucestershire-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 Undertake the Silver quality-improvement project to improve identification of individual falls risks and consistent use of preventative measures through the Safety Hour Checklist.
Verbatim wording from the response “Evidence was heard from ████████ at the inquest about specific measures being taken to improve staff awareness and appreciation of falls prevention and management on Ward 5b. One main measure is the Silver QI project being undertaken by ████████, part of which is directed at reducing the risk of falls by more reliably acquiring knowledge of individual patient risks, and also ensuring more consistent use of preventative measures eg magnet signage above patients beds (see attached Driver diagram and GSAIA Quality Improvement summary which details the issues to be addressed). The aim of the project is to increase completion of the First Hour Priority Form (renamed Safety Hour Checklist) by 70% by May 2019. This form will record (amongst other factors) the handover of any falls risks for the patient being transferred.” Source location 2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust
Open published response
12 Mar 2019 Mr Frederick Raymond BROOKER · Prevention of Future Deaths report East London
View report summary
Concerns raised 6
Lack of care plans addressing identified high fall risk View source Failure to report multiple falls to the care commissioner View source Failure to encourage wheelchair seatbelt use after falls View source
Failure to investigate subsequent falls View source Failure to encourage compliance with wheelchair-fall prevention measures View source Failure to plan measures to prevent wheelchair falls View source See 3 more concerns
This report raised 3 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. 2
Hc-One Limited
Implement organisation-wide multifactorial falls risk assessments, including reassessment, care planning, documentation and review requirements.
View source
Hc-One Limited
Develop and provide a post-fall protocol flow chart and checklist to guide staff through required actions, documentation and investigation.
View source
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AI-generated summary
Mr Frederick Raymond BROOKER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Frederick Raymond Brooker, who used a wheelchair in a residential care home, sustained multiple falls, including a fall on 10 July 2018 that caused a catastrophic traumatic bleed and from which he died on 14 July 2018. The principal concerns were that, despite his recognised high risk of falling, the care home did not put adequate care plans or other measures in place, review the wheelchair or involve relevant services, investigate subsequent falls, or provide evidence of encouragement to use the wheelchair seatbelt.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of care plans addressing identified high fall risk
Wider context from the report “(1) Despite Mr Brooker sustaining multiple falls of increasing severity, no reasonable measures were taken by the Care Home staff to address the high risk of falling. Risk assessments were completed. The high risk was recognised, but there were no care plans to address the identified risk .
” Source location Mr Frederick Raymond BROOKER · 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 report multiple falls to the care commissioner
Wider context from the report “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt.
” Source location Mr Frederick Raymond BROOKER · 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 encourage wheelchair seatbelt use after falls
Wider context from the report “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt .
” Source location Mr Frederick Raymond BROOKER · 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 investigate subsequent falls
Wider context from the report “(3) An investigation took place into a fall on the 15th March 2018. No further investigations were carried out by the home into the subsequent falls, including those falls resulting in injury . Senior staff were not, therefore, always aware of the circumstances of each fall. They were therefore not able to identify the optimum means of attempting to reduce the risk of further falls.
” Source location Mr Frederick Raymond BROOKER · 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 encourage compliance with wheelchair-fall prevention measures
Wider context from the report “(4) There was reliance on the fact that Mr Brooker had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair – or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe. The only record of Mr Brooker declining to use the wheelchair seatbelt, was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair .
” Source location Mr Frederick Raymond BROOKER · 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 plan measures to prevent wheelchair falls
Wider context from the report “(4) There was reliance on the fact that Mr Brooker had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair – or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe. The only record of Mr Brooker declining to use the wheelchair seatbelt, was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair.
” Source location Mr Frederick Raymond BROOKER · 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 organisation-wide multifactorial falls risk assessments, including reassessment, care planning, documentation and review requirements.
Verbatim wording from the response “a. Multi-factorial Risk Assessments” Source location 2019-0097-Response-by-HC-One
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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 Develop and provide a post-fall protocol flow chart and checklist to guide staff through required actions, documentation and investigation.
Verbatim wording from the response “A Post Fall Protocol Flow Chart [Exhibit 3] is available and provides useful at-a-glance guidance for staff. To remind them of the steps to follow after a fall. In order to ensure compliance with the process, a checklist has been developed to provide prompts to the care home team on documentation and process [Exhibit 4] and to ensure that our staff teams are actively thinking about each of the actions required after a fall.” Source location 2019-0097-Response-by-HC-One
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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 among older people cannot always be prevented, although risks can be minimised and staff responses improved.
Verbatim wording from the response “Regrettably, it is not uncommon for older people to experience a fall, for a variety of reasons. Such falls cannot always be prevented but as an organisation we are committed to supporting people to maintain their safety wherever possible and to ensure that our Colleagues respond appropriately in the event that a fall does occur.” Source location 2019-0097-Response-by-HC-One
Open published response
26 Feb 2019 Mr Geoffrey Jackson · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to complete falls risk assessments in accordance with Trust requirements 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
Mr Geoffrey Jackson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Geoffrey Jackson died at Trafford General Hospital on 6 November 2018 following congestive cardiac failure and ischaemic heart disease, with left hip replacement and hospital-acquired pneumonia also recorded. He had an unwitnessed fall after required falls-risk assessments were not completed, although there was no evidence that the fall contributed to or materially hastened his death. Concerns included continuing omissions in falls-risk assessments and nursing records that lacked structured narrative accounts of patients’ conditions.
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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 in accordance with Trust requirements
Wider context from the report “1. Notwithstanding the actions which have been taken following the Trust’s investigation into the circumstances of Mr Jackson’s fall, a spot-check recently undertaken by the Matron on Ward 6 found 2 out of 32 patients had not had Risks of Falls Assessments completed in accordance with Trust requirements ;
” Source location Mr Geoffrey Jackson · Prevention of Future Deaths report
Open source report
25 Feb 2019 Brenda Kathleen GOWAN · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to provide falls-management equipment before discharge View source
This report raised 7 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. 2
Barts Health NHS Trust
Ensure essential discharge equipment is provided and installed before discharge, with provision checked through the discharge checklist.
View source
Barts Health NHS Trust
Monitor discharge-checklist completion through Ward Manager oversight.
View source
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AI-generated summary
Brenda Kathleen GOWAN · 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
Brenda Gowan suffered a moderately severe stroke and was discharged home for a trial period despite being assessed as requiring 24-hour supervision and being at risk of falls. Five days after discharge, she fell near her bed in the early hours and sustained catastrophic head injuries, from which she died. Concerns included insufficient care and equipment, inadequate advice and assessment of night-time falls risk, and failure to reconsider the care plan after the family reported that she was getting up frequently at night.
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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 provide falls-management equipment before discharge
Wider context from the report “(5) The equipment required for managing the risk of falls had not been provided prior to Brenda’s fall (5 days after discharge from hospital).
” Source location Brenda Kathleen GOWAN · 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 Ensure essential discharge equipment is provided and installed before discharge, with provision checked through the discharge checklist.
Verbatim wording from the response “The Care Planning documentation will address the risks identified and how they are to be managed; the equipment required and whether it will be installed prior to discharge; the plan for any required training and detail of the community support available.
Where equipment is required as essential for discharge this provision will be in place prior to discharge and checked as part of the discharge checklist. The completion of the Discharge Checklist will be monitored by the Ward Manager to ensure correct completion. Where needs change these will be re-assessed by a senior professional and where risks are identified this could include urgent re-admission to the stroke pathway.” Source location 2019-0064_Response-by-Barts-Health-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 Monitor discharge-checklist completion through Ward Manager oversight.
Verbatim wording from the response “The Care Planning documentation will address the risks identified and how they are to be managed; the equipment required and whether it will be installed prior to discharge; the plan for any required training and detail of the community support available.
Where equipment is required as essential for discharge this provision will be in place prior to discharge and checked as part of the discharge checklist. The completion of the Discharge Checklist will be monitored by the Ward Manager to ensure correct completion. Where needs change these will be re-assessed by a senior professional and where risks are identified this could include urgent re-admission to the stroke pathway.” Source location 2019-0064_Response-by-Barts-Health-NHS-Trust
Open published response
14 Feb 2019 Douglas Albert Walter MINNS · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Unavailability of a home-based falls response service View source
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AI-generated summary
Douglas Albert Walter MINNS · 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
Douglas Albert Walter MINNS, aged 93, fell at home on 21 August 2018 and made an emergency call. He was attended by ambulance after approximately four hours, taken to hospital with subarachnoid and subdural bleeding, and died there on 22 August 2018. The principal concern was the withdrawal of a falls service and the resulting delay in responding to people who had fallen, particularly amid strains on the ambulance service.
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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 Unavailability of a home-based falls response service
Wider context from the report “During the course of the evidence it was explained to me that the provision of a falls service was withdrawn some years ago , the service would provide for someone to attend the home of the person who had fallen, get them on their feet, assess their wellbeing, serve a cup of tea and get them back into bed if required. If they required more urgent treatment, they would report to the ambulance service. The withdrawal of the service puts patient's lives at risk and, in view of the strains on the ambulance service, consideration should be given to re-introducing it. It is unacceptable for a 93 year old man to be left lying on the floor for four hours before someone responds.
” Source location Douglas Albert Walter MINNS · 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 Operate a 24/7 Home 1st Rapids service providing rapid triage, home attendance, assessment and escalation for acute falls.
Verbatim wording from the response “• A Home 1st Rapids service provided by our community provider, CNWL, comprising of experienced nurse practitioners and prescribers, who respond to a call from a GP, ambulance services or other allied health professional.” Source location 2019-0052-Response-by-Milton-Keynes-CCG
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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 commissioned services sufficiently replace the discontinued falls service, covering acute, preventative and non-urgent community fall needs.
Verbatim wording from the response “I hope the above description of commissioned services provides suitable assurance that although the original falls services was discontinued, it has been replaced by a 24/7 Home 1st Rapids service to deal with acute episodes of falling in the community; supported by two in office hours services which focus on prevention and non-urgent needs. The Home 1st Rapids service reflects the objectives of the original falls service in that they attend the home, carry out an assessment, make the individual comfortable and call an ambulance if required.” Source location 2019-0052-Response-by-Milton-Keynes-CCG
Open published response
8 Feb 2019 Jean Mary Cutler · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5
Inadequate assurance of wheelchair-fall risk management View source Undated and unsigned falls risk management and assessment documents View source Reliance on staff presence to prevent falls View source
Inadequate completion of falls risk assessments View source Reliance on staff intervention during wheelchair falls View source See 2 more concerns
This report raised 5 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. 2
Cole Valley Nursing Home
Implement wheelchair risk assessments and lap-belt protocols, brief staff, provide care-folder access, and monitor compliance through management oversight.
View source
Cole Valley Nursing Home
Introduce and complete comprehensive Falls Risk Assessments for all residents, with monthly or condition-triggered recalculation.
View source
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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 Inadequate assurance of wheelchair-fall risk management
Wider context from the report “3. I heard evidence that following the incident the Care Quality Commission and Clinical Commission Group had requested from the nursing home copies of revised risk management documents. In my opinion this has led to the nursing home being given the impression their management of residents from falling out of wheelchairs is adequate .
” Source location Jean Mary Cutler · 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 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 × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Reliance on staff presence to prevent falls
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 × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate completion of falls risk assessments
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 × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Reliance on staff intervention during wheelchair falls
Wider context from the report “2. Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling.
” Source location Jean Mary Cutler · 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 Implement wheelchair risk assessments and lap-belt protocols, brief staff, provide care-folder access, and monitor compliance through management oversight.
Verbatim wording from the response “v) All nursing and care staff working at the Home have been made aware of the new Falls Risk Assessments and Wheelchair Risk Assessments during handover and in staff meetings. The new risk assessments are available within each person’s care folder – which staff have access to throughout the 24-hour period. The protocol for ensuring lap belts are used when people use their wheelchairs (as specified within the new Wheelchair Risk Assessment) has been reiterated to all staff and appropriate use and implementation is monitored by members of the Home’s management team.” Source location 2019-0040-Response-by-Cole-Valley-Nursing-Home
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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 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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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
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28 Nov 2018 John Lea · Prevention of Future Deaths report Manchester North
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Concerns raised 2
Failure to update and complete critical risk assessments View source Failure to adhere to falls prevention policy and protocol View source
This report raised 6 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
John Lea · 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
John Lea was admitted to hospital for management of heart failure and was later found collapsed on the ward after the bay-tagging nurse temporarily left without arranging monitoring. Resuscitation was unsuccessful and his death was confirmed on 12 June 2017; the report considered a sudden cardiac-related event more likely than not. Concerns included incomplete risk assessments, poor communication, gaps in documentation, failure to escalate a change in oxygen saturations, incorrectly calculated NEWS scores, and failures to follow relevant policies and protocols.
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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 and complete critical risk assessments
Wider context from the report “1. In this case, critical risk assessments had not been updated and/or completed (falls, cot sides etc.) There were missed opportunities to re-assess .
” Source location John Lea · 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 adhere to falls prevention policy and protocol
Wider context from the report “6. Failure to adhere to Trust policy/protocol – prevention of falls , patient observation.
” Source location John Lea · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to conduct falls risk assessments regularly View source Failure to follow falls risk assessments and care plans View source
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
Ronald Houchin · 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
Ronald Houchin died on 5 September 2017 after an unwitnessed fall at Rosehill House Care Home, having sustained a subdural haematoma; the recorded medical cause of death was aspiration pneumonia caused by the haematoma. The report identified concerns that falls risk assessments and care plans were not reviewed regularly or followed, despite Mr Houchin having fallen seventeen times.
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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 conduct falls risk assessments regularly
Wider context from the report “Evidence was given before the Court that the falls risk assessment carried out on 31.12.15 was not followed. As such Mr Houchin was not assisted and supervised when mobilising.
Mr Houchin fell seventeen times between 31.12.15 and 10.08.17.
The falls risk assessment was updated twice between 31.12.15 and 10.08.17.
Mr Houchin died as a result of aspiration pneumonia caused by a subdural haematoma sustained in an unwitnessed fall.
In my opinion there is a risk that future deaths may occur unless a system is established within Rosehill House Care Home whereby falls risk assessments are conducted regularly and assessments and care plans are followed.
” Source location Ronald Houchin · 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 follow falls risk assessments and care plans
Wider context from the report “Evidence was given before the Court that the falls risk assessment carried out on 31.12.15 was not followed . As such Mr Houchin was not assisted and supervised when mobilising.
Mr Houchin fell seventeen times between 31.12.15 and 10.08.17.
The falls risk assessment was updated twice between 31.12.15 and 10.08.17.
Mr Houchin died as a result of aspiration pneumonia caused by a subdural haematoma sustained in an unwitnessed fall.
In my opinion there is a risk that future deaths may occur unless a system is established within Rosehill House Care Home whereby falls risk assessments are conducted regularly and assessments and care plans are followed .
” Source location Ronald Houchin · Prevention of Future Deaths report
Open source report
19 Nov 2018 Beryl Ann Walsh · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 5
Failure to refer people at high risk of falls to the falls prevention team View source Failure to undertake falls prevention care plans View source Failure to provide falls prevention equipment View source
Failure to undertake falls risk assessments View source Failure to identify people at high risk of falls View source See 2 more concerns
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
Beechwood Lodge
Implement a falls matrix to monitor falls and support referrals to the falls team when required.
View source
Beechwood Lodge
Refer all falls-risk concerns to appropriate professionals, including doctors and falls teams.
View source
Beechwood Lodge
Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.
View source
Beechwood Lodge
Strengthen risk assessments for residents who have experienced falls.
View source See 1 more action
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AI-generated summary
Beryl Ann Walsh · 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
Beryl Ann Walsh sustained catastrophic head injuries in an unwitnessed fall from her bed at Beechwood Lodge Care Home on 3 June 2018, which led directly to her death. The principal concerns were missed opportunities to identify her as being at high risk of falls, refer her to the falls team, provide falls-prevention equipment, and undertake falls-risk assessments and care plans.
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 refer people at high risk of falls to the falls prevention team
Wider context from the report “1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home.
During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken
” Source location Beryl Ann Walsh · 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 undertake falls prevention care plans
Wider context from the report “1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home.
During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken
” Source location Beryl Ann Walsh · 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 provide falls prevention equipment
Wider context from the report “1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home.
During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment . No care plans and falls risk assessments had been undertaken
” Source location Beryl Ann Walsh · 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 undertake falls risk assessments
Wider context from the report “1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home.
During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken
” Source location Beryl Ann Walsh · 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 identify people at high risk of falls
Wider context from the report “1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home.
During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken
” Source location Beryl Ann Walsh · 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 falls matrix to monitor falls and support referrals to the falls team when required.
Verbatim wording from the response “3. We have now put all new risk assessments in all care plans about safety equipment whether they use it or why they do and the reasons why they don’t. I also have put in place a falls matrix, so I can monitor falls and do referrals to falls team when required.” Source location 2018-0359-Response-by-Beechwood-Lodge
Open published response
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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 Refer all falls-risk concerns to appropriate professionals, including doctors and falls teams.
Verbatim wording from the response “4. We will ensure all falls risk concerns are referred to appropriate professionals i.e. doctors and falls teams.” Source location 2018-0359-Response-by-Beechwood-Lodge
Open published response
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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 Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.
Verbatim wording from the response “3. We have now put all new risk assessments in all care plans about safety equipment whether they use it or why they do and the reasons why they don’t. I also have put in place a falls matrix, so I can monitor falls and do referrals to falls team when required.” Source location 2018-0359-Response-by-Beechwood-Lodge
Open published response
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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 Strengthen risk assessments for residents who have experienced falls.
Verbatim wording from the response “1. We have put more in robust risk assessments for residents who have had falls.” Source location 2018-0359-Response-by-Beechwood-Lodge
Open published response
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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 Falls-prevention equipment was considered inappropriate because of trip hazards from extremely poor eyesight, with the existing call bell enabling assistance when required.
Verbatim wording from the response “The falls that BW sustained was over a 3 and half year period, the equipment what would be usually required was more of a risk to BW due to extremely poor eyesight so equipment for falls prevention was not appropriate due to trip hazards, however BW had good capacity so was able to use the call bell she had in place when she required assistance.” Source location 2018-0359-Response-by-Beechwood-Lodge
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.