23 Apr 2021 Derek Albert RUSSELL · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Chronic shortages of falls alarm equipment for patients assessed as requiring it View source
Linked response
Medway NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Medway NHS Foundation Trust
Purchase additional falls alarms, bed sensor pads and chair sensor pads to increase available equipment.
View source
Medway NHS Foundation Trust
Implement ward-level stocktaking, local stock monitoring and daily checks alongside the centrally held falls-equipment reserve.
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Medway NHS Foundation Trust
Identify budget and establish RFID tagging, logging and tracking for falls equipment.
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Medway NHS Foundation Trust
Disseminate and require compliance with the falls-equipment procurement and non-availability escalation procedure.
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Medway NHS Foundation Trust
Maintain up-to-date falls-equipment training for staff working predominantly nights.
View source
Medway NHS Foundation Trust
Remind appropriate staff to report and escalate falls-equipment shortages promptly.
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Medway NHS Foundation Trust
Require Clinical Engineering to notify the dedicated falls team of shortages and provide twice-yearly stock reports and annual stocktakes.
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Medway NHS Foundation Trust
Maintain 10 dedicated, tracked falls alarms in the Emergency Cupboard at all times.
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AI-generated summary
Derek Albert RUSSELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Derek Albert Russell, who had a history of falls, was admitted to hospital after an unwitnessed fall and was assessed as being at high risk of further falls. Despite repeated requests, falls alarm equipment was unavailable, and he later suffered another unwitnessed fall and brain haemorrhages before developing COVID-19 and dying. The principal concern was the chronic shortage of falls alarm equipment at Medway Maritime Hospital, which increased patients’ risk of falls and serious injury and compromised clinical staff’s ability to monitor and reduce that risk.
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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 Chronic shortages of falls alarm equipment for patients assessed as requiring it
Wider context from the report “I am concerned that:
(a) Patients who are assessed as requiring falls alarm equipment in future will not receive it due to chronic shortages of that equipment in the Medway Maritime Hospital.
(b) By failing to provide adequate falls alarm equipment , patients are at increased risk of falling and sustaining fatal injuries (or injuries such as fractures and brain injury that can lead to immobility, susceptibility to infection and death).
(c) The ability of clinical staff to monitor and reduce the risk of patients falling and sustaining fatal injuries is seriously compromised by the lack of this basic safety equipment and is putting lives at risk.
” Source location Derek Albert RUSSELL · 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 Purchase additional falls alarms, bed sensor pads and chair sensor pads to increase available equipment.
Verbatim wording from the response “Since 2015 Medway NHS Foundation Trust has purchased 236 falls alarms, the last purchase being 100 alarms available for use February 2020 with each ward being allocated two dedicated falls alarms. Our Frailty Assessment Unit has also purchased nine additional alarms, and in response to the concerns raised by HM Coroner the Trust is in the process of increasing stock by purchasing a further 75 falls alarms, 75 bed sensor pads, and 10 chair sensor pads.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement ward-level stocktaking, local stock monitoring and daily checks alongside the centrally held falls-equipment reserve.
Verbatim wording from the response “Our comprehensive investigation following this Regulation 28 report identified that the tracking of stock throughout the hospital was not as robust as it could be, and as such changes are being implemented to stocktake current provisions and equip wards with the ability to monitor and maintain their own stock in addition to the centrally held reserve; falls equipment levels and availability will be added to the daily checks each ward completes. Budget will be identified and Clinical Engineering, who maintains the equipment stores, will be establishing a robust process for the RFID tagging, logging and tracking of falls equipment as they do with other critical equipment. We have also contacted other local Trusts to learn from any helpful processes they have in place.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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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 Identify budget and establish RFID tagging, logging and tracking for falls equipment.
Verbatim wording from the response “Our comprehensive investigation following this Regulation 28 report identified that the tracking of stock throughout the hospital was not as robust as it could be, and as such changes are being implemented to stocktake current provisions and equip wards with the ability to monitor and maintain their own stock in addition to the centrally held reserve; falls equipment levels and availability will be added to the daily checks each ward completes. Budget will be identified and Clinical Engineering, who maintains the equipment stores, will be establishing a robust process for the RFID tagging, logging and tracking of falls equipment as they do with other critical equipment. We have also contacted other local Trusts to learn from any helpful processes they have in place.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate and require compliance with the falls-equipment procurement and non-availability escalation procedure.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain up-to-date falls-equipment training for staff working predominantly nights.
Verbatim wording from the response “Since January 2019 there have been 9 reports of inability to obtain a falls alarm, with all incidents occurring overnight. Escalation of these incidents to the dedicated falls team did not always happen, but where they were alerted additional alarms were purchased in response. The occurrence of the majority of these incidents being overnight has led to the Trust ensuring training is up” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 Remind appropriate staff to report and escalate falls-equipment shortages promptly.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 Require Clinical Engineering to notify the dedicated falls team of shortages and provide twice-yearly stock reports and annual stocktakes.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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 Maintain 10 dedicated, tracked falls alarms in the Emergency Cupboard at all times.
Verbatim wording from the response “All staff have been reminded of the importance of maintaining good stock management processes as well as prompt identification and escalation of any supply issues. The attached standard operating procedure for procuring falls equipment for patients will be disseminated and must be followed, and the outlined escalation process actioned in the event of non-availability. In addition, Clinical Engineering will now contact the dedicated falls team if there is any shortage of falls equipment in their stores, with a twice yearly report of stock levels and stock integrity/expiry, and a full yearly stocktake occurring. There will be 10 dedicated and tracked falls alarms held within the Emergency Cupboard at all times.” Source location 2021-0119-Response-from-Medway-NHS-Foundation-Trust-Redacted
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14 Apr 2021 Amy Chiverall · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to provide accessible call alarms for residents at moderate or high risk of falls View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
RochCare (UK) Ltd
Direct staff to attach call bells to people rather than walls, including enabling at-risk independent people to wear them.
View source
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AI-generated summary
Amy Chiverall · 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
Amy Chiverall, a resident of Royley House Care Home, had an unwitnessed fall on 1 July 2020 and was later found to have multiple rib fractures and a traumatic pneumothorax. The concerns included that her fixed call bell was out of reach, medical attention was not sought in a timely manner, and post-fall observations were not conducted in line with care home policy.
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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 accessible call alarms for residents at moderate or high risk of falls
Wider context from the report “The Court heard the home do not use pendant call alarms. This was described as a business decision. The Home has 18 residents of mixed falls risk but less than half would be of a moderate or high risk of falls. The Court was concerned that for those residents a fixed call bell may not be of assistance, as in this case, as it would be out of reach when required.
” Source location Amy Chiverall · 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 Direct staff to attach call bells to people rather than walls, including enabling at-risk independent people to wear them.
Verbatim wording from the response “• The info points all people to have the call bell attached to the person, not to the wall. For those people who do independently and have capacity, but are at risk of falls, they can wear the call bell to summon help when required.” Source location 2021-0178-Response-from-Rochcare-Redacted
Open published response
Concerns raised 4
Failure to report falls-related matters to regulatory bodies View source Delayed staff supervision and discussion of falls prevention View source Failure to commence a timely investigation of falls-related matters View source
Failure to apply falls risk assessment and prevention procedures View source See 1 more 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. 6
Anchor Hanover Group
Reinforce falls procedures through staff supervision and deliver falls-awareness presentations across the care home, district and national services.
View source
Anchor Hanover Group
Review the internal coroner process and introduce formal safeguarding-team triage to monitor trends and support risk assessment.
View source
Anchor Hanover Group
Maintain and apply comprehensive falls-management procedures covering risk assessment, prevention plans, post-fall observations, audits, response guidance, documentation and staff training.
View source
Anchor Hanover Group
Introduce sensor-mat guidance and mandatory sensor-check documentation through the updated Call Systems and Assistive Technology policy.
View source
Anchor Hanover Group
Implement falls-monitoring workbooks requiring individual tracking, physical home-manager audits and monthly national reporting to strengthen oversight and intervention.
View source
Anchor Hanover Group
Develop and nationally roll out a simplified falls-response flowchart.
View source See 3 more actions
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AI-generated summary
Pauline BRUMFITT · 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
Pauline BRUMFITT died on 15 April 2020 after a fall at a care home led to hospital admission and diagnosis of an intracranial bleed. The concerns were that falls risk assessments, prevention measures and referrals were not implemented after her previous falls, and that the incident was not promptly reported or investigated.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to report falls-related matters to regulatory bodies
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Source location Pauline BRUMFITT · 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 Delayed staff supervision and discussion of falls prevention
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021 , appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Source location Pauline BRUMFITT · 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 commence a timely investigation of falls-related matters
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been.
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Source location Pauline BRUMFITT · 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 apply falls risk assessment and prevention procedures
Wider context from the report “[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been.
(2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been .
(3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence.
” Source location Pauline BRUMFITT · 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 Reinforce falls procedures through staff supervision and deliver falls-awareness presentations across the care home, district and national services.
Verbatim wording from the response “As a result of our investigation and the concerns identified once made aware of this inquest, we have taken a number of actions to reinforce our expectations around falls management, transparency and reporting. This has been communicated across all of our services.” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the internal coroner process and introduce formal safeguarding-team triage to monitor trends and support risk assessment.
Verbatim wording from the response “In addition, we have also recently introduced the following:” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain and apply comprehensive falls-management procedures covering risk assessment, prevention plans, post-fall observations, audits, response guidance, documentation and staff training.
Verbatim wording from the response “We have extensive falls management policies and procedures that apply across all of our care homes. Upon admission to one of our homes, all residents are required to be assessed for falls risk and the outcome recorded in a falls risk assessment. Where deemed to be at risk of falls the resident will have a falls prevention plan (FPP) put in place. Staff in our homes work closely with GP services and are aware of how to refer to the local authority falls team, where necessary, to ensure that healthcare professionals actively support the home in developing the highest possible standards of FPP.” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce sensor-mat guidance and mandatory sensor-check documentation through the updated Call Systems and Assistive Technology policy.
Verbatim wording from the response “f) Our Call Systems and Assistive Technology policy issued in December 2020 which introduced additional guidance regarding the use of sensor mats, the importance of ensuring they are placed correctly to reduce the risk of resident falls and production of a new Assistive Technology Sensor Checks form which is completed every time sensors are used to ensure they are positioned and working correctly;” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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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 falls-monitoring workbooks requiring individual tracking, physical home-manager audits and monthly national reporting to strengthen oversight and intervention.
Verbatim wording from the response “i) Introduced a detailed individual falls tracker through a falls monitoring workbook. This was in place at the care home in June 2020 to enhance falls analysis and person centred intervention and support;” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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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 nationally roll out a simplified falls-response flowchart.
Verbatim wording from the response “p) Our District Manager is working with our Care Quality Team to produce a more simplified version of the falls flowchart which is in the process of national rollout.” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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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 Reporting and record-keeping shortcomings were deliberate, isolated to the care home, and not representative of organisational operations.
Verbatim wording from the response “As already explained above, we are of the view that the shortcomings in this case around reporting and record keeping were deliberate and isolated to the care home involved. They are not representative of how we operate across our organisation. Once identified, swift action was taken against those responsible.” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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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 Existing falls-risk, risk-management and governance processes are considered robust, suitable and effective across all registered locations.
Verbatim wording from the response “We are confident that all of our processes and procedures around falls risk, risk management and governance are robust, suitable and continue to work well across all of our registered locations.” Source location 2021-0098-Response-from-Anchor-Hanover-Group-1
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29 Mar 2021 Raymond Alfred POWELL · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2
Failure to formally review falls risk assessments and care policies after a resident death View source Failure to update residents' falls risk assessments View source
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
Cole Valley Nursing Home
Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.
View source
Cole Valley Nursing Home
Display a named nurse list and have the manager and deputy manager monitor and plan evaluations and risk assessments when nurses are unavailable.
View source
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AI-generated summary
Raymond Alfred POWELL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Raymond Alfred POWELL became increasingly frail, moved into Cole Valley Nursing Home, and suffered falls on 3 November 2020 that caused an acute subdural haematoma. He later developed an infection and seizure and died on 5 December 2020. Concerns included failures to record a preceding fall, update his falls risk assessment, accurately document observations, formally review the circumstances, and comply with court orders for evidence, creating an ongoing risk to other residents.
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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 formally review falls risk assessments and care policies after a resident death
Wider context from the report “1. The nursing home manager confirmed that Cole Valley Nursing Home had not conducted an internal investigation into the circumstances of Raymond's death . The rationale was "no foul play or inappropriate behaviour was suspected. Staff acted appropriately and phoned 999". I am concerned that it was not thought necessary to formally review the appropriateness of Raymond's falls risk assessment and the nursing home's policies and procedures to see what lessons could be learned to improve the safety of other residents.
” Source location Raymond Alfred POWELL · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to update residents' falls risk assessments
Wider context from the report “(2) The nursing home manager in her written report to the Coroner stated that Raymond's falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon Raymond's arrival, and had never been updated . Raymond's named nurse should have reviewed and updated it at the end of October with the preceding fall on 15 October being a key factor in the updated assessment. The nursing home manager was unable to explain why the named nurse did not update the falls risk assessment as expected.
” Source location Raymond Alfred POWELL · 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 Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.
Verbatim wording from the response “1. Manager to conduct internal investigations to all falls and attach action plans. All falls and incidents to be reported on the weekly manager’s report and submitted to Nominated Individual.” Source location 2021-0089-Response-from-Cole-Valley-Nursing-Home-Redacted
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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 Display a named nurse list and have the manager and deputy manager monitor and plan evaluations and risk assessments when nurses are unavailable.
Verbatim wording from the response “The manager has now completed a new named nurse list and now is displayed in the nurse’s office. The deputy manager and manager to effectively monitor and plan evaluations and risk assessment when nurses are unable to due to unforeseen circumstances such as sickness.
Upon reflection, new strategies and monitoring systems have been implanted. Resident of the day has been implemented with feedback from all departments to ensure accurate reflection of person-centred care and avoidance of missed evaluations in the future.
Supervisions have now been allocated to head of departments and a matrix is now available for view in nurses offices.
A new daily task folder has also been implemented for the nurses to complete. This contains allocated audits (i.e care plan audits and resident of the day).” Source location 2021-0089-Response-from-Cole-Valley-Nursing-Home-Redacted
Open published response
Concerns raised 1
Lack of care and nursing staff awareness of the risks of medical complications following falls and long lies View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Hart Care Limited
Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
View source
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AI-generated summary
Clara Ellen Freeman · 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
Clara Ellen Freeman suffered an unwitnessed fall at a care home and remained immobilised on the floor for approximately four hours while awaiting an ambulance. She later died in hospital after developing medical complications. The principal concerns related to staff proficiency in caring for her after the fall and communicating relevant information, including changes in her condition, to 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 Lack of care and nursing staff awareness of the risks of medical complications following falls and long lies
Wider context from the report “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition.
It is requested that the training for care and nursing staff be reviewed to consider;
a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency
b) Accurate recording of medical information including vital signs
c) Awareness of the risks of medical complications following falls and long lies .
” Source location Clara Ellen Freeman · 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 Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
Verbatim wording from the response “In accordance with the Regulation 28 Report to Prevent Future Deaths dated 26th March 2021, I write to confirm that we have taken action and all our staff members who are in charge of shifts in the home have attended First Aid Training on the 11th and 13th May 2021 in addition to the mandatory training programme we have in place.” Source location 2021-0085-Response-from-Hart-Care-Redacted
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12 Mar 2021 Elizabeth Robinson · Prevention of Future Deaths report Gwent
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Concerns raised 2
Failure to complete falls risk assessments and documentation View source Omissions in the falls risk assessment process View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Elizabeth Robinson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elizabeth Robinson, an 87-year-old woman at Ysbyty Ystrad Fawr for rehabilitation after hip surgery, fell and sustained a fatal head injury on 21 October 2019. Concerns included inadequate falls-risk assessment and documentation, staffing levels that nurses considered insufficient to deliver safe care, and nursing staff not having seen the internal investigation findings more than a year after her death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to complete falls risk assessments and documentation
Wider context from the report “1. Staffing Levels
Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by ████████ and ████████ confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling . Whilst the documentation was not completed , two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients. Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients.
Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist.
” Source location Elizabeth Robinson · Prevention of Future Deaths report
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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 Omissions in the falls risk assessment process
Wider context from the report “2. Serious Concerns report findings
At the inquest, Mrs Rowlands described the omissions in the falls risk assessment process and the steps that are now being taken to ensure that staff complete the documentation properly. It is my understanding that the internal investigation is an essential component of organisational learning to improve the quality of care to patients and also prevent future deaths. Mrs Rowlands informed me that falls were the greatest risk posed to patients by the Health Board. I was therefore concerned to hear that neither of the nursing staff who gave evidence had seen the findings of the internal investigation some 1 years and 4 months since Mrs Robinson’s death.
” Source location Elizabeth Robinson · Prevention of Future Deaths report
Open source report
16 Feb 2021 Alan Jones · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 2
Failure to provide required enhanced supervision for high-falls-risk patients View source Failure to provide multidisciplinary falls prevention and management View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Aneurin Bevan University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Aneurin Bevan University LHB
Increase the substantive Health Care Support Worker workforce to support enhanced care and continuity.
View source
Aneurin Bevan University LHB
Revise the Falls Policy for Hospital Adult Inpatients to define multidisciplinary assessment, care planning and professional responsibilities.
View source
Aneurin Bevan University LHB
Obtain ratification and publish the revised Falls Policy for Hospital Adult Inpatients.
View source
Aneurin Bevan University LHB
Develop and implement a multidisciplinary falls-policy implementation plan, including ward-based and online staff training.
View source
Aneurin Bevan University LHB
Evaluate falls training and monitor compliance, including multidisciplinary participation.
View source
Aneurin Bevan University LHB
Introduce ward-level Falls Prevention Collaboratives using quality-improvement methods, thematic reviews and multidisciplinary participation.
View source
Aneurin Bevan University LHB
Review and monitor completion of falls-prevention actions and evidence of multidisciplinary care-plan participation and ownership.
View source See 4 more actions
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AI-generated summary
Alan 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
Alan Jones was admitted to Neville Hall Hospital after a fall at home and, during his admission, fell seven times. On 13 November 2019 he fell while he should have been under constant supervision, suffered a fatal head injury, and died the following day. Concerns included inadequate multidisciplinary management of his falls risk, failure to provide the required supervision, and unsafe staffing levels.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide required enhanced supervision for high-falls-risk patients
Wider context from the report “1:1 Supervision
Throughout Mr Jones’ admission I heard evidence that he required either 1:1 supervision (Enhanced Care Level 5) or to be supervised in a cohorted bay (Enhanced Care Level 4). This level of care was not achieved and as a result within less than 3 weeks of his admission, Mr Jones had fallen on 7 occasions, at times as a direct result of a failure to provide adequate supervision . I am satisfied that the nursing staff were aware of the level of supervision required and regularly requested additional nursing support. These requests were not resourced.
It appears that the nursing staff had become used to this situation and tried to do the best they could in the circumstances. It also appeared that a ward which cares for patients who are the most likely to require extra support because they are confused, elderly and at risk of falls, is staffed to a minimum level which does not take account of any fluctuations in acuity.
Of concern was that despite hearing evidence that improvements in falls management had been introduced, I also heard evidence that nursing staff on the ward continue to find themselves nursing with unsafe levels of staff.
” Source location Alan 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 Failure to provide multidisciplinary falls prevention and management
Wider context from the report “Multidisciplinary Care
Mr Jones’ level of confusion and his agitation appears to have increased during his admission and yet I have seen no evidence of a truly multidisciplinary approach to how this should be managed .
The risk assessment is multifactorial but the evidence presented suggested that care lies wholly within the nursing domain.
Throughout this time, Mr Jones was clearly in the highest category of falls risk, he was confused, agitated, unsafe on his feet and yet there is no evidence that nurses and doctors and physios and pharmacists met together to discuss how these problems would be managed . The fact that during Mr Jones’ hospital stay from 25th October 2019 to his death on 14th November 2019 he fell 7 times and the last time resulted in his death, demonstrates a complete failure in the falls prevention strategy at ABUHB .
” Source location Alan 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 Increase the substantive Health Care Support Worker workforce to support enhanced care and continuity.
Verbatim wording from the response “previously identified a need for an increase in Health Care Support Worker’s to support enhanced care by night and as a consequence the substantive HCSW workforce was increased to support this requirement.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
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 Revise the Falls Policy for Hospital Adult Inpatients to define multidisciplinary assessment, care planning and professional responsibilities.
Verbatim wording from the response “Your concerns as set out in the Regulation 28 notice, rightly point to the care planning that follows from the initial multifactorial assessment when a patient arrives on a ward or their circumstances change. To be effective in reducing falls and protecting patients from related harm, the care plan must be multidisciplinary, which the Health Board has recognised in revising its Falls Policy for Hospital Adult Inpatients. The entire policy has been reviewed through this lens, to make clear the responsibilities of all professions and disciplines that can contribute to the care of a hospital patient. The policy makes clear the expectation of joint multidisciplinary assessment and care planning. The policy revisions have been completed and are awaiting ratification by the Health Board’s Clinical Standards and Policy Group before publication.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
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 Obtain ratification and publish the revised Falls Policy for Hospital Adult Inpatients.
Verbatim wording from the response “Your concerns as set out in the Regulation 28 notice, rightly point to the care planning that follows from the initial multifactorial assessment when a patient arrives on a ward or their circumstances change. To be effective in reducing falls and protecting patients from related harm, the care plan must be multidisciplinary, which the Health Board has recognised in revising its Falls Policy for Hospital Adult Inpatients. The entire policy has been reviewed through this lens, to make clear the responsibilities of all professions and disciplines that can contribute to the care of a hospital patient. The policy makes clear the expectation of joint multidisciplinary assessment and care planning. The policy revisions have been completed and are awaiting ratification by the Health Board’s Clinical Standards and Policy Group before publication.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and implement a multidisciplinary falls-policy implementation plan, including ward-based and online staff training.
Verbatim wording from the response “The Health Board recognises that publishing a revised policy will not in itself enable the required change in emphasis towards multidisciplinary care planning and so a policy implementation plan is being developed. The policy implementation plan will be overseen and monitored by the Falls & Bone Health Steering Group, which is both multidisciplinary in its membership and also diverse in representing all divisions across the Health Board. The Falls & Bone Health Steering Group reports to the Health Board’s Quality and Patient Safety Committee (a formal committee of the Board). The implementation plan will largely focus on training, targeting the multidisciplinary team and will be delivered both through online learning but also, importantly, through face to face training on the wards.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
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 Evaluate falls training and monitor compliance, including multidisciplinary participation.
Verbatim wording from the response “Informing the training will be learning taken directly from serious incident investigations involving hospital falls, using actual case studies. The training will be evaluated and compliance will be monitored, including multidisciplinary participation.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce ward-level Falls Prevention Collaboratives using quality-improvement methods, thematic reviews and multidisciplinary participation.
Verbatim wording from the response “To further support awareness of the multidisciplinary requirements set out in the revised policy, a Health Board wide communications campaign will be developed and launched to coincide with the publication of the policy. The Falls & Bone Health Steering Group has also developed an action plan for reducing inpatient falls (enclosed). This action plan includes a wide range of action beyond the revision of the policy. A key action in the plan is introducing ‘Falls Prevention Collaboratives’, which utilise quality improvement methodologies which support identification of specific areas for focus alongside thematic reviews. The ‘Collaboratives’ follow a similar approach adopted by the Health Board to successfully reduce pressure damage in hospital; they are delivered at ward level with full multidisciplinary participation.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
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 Review and monitor completion of falls-prevention actions and evidence of multidisciplinary care-plan participation and ownership.
Verbatim wording from the response “In direct response to the Coroner’s concerns about multidisciplinary care, the Falls & Bone Health Steering Group will be actively reviewing and monitoring completion of the actions described, with a clear expectation that multidisciplinary participation and ownership of falls prevention care plans can be evidenced.” Source location 2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
Open published response
10 Feb 2021 Eric Harold Bird · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 4
Failure to complete required referral to the physiotherapy team View source Failure to identify and address patterns of falls and increasing risk View source Failure to update falls risk assessments and care plans after every fall View source
Failure to update falls risk assessments and care plans after every fall View source See 1 more concern
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Castlehill Specialist Care Centre
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
Castlehill Specialist Care Centre
Hold weekly ward rounds with the GP and senior nursing team to discuss information and multidisciplinary referrals and make appropriate referrals.
View source
Care Quality Commission
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
View source
Castlehill Specialist Care Centre
Continue raising safeguarding alerts after falls.
View source
Castlehill Specialist Care Centre
Request one-to-one funding where appropriate to maintain resident safety during further assessments.
View source See 1 more action
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AI-generated summary
Eric Harold Bird · 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
Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.
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 complete required referral to the physiotherapy team
Wider context from the report “1. After Mr Bird’s admission and initial falls risk assessment, there was a reference that Mr Bird needed to be referred to the physio team but no evidence this was actually done ;
” Source location Eric Harold Bird · 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 and address patterns of falls and increasing risk
Wider context from the report “9. There were discrepancies in the recording of the falls on the monthly accidents and incidents form and no evidence that any consideration had been given to a pattern of falls which needed to be addressed to reduce Mr Bird’s apparent increasing risks .
” Source location Eric Harold Bird · 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 update falls risk assessments and care plans after every fall
Wider context from the report “7. There was no evidence of any changes being made to Mr Birds falls care plan after the fall on 14/11/20 and no rationale recorded for not doing so ;
” Source location Eric Harold Bird · 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 update falls risk assessments and care plans after every fall
Wider context from the report “6. There was no evidence that Mr Bird’s falls risk assessment and falls care plan had been updated after every fall ;
” Source location Eric Harold Bird · 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 Hold weekly ward rounds with the GP and senior nursing team to discuss information and multidisciplinary referrals and make appropriate referrals.
Verbatim wording from the response “We have a weekly ward round with the GP are our Senior nursing team where all information including multi-disciplinary referrals are discussed and appropriate referrals are made by the GP.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
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 Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Verbatim wording from the response “The matters of concern which arose from the preventing future deaths report have prompted the CQC to take action. In direct response, we held a management review meeting on 17 February 2021. Following the management review meeting, we reviewed the evidence we held about Castlehill Specialist Care Centre, the information held following the specific incident review related to Mr Bird’s death and information following the inspection completed in January 2021.” Source location 2021-0122-Response-from-Care-Quality-Commission-Redacted
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 Continue raising safeguarding alerts after falls.
Verbatim wording from the response “Upon any fall we continue to raise safeguarding alerts and will request 1:1 funding to maintain the resident’s safety whilst further assessments take place where appropriate. This funding is often declined and in that eventuality we will review the suitability of the placement.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
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 Request one-to-one funding where appropriate to maintain resident safety during further assessments.
Verbatim wording from the response “Upon any fall we continue to raise safeguarding alerts and will request 1:1 funding to maintain the resident’s safety whilst further assessments take place where appropriate. This funding is often declined and in that eventuality we will review the suitability of the placement.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
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 CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Verbatim wording from the response “• As a result of these findings, CQC held a management review meeting on 18 March 2021 to discuss the findings under our specific incident guidance. In order to open a formal criminal investigation, we have to be able to evidence a Registered Person (either a Registered Provider or Registered Manager) failed to provide safe care and treatment to Mr Bird in relation to this incident and can prove beyond reasonable doubt this incident was avoidable. We did not feel that this threshold was met and therefore will not progress the case.” Source location 2021-0122-Response-from-Care-Quality-Commission-Redacted
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 Declined one-to-one funding can prevent maintaining enhanced supervision while further resident safety assessments are undertaken.
Verbatim wording from the response “Upon any fall we continue to raise safeguarding alerts and will request 1:1 funding to maintain the resident’s safety whilst further assessments take place where appropriate. This funding is often declined and in that eventuality we will review the suitability of the placement.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
Open published response
2 Feb 2021 Michael Yemm · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to provide appropriate falls prevention for patients in cohorted hospital bays View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Michael Yemm · 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
Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in hospital.
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 provide appropriate falls prevention for patients in cohorted hospital bays
Wider context from the report “That he was able, in a cohorted patient bay, to climb past raised bedrails , he did not have a lowered bed , whilst staff were present. A cohorted bay has extra staff to deal with challenging patients and fell fracturing his hip , necessitating surgery. For the whole of his stay Mr Yemm was agitated, confused anxious and distressed, he had to move wards because of the need for surgery which further exacerbated his condition.
” Source location Michael Yemm · 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 Complete review and adjustment of the NICE-compliant falls-risk assessment, Safety Sides assessment and associated policy.
Verbatim wording from the response “The Falls Risk and Safety Sides assessments are under review as part of an ongoing project. ████████ has been working with ████████, Deputy Chief Nurse on the project. A NICE compliant Falls Risk assessment has been trialled and a final draft has been put together (see attached). The assessments and the associated policy are currently at the final adjustment/review stage. It will then be a question of implementing the roll out of the documents. These presently form part of a risk assessment booklet which means complete roll out is dependent on other risk assessment documents being reviewed. There is no final completion date at the moment. Alongside the change in risk assessments, it is planned that there will be an education package to support staff through the changes and to recognise the multifactorial elements of falls prevention.” Source location 2021-0024-Response-from-Norfolk-and-Norwich-University-Hospital-Redacted
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 Implement the revised falls-risk and Safety Sides assessment documents after final review and completion of related booklet reviews.
Verbatim wording from the response “The Falls Risk and Safety Sides assessments are under review as part of an ongoing project. ████████ has been working with ████████, Deputy Chief Nurse on the project. A NICE compliant Falls Risk assessment has been trialled and a final draft has been put together (see attached). The assessments and the associated policy are currently at the final adjustment/review stage. It will then be a question of implementing the roll out of the documents. These presently form part of a risk assessment booklet which means complete roll out is dependent on other risk assessment documents being reviewed. There is no final completion date at the moment. Alongside the change in risk assessments, it is planned that there will be an education package to support staff through the changes and to recognise the multifactorial elements of falls prevention.” Source location 2021-0024-Response-from-Norfolk-and-Norwich-University-Hospital-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an education package supporting revised falls assessments and recognition of multifactorial falls risks.
Verbatim wording from the response “The Falls Risk and Safety Sides assessments are under review as part of an ongoing project. ████████ has been working with ████████, Deputy Chief Nurse on the project. A NICE compliant Falls Risk assessment has been trialled and a final draft has been put together (see attached). The assessments and the associated policy are currently at the final adjustment/review stage. It will then be a question of implementing the roll out of the documents. These presently form part of a risk assessment booklet which means complete roll out is dependent on other risk assessment documents being reviewed. There is no final completion date at the moment. Alongside the change in risk assessments, it is planned that there will be an education package to support staff through the changes and to recognise the multifactorial elements of falls prevention.” Source location 2021-0024-Response-from-Norfolk-and-Norwich-University-Hospital-Redacted
Open published response
5 Jan 2021 Hariharan Harichandra · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Failure by staff to properly review Falls Assessment Tools View source Failure to properly complete Falls Assessment Tools View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Hariharan Harichandra · 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
Hariharan Harichandra, a 65-year-old man, fell from an electric wheelchair in hospital on 5 December 2019, sustaining a neck fracture, and died at The Royal Free Hospital on 19 December 2019. The concerns included errors in reporting and reviewing the CT scan, incomplete falls assessment, insufficient consideration of wheelchair safety equipment and spinal condition, and failure to record a severe adverse reaction to a naso-gastric tube.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure by staff to properly review Falls Assessment Tools
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” Source location Hariharan Harichandra · 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 properly complete Falls Assessment Tools
Wider context from the report “I am concerned that:
(a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained.
(b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician.
(c) The Falls Assessment Tool was not properly completed or reviewed by staff;
(d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices;
(e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived.
” Source location Hariharan Harichandra · 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 Validate Perfect Ward documentation-audit results through monthly senior-nurse review of submitted results and supporting documentation.
Verbatim wording from the response “Documentation audits have been on-going via the Perfect Ward app. This real time audit tool measures the approaches to a wide and varied group of safety metrics, which includes moving and handling, completion of the falls risk assessment and whether the risks are reassessed at appropriate points through the patients care. It is recognised that this data needs to be independently validated in order to provide assurance that results are accurate.” Source location 2021-0001-Response-from-Royal-Free-Hospital-Redacted
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.